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

Primary Care Office visit

$10 Copayment per visit

$15 Copayment per visit

Specialist's Office Visit

$10 copayment per visit

$20 copayment per visit

Emergency Urgent Care Center

$20 copayment per visit

$30 copayment per visit

Emergency Room

$40 copayment per visit

$50 copayment per visit

Outpatient Surgical Facility

No charge

$50 copayment per visit

Inpatient Hospital
(including emergency admissions)

No charge

$50 copayment per day up to a maximum of $250 per member per year

Prescription Drugs

$10 generic

$20 formulary brand-name

$35 non-formulary brand-name for up to 34 day supply,

$15 generic

$25 formulary brand-name

$40 non-formulary brand-name for up to 34 day supply,

Mail Order Prescription Drugs

2 times the above copays for up to a 100 day supply through mail order

2 times the above copays for up to a 100 day supply through mail

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 1-800-251-7722, or write to us at ConnectiCare, Inc., 175 Scott Swamp Road, Farmington, CT 06032-3124. You may also request replacement cards through our Web site at www.connecticare.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. This list is also on our Web site. Since the list changes it is best to contact us to confirm that a provider participates.

� Plan facilities

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

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. You can choose a PCP from our provider directory. If you don't provide us with your PCP, we will select one for you, which you can change at any time by calling 1-800-251-7722.

� Primary care

Your primary care physician can be a family practitioner, internist, general practitioner or a 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

Members may see any participating doctor for covered services without a referral with the following exceptions.

For information on how to obtain specialty care services, contact us at 1-800-251-7722.

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 work with your specialist and the Plan 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 1-800-251-7722. 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 Plan authorization.

Your doctor will get Plan authorization for: hospital admissions (except out-of-service area emergencies), outpatient alcohol and substance abuse treatment, home health care, out-of-Plan services (nonparticipating providers), human organ transplants, and skilled nursing facilities. For a complete listing, call our Member Services Department at 1-800-251-7722.

For information on how to obtain specialty care services, contact us at 1-800-251-7722.

Copayments

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

Example: When you see your primary care physician you pay a copayment of $10 per office visit and when you go in the hospital, you pay $100 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. We do not have a deductible on our overall Plan.

Coinsurance

Coinsurance is the percentage of our allowance that you must pay for your care. DME has coinsurance.

Your catastrophic protection out-of-pocket maximum

Copayments for services are minimal. The plan provides unlimited benefits (except as noted in the plan document) for covered services.

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

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

Plan physicians must provide or arrange your care.

We have no calendar year deductible, except for DME.

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 Primary Care Physician's office

In Specialist's office

$15 per office visit

$20 per office visit

Professional services of physicians

In an urgent care center

During a hospital stay

In a skilled nursing facility

Office medical consultations

Second surgical opinion

$30 per office visit

Nothing.

Nothing for up to 90 days per calendar year.

$15 for PCP, $20 for Specialists, per office visit.

$15 for PCP, $20 for Specialists, per office visit.

At home

$15 for PCP, $20 for Specialists, per visit.

Vaccines for pediatric and adult immunizations

Nothing if you receive these services during your office visit.

Not covered

Nondental treatment of temporomandibular joint (TMJ) syndrome

Services for which a member has no responsibility to pay

Services for intentionally inflicted injuries

Services for injuries resulting from hazardous activities

Injuries received in connection with the commission of a felony

All charges

Tests, such as:

Blood tests

Urinalysis

Non-routine pap tests

Pathology

X-rays

Non-routine Mammograms

CAT Scans/MRI

Ultrasound

Electrocardiogram and EEG

$15 in a Primary Care Physician's office,

$20 in a Specialist's office

Routine screenings, such as periodic check-ups and routine immunizations including those tests as ordered by your doctor.

Total Blood Cholesterol

Colorectal Cancer Screening, including

Fecal occult blood test

Sigmoidoscopy, screening - every five years starting at age 50

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

Colonoscopy screening - every ten years starting at age 50

$15 per office visit

$20 in a Specialist's office

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

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 office visit

$15 per office visit

$20 in a Specialist's office

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

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

From age 40 through 64, one every calendar year

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

$15 per office visit

$20 in a Specialist's office

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

Nothing if you receive these services during your office visit; otherwise $15 per office visit.

$20 in a Specialist's office

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

All charges.

Childhood immunizations recommended by the American Academy of Pediatrics

Nothing if you receive these services during your office visit; otherwise $15 per office visit.

$20 in a Specialist's office

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

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

Nothing if you receive these services during your office visit; otherwise $15 per office visit.

$20 in a Specialist's office

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 12 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 visit, then nothing.

$20 in a Specialist's office

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 (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.

$15 per office visit

$20 in a Specialist's office

Not covered:

Reversal of voluntary surgical sterilization

Genetic counseling.

All charges.

Diagnosis and treatment of infertility such as:

Artificial insemination:

intravaginal insemination (IVI)

intracervical insemination (ICI)

intrauterine insemination (IUI)

Fertility drugs

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

$20 per office visit

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

All charges.

Testing and treatment

Allergy injections

$20 per office visit

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 29.

Respiratory and inhalation therapy

Dialysis - hemodialysis and peritoneal dialysis

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

Growth hormone therapy (GHT)

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

Note: We only cover GHT when we preauthorize the treatment. Your doctor would have to submit your case in writing to the Plan. Your case will be reviewed for medical necessity and, if approved, you may then seek treatment.

Nothing.

Not covered:

All charges.

60 visits per condition per calendar year for the services for each of the following:

qualified physical therapists and

occupational therapists

Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury.

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction is provided as part of your rehabilitation.

$20 per office visit

$20 per outpatient visit

Nothing per visit during covered inpatient admission

Not covered:

Long-term rehabilitative therapy

Exercise programs

All charges.

60 visits per condition per calendar year

$20 per office visit

$20 per outpatient visit

Nothing per visit during covered inpatient admission.

Not covered:

Non-authorized, non-medically necessary treatment

All charges.

First hearing aid and testing only when necessitated by accidental injury

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

$15 copayment in PCP office;

$20 copayment in specialist's office

Not covered:

All other hearing testing

Hearing aids, testing and examinations for them

All charges.

Our vision program includes frames and lenses, prescription contact lenses available only at Plan routine vision providers (offered at various discounts, not a $10 copay). For a full description of the Vision Care Coverage, please see the routine vision information located in the enrollment packet.

25% discount on frames and lenses at or below $250; 30% discount over $250 at plan vision providers

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)

Annual eye refractions once per calendar year, when obtained by Plan providers

25% discount on frames and lenses at or below $250; 30% discount over $250 at plan vision providers.

$15 per office visit

$15 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.

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 copayment in PCP office;

$20 copayment in a specialist's office

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.

Artificial limbs and eyes; stump hose

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

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following mastectomy. Note: See 5(b) for coverage of the surgery to insert the device.

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following mastectomy. Note: Internal prosthetic devices are paid as hospital benefits; see Section 5(c) for payment information. Insertion of the device is paid as surgery; see Section 5(b) for coverage of the surgery to insert the device.

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

$15 copayment in PCP office

$20 copayment in a specialist's office

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.

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; (Motorized chairs covered only with plan approval of doctor's written request detailing medical necessity);

Crutches;

Walkers;

Blood glucose monitors; and

Insulin pumps.

Note: Call us at 1-800-251-7722 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

$100 deductible per calendar year and 20% of charges up to a maximum Plan payment of
$1,500 per calendar year.

Note: Prior Plan authorization is required and coverage is limited to the initial acquisition.

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 aide.

Services include oxygen therapy, intravenous therapy and medications.

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.

Manipulation of the spine and extremities; 20 visits per calendar year

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

$20 per office visit

Alternative treatments - continued on next page

Acupuncture - by a doctor of medicine or osteopathy for: anesthesia, pain relief

All charges.

Not covered:

Naturopathic services

Hypnotherapy

Biofeedback

All charges.

Diabetes, Heart, Asthma and Smoking Cessation programs are available. Information can be obtained by calling Member Services at 1-800-251-7722.

Nothing.

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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 except for DME.

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 FOR SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.

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A comprehensive range of services, such as:

Operative procedures

Treatment of fractures, including casting

Normal pre- and post-operative care by the surgeon

Correction of amblyopia and strabismus

Endoscopy procedures

Biopsy procedures

Removal of tumors and cysts

Correction of congenital anomalies (see Reconstructive surgery)

$15 copayment in PCP office

$20 per office visit

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

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

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.

Nothing (when approved in advance by Plan.)

Nothing.

$15 copayment in PCP office

$20 per office visit

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.

$15 copayment in PCP office

$20 per office visit

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.

� Oral surgery services: Medically necessary oral surgical services for
the treatment of tumors, cysts (of non-dental origin), injuries of the facial bones and for the treatment of fractures and dislocations involving the face and jaw, including temporamandibular joint (TMJ) dysfunction surgery (for demonstrable joint disease only) provided by a Participating Physician are covered. Certain oral surgery requires Pre-Authorization.

$15 copayment in PCP office

$20 per office visit

Not covered:

Oral implants and transplants

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

All 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

National Transplant Program (NTP)

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.

$50 per day up to a maximum of $250 per member per year for inpatient hospital procedures

Note: Plan authorization is required at the time of diagnosis, prior to any evaluative services and will only be authorized at Plan facilities, contracted Centers of Excellence.

Not covered:

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

Implants of artificial organs

Transplants not listed as covered

All charges.

Professional services provided in -

Hospital (inpatient)

Nothing

Professional services provided in -

Hospital outpatient department

Skilled nursing facility

Ambulatory surgical center

Office

$20 per 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 and you must be hospitalized in a Plan facility.

We have no calendar year deductible, except for DME.

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 PHYSICIANMUSTGETPRECERTIFICATIONFORHOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification.

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Benefit Description

You pay

Inpatient hospital

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.

$50 per day up to a maximum of $250 per member per year

Inpatient hospital (continued)

You pay

Other hospital services and supplies, such as:

Operating, recovery, maternity, and other treatment rooms

Prescribed drugs and medicines

Diagnostic laboratory tests and X-rays

Blood or blood plasma, if not donated or replaced

Dressings, splints, casts, and sterile tray services

Medical supplies and equipment, including oxygen

Anesthetics, including nurse anesthetist services

Take-home items

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

Nothing

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.

Outpatient hospital or ambulatory surgical center

You pay

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 visit.

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

All charges.

Extended care benefits/Skilled nursing care facility benefits

Skilled Nursing Facility (SNF): The Plan provides a comprehensive range of benefits for up to 90 days 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.

Nothing for up to 90 days per calendar year.
Prior authorization required.

Not covered: Custodial care

All charges.

Hospice care

Hospice Care: 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

Not covered: Independent nursing, homemaker services

All charges.

Ambulance

Local professional ambulance service when medically appropriate

Nothing

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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, except for DME.

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

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What is a medical emergency?

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

What to do in case of emergency:

Emergencies within our service area: If you are in an urgent care situation within our service area, please call your primary care doctor (available 24 hours a day through their answering service). In extreme emergencies, contact the local emergency system (e.g., the 911 telephone system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a family member should notify the Plan within 24 hours of an admission to the hospital unless it was not reasonably possible to do so. It is your responsibility to ensure that the Plan has been timely notified.

If you need to be hospitalized in a non-Plan facility, the Plan must be notified within 24 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If you are hospitalized in non-Plan facilities and Plan doctors believe care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

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

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

The Plan pays reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers.

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 need to be hospitalized, the Plan must be notified within 24 hours of an admission or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred 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 or provided by Plan providers.

Benefit Description

You pay

Emergency within our service area

Emergency care at a doctor's office

Emergency care at a specialist's office

Emergency care at an urgent care center

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

$15 per office visit

$20 per office visit

$30 for covered emergency services

Copayment waived if emergency results in hospital admission.

$50 for covered emergency services

Copayment waived if emergency results in hospital admission.

Not covered: Elective care or non-emergency care

All charges.

Emergency outside our service area

Emergency care at a doctor's office

Emergency care at a specialist's office

Emergency care at an urgent care center

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

$15 per office visit

$20 per office visit

$30 for covered emergency services

Copayment waived if emergency results in hospital admission.

$50 for covered emergency services

Copayment waived if emergency results in hospital admission.

Ambulance

Professional ambulance service when medically appropriate.

Air ambulance

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

Nothing.

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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, except for DME.

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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Benefit Description

You pay

Mental health and substance abuse benefits

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.

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

Medication management

$20 per office visit

Diagnostic tests

Nothing.

Services provided by a hospital or other facility

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

Copayment of $50 per day to a maximum
of $250 per member per year.

Copayment according to type of services.`

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: Please call 1-800-424-5669 for all mental health requests. This number is printed on the back of your ConnectiCare, Inc. member ID card as well.

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, except for DME.

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.

We have an open formulary. If your physician believes a brand-name product is necessary or there is no generic available, your physician may prescribe a brand-name drug from a formulary list. The list of brand-name drugs is a preferred list of drugs that we've selected to meet patient's needs at a lower cost. We have the right to change the drugs or supplies in each tier, in our discretion, even in the middle of the year. You should call Member Services or visit the Web site to find out which tier (if any) a prescription drug or supply is in To order a formulary listing, go to our Web site www.connecticare.com.

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

Who can write your prescription. A licensed physician must write the prescription.

� Where you can obtain them. You must fill the prescription at a Express Scripts pharmacy, or by mail for a maintenance medication. The only exception is for out-of-area emergencies.

Pharmacy: You may obtain your prescriptions at any Express Scripts, Inc. pharmacy (in 98% of US Pharmacies.)

Mail order: Maintenance medication, those medications needed for conditions such as diabetes, high blood pressure, epilepsy and heart conditions, can be obtained either via mail order or at the pharmacy in a
100-day supply. If you choose mail order at 2 times the copay, call Member Services at 1-800-251-7722 to request and order form. If you choose to go to your pharmacy, the co-pay will be 3 times the co-pay. All rules that apply to the regular Prescription Plan apply to the Mail Order Program as well. Note: Not all drugs are available via mail order and your doctor must write a maintenance prescription.

We use a formulary. We work with our network physicians and our pharmacy network, Express Scripts, Inc., to build a Formulary Drug List. This Formulary Drug List includes over 80% of the drugs currently available in the market, including all generic and some name brand drugs. Formulary and Non-Formulary drugs are available at a cost difference when a generic is available. Our Formulary is available by calling Member Services at 1-800-251-7722 or on the Web at www.connecticare.com

All members receive educational information describing the Formulary drug program. Members using non-Formulary drugs are sent a series of letters recommending that they speak to their physician about preferred alternatives.

We have an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your physician may prescribe a name brand drug from a formulary list. This list of name brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower cost. To order a prescription drug brochure, call 1-800-251-7722.

These are the dispensing limitations. Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 34-day supply; 240 milliliters of liquid (8oz.); 60 grams of ointment, creams or topical preparation; or one commercially prepared unit (i.e., one inhaler, one vial ophthalmic medication or Insulin) of medication per prescription or refill. You pay a $15 copay per prescription unit or refill for generic drugs or a $25 copay for name brand Formulary drugs when generic substitution is not permissible. When generic substitution is permissible and, you or your doctor request the Formulary name brand drug, you pay the price difference between the generic and name brand drug as well as the $15 copay per prescription unit or refill. Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug Formulary. Non-Formulary drugs will be covered when prescribed by a Plan doctor, but at a higher copay. If you are in the military and called to active duty due to an emergency, please contact us if you need assistance in filling a prescription before your departure.

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

Why use generic drugs? Per the FDA (Federal Drug Administration), generic drugs and name brand drugs share identical basic ingredients. The color and shape may differ but the result should be the same. Many generic patents are owned by the name brand drug companies. Generic drugs are an affordable alternative. You can always get the brand-name, you just pay more.

NOTE: Not all prescriptions are available through the Maintenance Mail Order Program depending on the type of drug, etc. We follow FDA dispensing guidelines. If you send in your order too soon, it can't be filled. Maintenance Mail Order refills should be requested after 75% of the prescription is used. Over the counter when you have 5 days left. If your prescription is for more than 34 days (1 month) prescription, you will be charged two and sometime three copays depending on how much was dispensed.

If you choose a non-Formulary drug when a generic or Formulary name brand drug is available, you pay a $15 copayment in addition to the cost difference between the Formulary and non-Formulary drug, up to 50% of the cost of the drug. If the cost is less than the copayment, you pay the lesser amount.

When you have to file a claim. There are no claims to file for prescription services received at Express Scripts, Inc. drug stores. If you are new to the plan and don't have your card when you first join and need a prescription, you must pay for it and call Member Services at 1-800-251-7722 for a prescription reimbursement form. Refunds take up to 8 weeks so always use your card when you get it.

Benefit Description

You pay

Covered medications and supplies

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

Disposable needles and syringes for the administration of covered medications

Drugs for sexual dysfunction (contact the plan for dose limits)

Contraceptive drugs and devices (oral and injectable plus diaphragms)

Fertility drugs are subject to $1,500 per calendar year

Intravenous fluids and medicine for home use (covered implantable drugs and covered injectable drugs are covered under medical and surgical benefits).

$15 copay per prescription unit or refill for generic drugs,

$25 copay for name brand Formulary drugs

$40 copay for non-Formulary drugs.

When a generic drug is available, but you or your doctor request the name brand drug, or non-Formulary brand drug, you pay the formulary price difference between the generic and name brand drug as well as the $15 copay per prescription unit or refill. Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug Formulary.

Our Formulary is open and available by calling Member Services at 1-800-251-7722 or by going to our Web site www.connecticare.com. Mail Order forms are also available by calling Member Services. Mail Order follows the same rules (cost sharing) and provides a 100 day supply for 2 times the copay.

Not covered:

Drugs and supplies for cosmetic purposes

Drugs to enhance athletic performance

Fertility drugs {Plan specific}

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

Nonprescription medicines

All charges.

Feature

Description

Flexible benefits option

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

We may identify medically appropriate alternatives to traditional care and 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.

Services for deaf and hearing impaired

Call the TDD/TTY number for the hearing impaired: 1-800-251-7722.

Our Web site
www.connecticare.com

You can change or add your PCP, look up a doctor or check our drug formulary at our Web site.

High risk pregnancies

ConnectiCare's Birth Expectations program was created to provide information to help you take precautions against giving birth too early. We'll send you a survey and follow up with a phone call if you're in a high-risk category for premature delivery. You'll learn about the signs of premature labor. We can then be in touch as needed and arrange for extra services that could help bring your pregnancy to full term. For instance, you may be eligible for home uterine monitoring, which ConnectiCare can coordinate with your doctor. By taking necessary precautions you can give your baby the healthiest possible start.

Centers of excellence

ConnectiCare's members will have access to more than 235 elite transplant programs and more than 170 clinical experts across the country. These programs have been carefully selected using strict evaluation criteria that were developed in conjunction with transplant physicians and surgeons. United Resource Network's (U.R.N.'s) Transplant Centers of Excellence network was developed through a process of quality measurement credentialing that is unique in the health care industry. Through this network ConnectiCare can assist the health care team and the member in determining the best transplant program for their specific need.

Travel benefits/services overseas

Severe chest pain. Trouble breathing. Severe bleeding. Poisoning. Seizures. These are all emergencies. And if an emergency ever happens to you, don't wait. Get to the closest emergency room right away - anywhere in the world. Call 911 if you need help getting there. Please notify us at 1-860-674-5870 within 24 hours of being admitted to the hospital. A friend or family member can call for you. If you can't act that quickly, notify us as soon as you or someone else is able to.

Alternative treatments

Discounts on homeopathic treatments, massage therapy, etc. See flyer enclosed in your enrollment kit or, call Member Services at 1-800-251-7722 and ask for a "Healthy Alternatives" brochure.

Accidental injury benefit

You pay

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

$15 in doctor's office
$20 in specialist's office
$30 in urgent care center
$50 in emergency room

Dental benefits

No benefit (Voluntary dental benefits offered separate from the FEHB Program)

Medical, hospital and
drug benefits

In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form. For claims questions and assistance, call us at 1-800-251-7722.

When you must file a claim - such as for services you receive outside the Plan's service area - submit it on the HCFA-1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show:

Covered member's name and ID number;

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

Dates you received the services or supplies;

Diagnosis;

Type of each service or supply;

The charge for each service or supply;

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

Receipts, if you paid for your services.

Submit your claims to:
Member Services
ConnectiCare, Inc.
175 Scott Swamp Road
Farmington, CT 06032-3124

Deadline for filing your claim

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

When we need more information

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

Step

Description

1

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

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

b) Send your request to us at: Member Services, 175 Scott Swamp Road, Farmington, CT 06032-3124; and

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

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

2

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

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

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

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

3

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

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

We will write to you with our decision.

4

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

You must write to OPM within:

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

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

120 days after we asked for additional information.

Write to OPM at: United States Office of Personnel Management, Insurance Services Programs, Health Insurance Group 3, 1900 E Street, NW, Washington, DC 20415-3630.

The disputed claims process (continued)

Send OPM the following information:

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

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

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

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

Your daytime phone number and the best time to call.

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

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

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

5

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

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

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

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

When you have other health coverage

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

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

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

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

What is Medicare?

Medicare is a Health Insurance Program for:

People 65 years of age or older.

Some people with disabilities under 65 years of age.

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

Medicare has two parts:

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

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

� Should I enroll in Medicare?

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

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

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

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

� The Original Medicare Plan (Part A or Part B)

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

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.

When Medicare is primary, we will cover what they don't assuming all other rules have been followed.

In most cases, if you inform your provider that you have two coverages, they will send the claims to the carriers. But, this is something they do as a convenience. You are always ultimately responsible to submit your claims to the carriers you deal with.

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

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

When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. You will not need to do anything. To find out if you need to do something to file your claim, call us at 1-800-251-7722.

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

Primary Payer Chart

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

The primary payer for the individual with Medicare is...

Medicare

This Plan

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

�

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

�

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

�

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

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

�

You have FEHB coverage through your spouse who is an annuitant

�

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

�

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

�for Part B services

� for other services

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

�*

B. When you or a covered family member...

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

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

�

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

�

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

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

�for 30-month coordination period

� Medicare was the primary payer before eligibility due to ESRD

�

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

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

�

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

�

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

�

� Medicare Advantage

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

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

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

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

TRICARE and CHAMPVA

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

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

Workers' Compensation

We do not cover services that:

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

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

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

Medicaid

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

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

When other Government agencies are responsible for your care

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

When others are responsible for injuries

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

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

Calendar year

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

Coinsurance

Coinsurance is the percentage of our allowance that you must pay for your care. You may also be responsible for additional amounts. See page 13.

Copayment

A copayment is a fixed amount of money you pay when you receive covered services. See
page 13.

Covered services

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

Custodial care

Home Health Care, light duty services at your home. Custodial care that lasts 90 days or more is sometimes known as long-term care.

Deductible

A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services. See page 13.

Experimental or investigational services

How do you decide if a service is experimental or investigational? ConnectiCare uses

outside medical experts and scientific literature reviews for determining whether a medical service is considered investigational and/or experimental.

Group health coverage

Health insurance sold only to group employers.

Medical necessity

Medical care provided for illness or injury that is determined by national standards to be Medically Necessary. Like a Mammogram, etc.

Us/We

Us and We refer to ConnectiCare, Inc.

You

You refers to the enrollee and each covered family member.

� No pre-existing condition limitation

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

� Where you can get information about enrolling in the FEHB Program

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

When you may change your enrollment;

How you can cover your family members;

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

When your enrollment ends; and

When the next open season for enrollment begins.

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

�

Section 11

Types of coverage available for you and your family

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

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

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

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

�

Section 11

Children's Equity Act

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

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

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

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

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

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

� When benefits and premiums start

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be paid according to the 2005 benefits of your old plan or option. However, if your old plan left the FEHB Program at the end of the year, you are covered under that plan's 2004 benefits until the effective date of your coverage with your new plan. Annuitants' coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

� When you retire

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

� When FEHB coverage ends

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

Your enrollment ends, unless you cancel your enrollment, or

You are a family member no longer eligible for coverage.

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

� Spouse equity coverage

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

� Temporary Continuation of Coverage (TCC)

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

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

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

� Converting to individual coverage

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

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

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

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

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

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

� Getting a Certificate of Group Health Plan Coverage

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

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

Important information

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

� What is an FSA?

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

There are two types of FSAs offered by FSAFEDS:

Health Care Flexible Spending Account (HCFSA)

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

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

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

Dependent Care Flexible Spending Account (DCFSA)

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

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

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

� Enroll during Open Season

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

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

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

What is SHPS?

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

Who is eligible to enroll?

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

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

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

� How much should I contribute to my FSA?

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

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

� What can my HCFSA pay for?

Every FEHB plan includes cost sharing features, such as deductibles you must meet before the Plan provides benefits, coinsurance or copayments that you pay when you and the Plan share costs, and medical services and supplies that are not covered by the Plan and for which you must pay. These out-of-pocket costs are summarized on page 61 and detailed throughout this brochure. Your HCFSA will reimburse you when those costs are for qualified medical care that you, your spouse and/or your dependents receive that is NOT covered or reimbursed by this FEHB Plan or any other coverage that you have.

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

� Tax savings with an FSA

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

Annual Tax Savings Example

With FSA

Without
FSA

If your taxable income is:

$50,000

$50,000

And you deposit this amount into an FSA:

$2,000

-$0-

Your taxable income is now:

$48,000

$50,000

Subtract Federal & Social Security taxes:

$13,807

$14,383

If you spend after-tax dollars for expenses:

-$0-

$2,000

Your real spendable income is:

$34,193

$33,617

Your tax savings:

$576

-$0-

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

� Tax credits and deductions

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

Health care expenses

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

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

Dependent care expenses

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

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

� Does it cost me anything to participate in FSAFEDS?

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

� Contact us

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

E-mail: FSAFEDS@shps.net

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

TTY: 1-800-952-0450

� It's important protection

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

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

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

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

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

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

� To find out more and to request an application

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

Benefits

You pay

Page

Medical services provided by physicians:

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

Office visit copay: $15 primary care physician; $20 specialist

16

Services provided by a hospital:

Inpatient.......................................................................................................

Outpatient....................................................................................................

$50 copayment per day to a maximum of $250 per member per year

$50 copayment

31

31

Emergency benefits

In-area emergency care hospital outpatient...........................................

Out-of-area emergency care hospital outpatient...................................

$50 per visit

$50 per visit

34

34

Mental health and substance abuse treatment..............................................

Regular cost sharing

36

Prescription drugs..............................................................................................

$15 generic
$25 Brand-name Formulary
$40 Brand-name non-formulary
Cost-sharing applies when generic is available

38-40

Dental care......................................................................................................... ..

No benefit

�

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

$10 routine exam, discounts available on eyewear and contacts.

22

Special features: Flexible benefits, services for the deaf and hearing impaired, ConnectiCare Web site, alternative treatments

41

Protection against catastrophic costs

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

You must share the cost of some services. This is called either a copayment (a set dollar amount) or coinsurance (a set percentage of charges). Please remember you must pay this amount when you rece4ive services. All "catastrophic" costs are paid by the Plan.

13