CALL — THE HEALTH CARE FRAUD HDHPTLINE

202-418-3300

OR WRITE TO:

United States Office of Personnel Management

Office of the Inspector General Fraud Hotline

1900 E Street NW Room 6400

Washington, DC20415-1100

Identification cards

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 1-800-344-8858 or write to us at 2600 Sixth Street SW, Canton, Oh 44710. You may also request replacement cards through our Web site: www.aultcare.com.

Where you get covered care

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

HDHP Plan: You will only pay deductibles and coinsurance and you will not have to file claims.

Network providers and facilities

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

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

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.

Out-of-network providers and facilities

Better Plan benefits are available when you use AultCare Providers. In order to receive maximum Plan benefits, you must use the services of Aultman Hospital and the Physicians within the AultCare network. If, on the other hand, you use a Non-AultCare Provider, lesser benefit amounts may be payable. Should you be referred by an AultCare Provider to a Non-AultCare Provider, and the referral is approved by AultCare, benefits are payable as if provided by an AultCare Provider up to the Usual, Customary and Reasonable (UCR) fee. If the referral is not approved by AultCare, you will be subject to a reduction in benefits.

What you must do to get covered care

HMO Plan: 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.

HDHP Plan: You can get care from any "covered provider" or "covered facility." How much we pay � and you pay � depends on the type of covered provider or facility you use. If you use our preferred providers, you will pay less.

Primary care

HMO Plan: only: Your primary care physician can be a family practitioner, internist, and 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

HMO Plan: Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must return to the primary care physician after the consultation, unless your primary care physician authorized a certain number of visits without additional referrals. The primary care physician must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your primary care physician gives you a referral. However, you may see obstetrician/gynecologist without a referral.

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 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 are 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

HMO Plan: 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 1-800-344-8858. 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.

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

1-800-344-8858.

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

HMO Plan: 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 precertification. Precertification is required for all non-AultCare admissions and all Home Health Care programs. You must notify the AultCare Utilization Department prior to any planned non-AultCare admissions or to any Home Health Care program.

Other services requiring precertification include:

Partial hospitalization programs provided out-of-network;

Intensive out patient programs provided out-of-network;

Rehabilitation facility admissions;

Skilled nursing facility admissions;

Hospice Care;

Therapies, including physical, occupational, speech, cognitive and growth hormone;

Mental Health and Substance Abuse; and

Certain Drugs

HDHP Plan: Pre-Certification: The process known as pre-certification is an evaluation of your medical case by your provider and AultCare medical professionals to determine the appropriateness of your Hospital admission and expected length of stay. In some cases, an alternative to Hospital admission, such as outpatient treatment, may be recommended.

If your medical professional is an AultCare Provider, the pre-certification process will be handled for you by your provider when required. You are only responsible for alerting your provider that you are an AultCare participant. However, if your medical professional is not an AultCare Provider, you are responsible for seeing that utilization review procedures are followed. Contact the Utilization Review Department or the Service Center at 1-800-344-8858. The Utilization Review Department will handle pre-certification and tell you if a second opinion is necessary for the procedure being done and/or if outpatient surgery is required.

Depending on the circumstances and time constraints of your situation, you may be asked to have a form completed. When possible, utilization requirements will be met with a simple phone call by the Utilization Review Department to your Doctor.

Failure to meet pre-certification requirements for Non-Panel Hospital admissions will result in a reduction of benefits.

Referral Procedure: Upon occasion, it may be necessary for your AultCare Provider to refer you to a Physician outside the AultCare Network. In order for you to receive the greatest benefit possible from your AultCare Plan, the following procedure must be followed:

Your AultCare Provider must contact the pre-admission coordinator at the AultCare Utilization Management Department to explain the circumstances of the referral. This can be done by telephone or by completing a referral form available to the Physician.

The completed referral request will be reviewed by the AultCare Medical Director. You and your Physician will be contacted directly as to whether the referral has been approved. If you do not receive written confirmation of your referral, please contact the AultCare Utilization Management Department at 1-800-344-8858 prior to your appointment at the Non-AultCare Provider. When a referral is approved, benefits will be payable as outlined for other AultCare Providers, subject to UCR limitation.

When a referral is not approved, or the above procedure is not followed, benefits are payable as outlined for other Non-AultCare Providers.

Case Management: The goal of AultCare's Medical Case Management is managing the high cost of catastrophic illnesses while maintaining quality of care. Case management is used to describe a number of different approaches to planning, coordinating, providing and financing medical care. Case Management requires the simultaneous cooperation of AultCare, the Physician, the patient, and the patient's family. Telephonic follow up is provided to create and evaluate a goal oriented treatment plan. The focus of case management can include, but is not limited to, chronic disease states such as diabetes, COPD, or CHF, complex or catastrophic cases. Medical Case Management programs develop an individual plan designed to coordinate and mobilize health care resources to address specific medical problems and patient needs. The result should be a claim savings through effective medical management.

Copayments

HMO Plan: 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 physician you pay a copayment of $10 per visit.

HDHP Plan: There are no copayments in the HDHP.

Deductible

HMO Plan: There is no deductible under the HMO.

HDHP Plan: A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for them.

If you use PPO providers, the calendar year deductible is $2,000 per person. Under a family enrollment, the deductible is satisfied for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $4,000. If you use non-PPO providers, your calendar year deductible increases to a maximum of $4,000 per person ($8,000 per family). Whether or not you use PPO providers, your calendar year deductible will not exceed $6,000 per person ($12,000 per family).

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

And, if you change from Self and Family to Self Only, or from Self Only to Self and Family during the year, we will credit the amount of covered expenses already applied toward the deductible of your old enrollment to the deductible of your new enrollment.

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

And, if you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your new option.

Coinsurance

HMO Plan: There is no coinsurance under the HMO.

HDHP Plan: Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance doesn't begin until you meet your deductible.

Example: You pay 20% of our allowance for a Preferred Provider

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

For example, if your physician ordinarily charges $100 for a service but routinely waives your 20% coinsurance, the actual charge is $80. We will pay $64 (80% of the actual charge of $80).

Your catastrophic protection out-of-pocket maximum

HMO Plan: There is no catastrophic protection out of pocket maximum.

HDHP Plan: There is a limit to the amount you must pay out-of-pocket for coinsurance for the year for certain charges. When you have reached this limit, you pay no coinsurance for covered services for the remainder of the calendar year.

PPO benefit: Your out-of-pocket maximum is $4,000 for a Self Only and $8,000 for Self and Family enrollment if you are using PPO providers. Only eligible expenses for PPO providers count toward this limit.

Non-PPO benefit: Your out-of-pocket maximum is $8,000 for a Self Only and $16,000 for a Self and Family enrollment if you are using Non-PPO providers. Eligible expenses for network providers also count toward this limit. Your eligible out-of-pocket expenses will not exceed this amount whether or not you use network providers.

Out-of-pocket expenses for the purposes of this benefit are:

The 20% you pay for PPO Inpatient hospital charges, Surgical, Maternity and Diagnostic and treatment services

The 40% you pay for non-PPO Inpatient hospital charges, Surgical, Maternity and Diagnostic and treatment services; and

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

Expenses in excess of our allowance or maximum benefit limitations

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

Any amounts you pay because benefits have been reduced for non-compliance with this Plan's cost containment requirements (see pages 13, 14, 15 and 16)

Expenses in excess of Plan maximums

Carryover

If you enrolled in our Plan during Open Season and your effective date is after January 1, your previous plan will be responsible for any medical care you received before your coverage in our Plan began. The old plan will pay your covered costs under this year's benefits since benefit changes start on January 1. If you did not meet your out-of-pocket maximum under your old plan last year, your covered out-of-pocket expenses will be applied to that maximum. If you did meet that maximum, your old plan's catastrophic protection benefit will continue to apply until your effective date in our Plan.

Differences between our allowance and the bill

In-network providersagree to limit what they will bill you. Because of that, when you use a network provider, your share of covered charges consists your copayments (HMO Plan only) or your deductible and coinsurance (HDHP Plan only).

HDHP Plan: Here is an example about coinsurance: You see a network physician who charges $150, but our allowance is $100. If you have met your deductible, you are only responsible for your coinsurance. That is, you pay just � 20% of our $100 allowance ($20). Because of the agreement, your network physician will not bill you for the $50 difference between our allowance and his bill.

Out-of-network providers, on the other hand, have no agreement to limit what they will bill you. When you use an out-of-network provider, you will pay your deductible and coinsurance � plus any difference between our allowance and charges on the bill. Here is an example: You see an out-of-network physician who charges $150 and our allowance is again $100. Because you've met your deductible, you are responsible for your coinsurance, so you pay 40% of our $100 allowance ($40). Plus, because there is no agreement between the out-of-network physician and us, he can bill you for the $50 difference between our allowance and his bill.

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

Physician's charge

$150

$150

Our allowance

We set it at: 100

We set it at: 100

We pay

80% of our allowance: 80

60% of our allowance: 60

You owe: Coinsurance

20% of our allowance: 20

40% of our allowance: 40

+Difference up to charge?

No: 0

Yes: 50

TOTAL YOU PAY

$20

$90

When Government facilities bill us

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

If we overpay you

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

I

M

P

O

R

T

A

N

T

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.

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

I

M

P

O

R

T

A

N

T

Professional services of physicians

In physician's office

In an urgent care center

Office medical consultations

Second surgical opinion

$10 per office visit

Tests, such as:

Blood tests

Urinalysis

Non-routine pap tests

Pathology

X-rays

Non-routine Mammograms

CAT Scans/MRI

Ultrasound

Electrocardiogram and EEG

Nothing if you receive these services during your office visit; otherwise, $10 per office visit

Routine screenings, such as:

Physicals

Total Blood Cholesterol

Colorectal Cancer Screening, including

- Fecal occult blood test

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

$10 per office visit

Routine Prostate Specific Antigen (PSA) test

$10 per office visit

Routine pap test

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

$10 per office visit

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

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

From age 40 through 64, one every calendar year

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

Nothing

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

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

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)

$10 per office visit

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.

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

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

We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5.1c) and Surgery benefits (Section 5.1b).

Nothing

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 5.1b)

Surgically implanted contraceptives

Injectable contraceptive drugs (such as Depo provera)

Intrauterine devices (IUDs)

Diaphragms

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

$10 per office visit

Not covered:

Reversal of voluntary surgical sterilization

Genetic counseling.

Elective abortion

All charges.

Diagnosis and treatment of infertility such as:

Artificial insemination:

- intravaginal insemination (IVI)

- intracervical insemination (ICI)

- intrauterine insemination (IUI)

Fertility drugs

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

$10 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

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 30

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. Call 1-800-344-8858 for preauthorization. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment; otherwise, we will only cover GHT services from the date you submit the information. If you do not ask or if we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3.

$10 per office visit

60 visits per conditionfor the services of 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.

$10 per outpatient visit

Nothing per visit during covered inpatient admission.

Not covered:

Long-term rehabilitative therapy

Exercise programs

All charges.

Speech therapy

60 visits per condition for the services of speech therapists.

$10 per office visit

First hearing aid and testing only when necessitated by accidental injury

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

$10 per office visit

Not covered:

All other hearing testing

Hearing aids, testing and examinations for them

All charges.

In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye, annual eye refractions (to provide a written lens prescription) may be obtained from Plan providers.

$10 per office visit

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

$10 per office visit

Eye exam to determine the need for vision correction for children and adults

Coverage includes:

one complete refractory eye examination by a Plan provider every 24 months; and

one set of prescribed frames with a $55 maximum Plan payment; or

one set of single vision lenses with a $35 maximum Plan payment; or

one set of bi-focal lenses with a $55 maximum Plan payment; or

one set of tri-focal lenses with a $150 maximum Plan payment; or

one set of prescribed contact lenses with a $150 maximum Plan payment

$10 per office visit

All charges over the maximum Plan payments

Not covered:

Eye exams from an optometrist

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.

$10 per office visit

Not covered:

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

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

All charges.

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: Internal prosthetic devices are paid as hospital benefits; see Section 5.1(c) for payment information. Insertion of the device is paid as surgery; see Section 5.1(b) for coverage of the surgery to insert the device.

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

Nothing

Not covered:

Orthopedic and corrective shoes

Arch supports

Heel pads and heel cups

Lumbosacral supports

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

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;

Wheel Chairs;

Crutches;

Walkers;

Blood glucose monitors; and

Insulin pumps.

Note: Call us at 1-800-344-8858 as soon as your Plan physician prescribes this equipment. We will arrange with a health care provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

Nothing

Not covered: Motorized wheelchairs.

All charges.

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

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

$10 per office visit

Not covered:

Maintenance care

All charges.

No Benefit

All charges.

I

M

P

O

R

T

A

N

T

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.

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 5.1(c) for charges associated with the facility (i.e. hospital, surgical center, etc.).

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

I

M

P

O

R

T

A

N

T

A comprehensive range of services, such as:

Operative procedures

Treatment of fractures, including casting

Normal pre- and post-operative care by the surgeon

Correction of amblyopia and strabismus

Endoscopy procedures

Biopsy procedures

Removal of tumors and cysts

Correction of congenital anomalies (see Reconstructive surgery)

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

Insertion of internal prosthetic devices. See Section 5.1(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.

$10 per office visit; nothing for hospital visits

Not covered:

Reversal of voluntary sterilization

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 Orthopedic 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.

$10 per office visit; nothing for hospital visits

Not covered:

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

Surgeries related to sex transformation

All charges.

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

TMJ treatment and services(non-dental); and

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

$10 per office visit; nothing for hospital visits

Not covered:

Oral implants and transplants

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

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 coordinate insurance related medical and hospital expenses of the donor when we cover the recipient.

Nothing

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)

Hospital Outpatient Department

Skilled Nursing facility

Ambulatory surgical center

Office

Nothing

I

M

P

O

R

T

A

N

T

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.

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 5.1(a) or (b).

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

I

M

P

O

R

T

A

N

T

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 semi-private room rate.

Nothing

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

Nothing

Not covered:

Custodial care

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

Private nursing care

All charges.

Operating, recovery, and other treatment rooms

Prescribed drugs and medicines

Diagnostic laboratory tests, X-rays, and pathology services

Administration of blood, blood plasma, and other biologicals

Blood and blood plasma, if not donated or replaced

Pre-surgical testing

Dressings, casts, and sterile tray services

Medical supplies, including oxygen

Anesthetics and anesthesia service

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

Nothing

Not covered:

Blood and blood derivatives not replaced by the member

All charges.

Extended care benefit:

The Plan provides a comprehensive range of benefits, with no day or dollar limit when 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

Not covered:

Custodial care

Rest Cures

Domiciliary

Convalescent care

All charges.

Supportive and palliative care

Inpatient and outpatient care

Family counseling

Note: limited to life expectancy of six (6) months or less

Nothing

Not covered:

Independent nursing, homemaker services

All charges.

Local professional ambulance service when medically appropriate

Nothing

I

M

P

O

R

T

A

N

T

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

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

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

I

M

P

O

R

T

A

N

T

What is a medical emergency?

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

What to do in case of emergency:

If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (e.g., the 911 telephone system) or go to the nearest hospital emergency room. 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 unless it is 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, the Plan must be notified within 48 hours or on the first working day following your admission, unless it is 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.

Emergency care at a doctor's office

Emergency care at an urgent care center

Emergency care as an outpatient at a hospital, including doctor's services

Nothing

Not covered:

Elective care or non-emergency care

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

All charges.

Professional ambulance service when medically appropriate.

Note: See 5.1(c) for non-emergency service.

Nothing

I

M

P

O

R

T

A

N

T

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

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

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

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

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

I

M

P

O

R

T

A

N

T

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

$10 per office visit

Diagnostic tests

$10 per office visit; nothing if you receive these services during your office visit; otherwise,

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

Nothing

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:

All non-AultCare admissions, partial hospitalizations programs and intensive out-patient programs require preauthorization. For preauthorization, call 1-800-344-8858.

I

M

P

O

R

T

A

N

T

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.

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.

Certain drugs require prior authorization where your physician will submit a letter of medical necessity. For a list of these drugs, call 1-800-344-8858.

I

M

P

O

R

T

A

N

T

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 may fill the prescription at a retail pharmacy. We pay a higher level of benefits when you use a network pharmacy.

We use a formulary. Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary, a set or list of medications indicating a preferred status. If your physician believes a name brand drug is necessary, or there is no generic available, your physician may prescribe a name brand drug from the Plan's formulary list. The Plan's formulary does not exclude medications from coverage, but requires a higher copayment for non-formulary drugs.

We have an open formulary. 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 1-800-344-8858.

These are the dispensing limitations. Prescriptions are filled up to a 34 day supply per copay. Maintenance drugs are dispensed up to a 90 day supply for one copay at retail.

During a National emergency or call to active military duty requiring an extended supply of prescription drugs,

call 1-800-344-8858.

Why use generic drugs? Generic drugs contain the same active ingredients and are equivalent in strength and dosage to the original brand name product. Generic drugs cost you and your plan less money than a brand name drug. The U.S. Food and Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the same standards of quality and strength as brand name drugs. You can save money by using generic drugs. However, you and your physician have the option to request a brand name if a generic option is available. Using the most cost-effective medication saves money.

We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy.

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; a copayment applies to each 34 day supply

Disposable needles and syringes for the administration of covered medications

Drugs for sexual dysfunction (see Section 3, prior approval)

Contraceptive drugs

Diabetic supplies, including insulin syringes, needles, glucose test tablets and test tape, Benedict's solution or equivalent, and acetone test tables.

Intravenous fluids and medication for home use are covered under Medical and Surgical Benefits

Smoking cessation drugs up to an annual $200 maximum per member

Growth hormone

$10 copayment for a generic drug

$20 copayment for a brand name drug on the Plan's formulary

$35 copayment for a brand name drug not on the Plan's formulary.

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

Not covered:

Drugs and supplies for cosmetic purposes

Drugs to enhance athletic performance

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

Nonprescription medicines

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

Medical supplies such as dressings and antiseptics

All charges.

Feature

Description

Aultman Healthline

For any of your health concerns, 7 days a week, you may call 1-800-393-9337 and talk with a registered nurse who will discuss treatment options and answer your health questions.

I Can Cope

Weekly cancer education sessions are presented by doctors, nurses and other professionals. The sessions are held by the Aultman Cancer Center and co-sponsored by the American Cancer Society. For information/registration, you may call 330-438-6290. Free parking is available.

Common Ground

A cancer support group for cancer patients and their caregivers. It's led by an Aultman oncology social worker. For information, call 330-438-6290. Free parking is available.

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.

Nothing

Preventive and Diagostic

Oral Exam (one per year)

Prophylaxis or cleaning (one per year)

Annual application of fluoride up to age 12

Sealants

X-rays, including bite wings (limited to once per year) and panoramic (limited to once every 5 years)

Vitality test

Oral cancer exam

Study Models

Emergency treatment, limited to the relief of pain, bleeding, swelling or life threatening conditions

Diagnostic services

Basic Restorative

Restorative

Endodontics

Periodontics

Oral Surgery

Prosthodontics

Major Restorative

Full and partial dentures

Fixed bridges

Crowns

Inlays

30% of allowable charges

Not Covered:

other dental services not shown as covered

All Charges

Summary

Thehigh-deductible health plan option is new the FEHB program. It provides comprehensive coverage for high-cost medical events and a tax-advantaged way to help you build savings for future medical expenses.  The Plan gives you greater control over how you use your health care benefits.

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

With this Plan, preventive care is covered in full up to the Plan maximums per person per year.  As you receive other non-preventive medical care, you must meet the Plan's deductible before we pay benefits according to the benefits outlined in this brochure.  You can choose to use funds available in your HSA to make payments toward the deductible or you can pay toward your deductible entirely out-of-pocket, allowing your savings to continue to grow.

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

In-network preventive care

The Plan covers preventive care services, such as periodic health evaluations (e.g., annual physicals), screening services (e.g., mammograms), routine prenatal and well-child care, child and adult immunizations. These services are fully described in section 5.2(a) You do not have to meet the deductible before using these services.

Traditional in-network medical care

After you have paid the Plan's deductible, we pay benefits under traditional in-network coverage described in Section 5.2(b).  The Plan typically pays 80% for in-network and 60% for out-of-network care.

Covered services include:

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

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

Hospital services; other facility or ambulance services

Emergency services/accidents

Mental health and substance abuse benefits

Prescription drug benefits

Savings

Health Savings Accounts or Health Reimbursement Arrangements provide a means to help you pay out-of-pocket expenses (see Section 5.2(c) for more details).

HSA

By law, HSAs are available to members who are not enrolled in Medicare or do not have other health insurance coverage.  In 2005, for each month you are eligible for an HSA premium pass through, we will contribute to your HSA $83.33 per month for a Self-Only enrollment or $166.66 per month for a Self and Family enrollment.   In addition to our monthly contribution, you have the option to make additional tax-free contributions to your HSA, so long as total contributions do not exceed the limit established by law, which is an annual $2,000 for a self only and $4,000 for a self and family.  See maximum contribution information in Section 5.2(c). You can use funds in your HSA to help pay your health plan deductible. and qualified medical expenses.

Federal tax tip: There are tax advantages to fully funding your HSA as quickly as possible. Your HSA contribution payments are fully deductible on your Federal tax return. By fully funding your HSA early in the year, you have the flexibility of paying medical expenses from tax-free HSA dollars or after tax out-of-pocket dollars. If you don't deplete your HSA and you allow the contributions and the tax-free interest to accumulate, your HSA grows more quickly for future expenses.

HSA features include:

Your HSA is administered by First HSA.

Your contributions to the HSA are tax deductible

Your HSA earns tax-free interest

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

Your unused HSA funds and interest accumulate from year to year

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

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

Important consideration if you want to participate in a Health Care Flexible Spending Account: If you are enrolled in this HDHP with a Health Savings Account (HSA), you are not able to participate in an FSAFEDS Health Care Flexible Spending Account (HCFSA). See the Federal Flexible Spending Account Program�FSAFEDS in Section 12.

HRA

For members who aren't eligible for an HSA and enrolled in Medicare or have another health plan, we will administer and provide an HRA.   

In 2005, we will give you an HRA credit of $1,000 per year for a Self-Only enrollment and $2,000for a Self and Family enrollment.  You can use funds in your HRA to help pay your health plan deductible and/or for certain expenses that don't count toward the deductible. 

HRA features include:

For our HDHP option, the HRA is administered by AultCare Health Plan.

Entire HRA credit (prorated from your effective date to the end of the plan year) is available from your effective date of enrollment

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

Unused credits carryover from year to year

HRA credit does not earn interest

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

An HRA does not affect your ability to participate in an FSAFEDS Health Care Flexible Spending Account (HCFSA). However, you must meet FSAFEDS eligibility requirements. See Who is eligible to enroll? in Section 12 under The Federal Flexible Spending Account Program--FSAFEDS.

Catastrophic protection for out-of-pocket expenses

When you use network providers, your annual maximum for out-of-pocket expenses (deductibles and coinsurance) for covered services is limited to $4,000 per person or $8,000 per family enrollment. However, certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses once you reach your out-of-pocket maximum (such as expenses in excess of the Plan's allowable amount or benefit maximum). Refer to Section 4 Your catastrophic protection out-of-pocket maximum, Section 5.2(a) Traditional medical coverage subject to the deductible, and Section 5.2(d) Catastrophic protection for out-of-pocket expenses for more details.

Health education resources and account management tools

Section 5.2(e) describes the health education resources and account management tools available to you to help you manage your health care and your health care dollars.  

I

M

P

O

R

T

A

N

T

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

The Plan pays 100% for the preventive care services listed in this Section (up to Plan maximums) as long as you use a network provider.

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

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.

I

M

P

O

R

T

A

N

T

Professional services, such as:

Routine Physicals/Routine Gynecological/Prostate

Note: limited to a combined $200 per calendar year.

Routine PAP

Routine Mammograms

Note: limited to $85 per calendar year.

Routine Immunizations

Routine Prenatal care

In network: 100% over plan allowance.

Out-of-network: 50% of the plan allowance and any difference between our allowance and the billed amount.

Not covered:

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

Immunizations, boosters, and medications for travel.

All charges.

Professional services, such as:

Well-child visits for routine examinations, immunizations and care up to 12 months then physical exam.

Childhood immunizations recommended by the American Academy of Pediatrics

Eye exam to determine the need for vision correction for children through age 17.

Note: See Vision services

In-network: Nothing

Out-of-network: 50% of any difference between our allowance and the billed amount.

Not covered:

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

Immunizations, boosters, and medications for travel.

All charges.

I

M

P

O

R

T

A

N

T

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

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

In-network preventive care is covered at 100% of plan allowance under Section 5.2 (a) and is not subject to the calendar year deductible.

The deductible is $2,000 per person or $4,000 per family enrollment. The family deductible can be satisfied by one or more family members. The deductible applies to almost all benefits in Section 5.2. You must pay your deductible before your Traditional Medical Coverage may begin.

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

When you use network providers, you are protected by an annual catastrophic maximum on out-of-pocket expenses for covered services. After your coinsurance and deductibles total $4,000 per person or $8,000 per family enrollment in any calendar year, you do not have to pay any more for covered services from network providers. However, certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses once you reach your out-of-pocket maximum (such as expenses in excess of the Plan's benefit maximum, or if you use out-of-network providers, amounts in excess of the Plan allowance).

In-network benefits apply only when you use a network provider. When a network provider is not available, out-of-network benefits apply.

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

I

M

P

O

R

T

A

N

T

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

100% of allowable charges until you meet the deductible of $2,000 per person or $4,000 per family enrollment.

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

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

Out-of-network: After you meet the deductible, you pay the indicated coinsurance based on our Plan allowance and any difference between our allowance and the billed amount.

Professional services of physicians

In physician's office

In an urgent care center for routine services

During a hospital stay

In a skilled nursing facility

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Tests, such as:

Blood tests

Urinalysis

Non-routine pap tests

Pathology

X-rays

Non-routine Mammograms

CAT Scans/MRI

Ultrasound

Electrocardiogram and EEG

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Complete maternity (obstetrical) care, such as:

Prenatal care (covered under Section 5.2(a) Preventive care)

Delivery

Postnatal care

Note: Here are some things to keep in mind:

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

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

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

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

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Note: Prenatal care is covered under Preventive Care (not subject to the deductible)

A range of voluntary family planning services, limited to:

Voluntary sterilization (See Surgical procedures Section 5.2)

Surgically implanted contraceptives

Injectable contraceptive drugs (such as Depo provera)

Intrauterine devices (IUDs)

Diaphragms

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

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Reversal of voluntary surgical sterilization .

Elective abortion

All charges.

Diagnosis and treatment of infertility such as:

Artificial insemination:

� intravaginal insemination (IVI)

� intracervical insemination (ICI)

� intrauterine insemination (IUI)

Fertility drugs

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

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

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

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Allergy Serum

In-network: Nothing

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

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 56.

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 medical plan.

Note: � We only cover GHT when we preauthorize the treatment. Call 330-438-6360 for preauthorization. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment; otherwise, we will only cover GHT services from the date you submit the information. If you do not ask or if we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3.

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

60 visits per conditionfor the services of 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.

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Long-term rehabilitative therapy

Exercise programs

All charges.

60 visits per condition for the services of speech therapists.

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

First hearing aid and testing only when necessitated by accidental injury

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

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

All other hearing testing

Hearing aids, testing and examinations for them

All charges.

Vision services (testing, treatment, and supplies)

Eye exam to determine the need for vision correction for children through age 17

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

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered services over age 17:

Eye exams from an optometrist

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.

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

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: Internal prosthetic devices are paid as hospital benefits; see Section 5.2(c) for payment information. Insertion of the device is paid as surgery; see Section 5.2(b) for coverage of the surgery to insert the device.

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

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

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

All charges.

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

Hospital beds;

Wheelchairs;

Crutches;

Walkers;

Blood glucose monitors; and

Insulin pumps.

Note: Call us at 1-800-344-8858 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.

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Motorized wheelchairs.

All charges.

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

Services include oxygen therapy, intravenous therapy and medications.

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

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

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

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Maintenance care

All charges.

No Benefit:

All charges.

Educational classes and programs

Smoking Cessation � Up to $200 for one smoking cessation program per member per lifetime, including all related expenses such as drugs.

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

After the deductible , you pay

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

A comprehensive range of services, such as:

Operative procedures

Treatment of fractures, including casting

Normal pre- and post-operative care by the surgeon

Correction of amblyopia and strabismus

Endoscopy procedures

Biopsy procedures

Removal of tumors and cysts

Correction of congenital anomalies (see Reconstructive surgery)

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

Insertion of internal prosthetic devices. See section5.2(b) � 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.

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not Covered;

Reversal of voluntary sterilization

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.

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

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

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

TMJ treatment and services (non dental); and

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

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

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 coordinate insurance related medical and hospital expenses of the donor when we cover the recipient.

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

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)

Hospital (outpatient department)

Skilled nursing facility

Ambulatory surgical center

Office

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Inpatient hospital

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

YOUR PHYSICIAN MUST GET PRECERTIFICATION OF Non-Network inpatient admission, all home health Care, skilled nursing FACILITIES and home health care; FAILURE TO DO SO may RESULT IN A MINIMUM of 50% PENALTY up to $500. Please refer to the precertification information shown in Section 3 to be sure which services require precertification.

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.

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

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

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Custodial care

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

Private nursing care

All charges.

Operating, recovery, and other treatment rooms

Prescribed drugs and medicines

Diagnostic laboratory tests, X-rays, and pathology services

Administration of blood, blood plasma, and other biologicals

Blood and blood plasma, if not donated or replaced

Pre-surgical testing

Dressings, casts, and sterile tray services

Medical supplies, including oxygen

Anesthetics and anesthesia service

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

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Blood and blood derivatives not replaced by the member

All charges.

Extended care benefit:

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

Bed, board and general nursing care

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

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Custodial care

Rest Cures

Domiciliary

Convalescent care

All charges.

Supportive and palliative care

Inpatient and outpatient care

Family counseling

Note: limited to life expectancy of six (6) months or less

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Independent nursing, homemaker services

All charges.

Local professional ambulance service when medically appropriate

20% of the Plan allowance and any difference between our allowance and the billed amount

What is a medical emergency?

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

What to do in case of emergency:

If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (e.g., the 911 telephone system) or go to the nearest hospital emergency room. 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 unless it is 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, the Plan must be notified within 48 hours or on the first working day following your admission, unless it is 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.

Emergency care at a doctor's office

Emergency care at an urgent care center

Emergency care as an outpatient at a hospital, including doctor's services

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Elective care or non-emergency care

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

All charges.

Emergency care at a doctor's office

Emergency care at an urgent care center

Emergency care as an outpatient at a hospital, including doctor's services

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Elective care or non-emergency care

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

All charges.

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

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

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

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

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

Medication management

In-network: 20% of the Plan allowance.

Diagnostic tests

In-network: 20% of the Plan allowance

Services provided by a hospital or other facility

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

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

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

In-network: 20% of the Plan allowance

Not covered: Services we have not approved.

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

All charges.

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

All non-AultCare admissions, partial hospitalizations programs and intensive out-patient programs require preauthorization. For preauthorization, call 1-800-344-8858.

In-network limitation If you do not obtain an approved treatment plan, we will provide only Out-of-network benefits.

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

Medication management

Out-of-network: 40% of plan allowance up to 30 visits per calendar year; all charges after 30 visits per calendar year.:

Diagnostic tests

Out-of-network: 40% of the Plan allowance up to 30 visits per calendar year; all charges after 30 visits per calendar year.

Services provided by a hospital or other facility

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

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

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

Out-of-network: 40% of the Plan allowance up to 30 days per calendar year; all charges after 30 days per calendar year.

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.

Lifetime maximum Alcohol/Substance Abuse Inpatient Care and Outpatient Treatment Programs are limited to a lifetime maximum of $50,000 with the exception of a minimum annual $550 benefit for treatment of alcoholism.

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

All non-AultCare admissions, partial hospitalizations programs and intensive out-patient programs require preauthorization. For preauthorization, call 1-800-344-8858

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

Section 3, How you get care, for information about catastrophic protection for these benefits.

Section 7, Filing a claim for covered services, for information about submitting out-of-network claims.

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

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

Where you can obtain them. You may fill the prescription at a network pharmacy or out-of-network pharmacy. We pay a higher level of benefits when you use a network pharmacy.

These are the dispensing limitations. Prescriptions are filled up to a 34 day supply.

You pay 100% of the discounted amount at network pharmacies when you use your Prescription Identification card. Your claims are submitted to AultCare electronically and will be reimbursed at 80% after your in-network deductible is met. When purchasing prescriptions at an out-of-network pharmacy, you will not receive the discount. It will be necessary for you to submit those prescriptions to AultCare for reimbursement at 80% after your in-network deductible is met.

During a National emergency or call to active military duty requiring an extended supply of prescription drugs call

1-800-344-8858.

Why use generic drugs? Generic drugs contain the same active ingredients and are equivalent in strength and dosage to the original brand name product. Generic drugs cost you and your plan less money than a brand name drug. The U.S. Food and Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the same standards of quality and strength as brand name drugs. You can save money by using generic drugs. However, you and your physician have the option to request a brand name if a generic option is available. Using the most cost-effective medication saves money.

When you do have to file a claim. When you do not use your prescription drug card.

We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy.

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; a copayment applies to each 34 day supply

Disposable needles and syringes for the administration of covered medications

Drugs for sexual dysfunction (see Section 3, prior approval)

Contraceptive drugs and devices

Diabetic supplies, including insulin syringes, needles, glucose test tablets and test tape, Benedict's solution or equivalent, and acetone test tables.

Intravenous fluids and medication for home use are covered under Medical and Surgical Benefits

Smoking cessation drugs up to an annual $200 maximum per member

Growth hormone

Using Prescription card: 20% of discounted amount.

Not using Prescription drug card: 20% of plan allowance. No applicable discount.

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

Not covered:

Drugs and supplies for cosmetic purposes

Drugs to enhance athletic performance

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

Nonprescription medicines

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

Medical supplies such as dressings and antiseptics

All charges.

Aultman Healthline

For any of your health concerns, 7 days a week, you may call 1-800-393-9337 and talk with a registered nurse who will discuss treatment options and answer your health questions.

I Can Cope

Weekly cancer education sessions are presented by doctors, nurses and other professionals. The sessions are held by the Aultman Cancer Center and co-sponsored by the American Cancer Society. For information/registration, you may call 330-438-6290. Free parking is available.

Common Ground

A cancer support group for cancer patients and their caregivers. It's led by an Aultman oncology social worker. For information, call 330-438-6290. Free parking is available.

Feature Comparison

Health Savings Account (HSA)

Health Reimbursement Arrangement (HRA)

Provided when you are
ineligible for an HSA

Custodian

The Plan will establish an HSA for you with first HAS, this HDHP's custodian as defined by Federal tax code and approved by IRS.

First HSA, Inc.

1044 MacArthur Road

Reading ,PA19605

Phone(610)678-6000 or www.firsthsa.com

AultCare Health Plan is the HRA fiduciary for this Plan.

AultCare

2600 Sixth Street SW P.O. Box 6910

Canton, OH44706

1-800-344-8858 or www.aultcare.com

Fees

First HSA, Inc.

Set-up fee is paid by the HDHP.

No additional cost to the member.

AultCare Health Plan

None.

Eligibility

Enrolled in First HSA, Inc.

No other health insurance coverage (does not apply to specific injury, accident, disability, dental, vision or long-term care coverage)

Not eligible for Medicare Part A or Part B

Not claimed as a dependent on someone else's tax return

Complete and return all banking paperwork

Eligibility is determined on the first day of the month

AultCare Health Plan

Eligibility is determined on the first day of the month

Funding

Self Only coverage

Self and Family
coverage

$1,000.00 annual premium pass through by HDHP directly into account

$2,000.00 annual premium pass through by HDHP directly into account

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

$1,000 is the annual credit provided by the HDHP upon the effective date.

$2,000 is the annual credit provided by the HDHP upon the effective date.

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

Contributions/credits

Self Only coverage

Self and Family
coverage

For each month you are eligible for HSA contributions,

The HDHP will make a premium pass through of $1,000. You may make a maximum annual contribution of $1,000.

The HDHP will make a premium pass through of $2,000 Your annual maximum contribution cannot exceed $2,000.

If you choose to contribute to your HSA,

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

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

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

The maximum that can be contributed to your HRA is an annual combination of HDHP premium pass through and enrollee contribution funds, which when combined, do not exceed the amount of the deductible, which is $2,000 self and $4,000 self and family.

The full HRA credit will be available, subject to proration, on the effective date of enrollment. The HRA does not earn interest. You cannot contribute to the HRA.

The maximum dollar amount that may be credited to an HRA Account for an Employee who participates for an entire 12-month Period of Coverage is $1,000 Self coverage.

The maximum dollar amount that may be credited to an HRA Account for an Employee who participates for an entire 12-month Period of Coverage is $2,000 for Self and Family coverage.

Access funds

You can access your HSA by the following methods :

Debit card

Withdrawal form

Checks

For qualified medical expenses under your HDHP, you will be automatically reimbursed when claims are submitted through AultCare Health Plan. For expenses not covered by the HDHP, such as orthodontia, a reimbursement form will be sent to you.

Distributions/withdrawals

Medical

After meeting the deductible, pay the out-of-pocket expenses for yourself, your spouse or your dependents even if they are not covered by the HDHP from the funds available in your HSA.

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

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

See IRS Publication 502 for a complete list of eligible expenses.

After meeting the deductible, pay the out-of-pocket expenses for qualified medical expenses for individuals covered under the HDHP.

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

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

See IRS Publication 502 for a complete list of eligible expenses.

Non-medical

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

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

Not applicable � distributions will not be made for anything other than non-reimbursed qualified medical expenses

Availability of funds

Funds are not available until:

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

The HDHP receives record of your enrollment and initially establishes your HSA account with the fiduciary by providing information it must furnish and by contributing the minimum amount required to establish an HSA

The fiduciary sends out HSA paperwork for the enrollee to complete and the fiduciary receives the completed paperwork.

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

Funds are not available until:

The HRA account has been credited at the beginning of their period of coverage.

Account owner

FEHB enrollee

HDHP

Portable

Yes, you can take this account with you when you separate or retire.

If you retire and remain in this HDHP, you may continue to use and accumulate credits in your HRA.

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

Annual rollover

Yes, accumulates without a maximum cap.

Yes, accumulates without a maximum cap.

HSA

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

"Premium pass through" contributions by the HDHP are not considered taxable income.

Can I contribute to my HSA?

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

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

Catch-up contributions

If you are age 55 or older, the IRS permits you to make additional catch-up contributions to your HSA. In 2005, you may contribute up to $500 in "catch-up" contributions. Catch-up contributions in later years increase up to a maximum of $1,000 in 2009 and beyond. Contributions must stop once an individual is eligible for Medicare. Additional details are available on the IRS Web site at www.irs.gov.

Rate of interest earned

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

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

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

What happens to my HSA if I die?

Your HSA would pass to your surviving spouse or named beneficiary tax free. If you do not have a named beneficiary, the money is disbursed to your estate and is taxable.

What expenses can I pay for with my HSA?

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

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

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

Non-qualified health expenses

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

Tracking your HSA balance

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

Minimum reimbursements from your HSA

You can request reimbursement in any amount.

HRAs

How do I know if I qualify for an HRA?

If you don't qualify for an HSA when you enroll, or later become ineligible for an HSA, the HDHP will establish an HRA for you. If you are enrolled in Medicare you are ineligible for an HSA and your HDHP will establish an HRA for you.

HRA and HSA differences

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

you cannot make contributions to an HRA

HRA funds are forfeited if you leave the HDHP

an HRA does not earn interest, and

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

Health education resources

The Aultman Institute publishes a newsletter to keep you informed on a variety of issues related to your good health. Visit our Web site at www.aultman.com. Visit this Web site for information on:

General health topics

Links to health care news

Cancer and other specific diseases

Drugs/medication interactions

Kids' health

Patient safety information

and several helpful Web site links.

Account management tools

For each HSA and HRA account holder, we maintain a complete claims payment history online through www.aultcare.com.

Your balance will also be shown on your explanation of benefits (EOB) form.

You will receive an EOB after every claim.

If you have an HSA,

You will receive a monthly bank statement from first HSAoutlining your account balance and activity for the month.

You may also access your account on-line at www.firsthsa.com

If you have an HRA,

Your HRA balance will be available online through www.aultcare.com

Your balance will also be shown on your EOB form.

Consumer choice information

As a member of this HDHP, you may choose any provider. However, you will receive discounts when you see a network provider. Directories are available online at www.aultcare.com

Link to online pharmacy through www.aultcare.com

Care support

Patient safety information is available online at www.aultcare.com

Case Management: The goal of AultCare's Medical Case Management is managing the high cost of catastrophic illnesses while maintaining quality of care. Case management is used to describe a number of different approaches to planning, coordinating, providing and financing medical care. Case Management requires the simultaneous cooperation of AultCare, the Physician, the patient, and the patient's family. Telephonic follow up is provided to create and evaluate a goal oriented treatment plan. The focus of case management can include, but is not limited to, chronic disease states such as diabetes, COPD, or CHF, complex or catastrophic cases. Medical Case Management programs develop an individual plan designed to coordinate and mobilize health care resources to address specific medical problems and patient needs. The result should be a claim savings through effective medical management.

How to claim benefits

To obtain claim forms or other claims filing advice or answers about our benefits, contact us at 1-800-344-8858 or at www.aultcare.com

In most cases, providers and facilities file claims for you. Your physician must file on the form HCFA-1500, Health Insurance Claim Form. Your facility must file on the UB-92 form. For claims questions and assistance, call us at 1-800-344-8858.

When you must file a claim � such as for services you receive outside of 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; and

Receipts, if you paid for your services. Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills.

Submit your claims to:

AultCare Health Plan

2600 Sixth Street SW

Canton, Ohio 44710

Records

Keep a separate record of the medical expenses of each covered family member. Save copies of all medical bills, including those you accumulate to satisfy a deductible. In most instances they will serve as evidence of your claim. We will not provide duplicate or year-end statements

Deadline for filing your claim

Send us all 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.

Overseas claims

For covered services you receive in hospitals outside the United States and Puerto Rico and performed by physicians outside the United States, send a completed Claim Form and the itemized bills to: AultCare Health Plan, 2600 Sixth Street SW, Canton, Ohio 44710.

When we need more information

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

1

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

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

b) Send your request to us at: AultCare Health Plan, 2600 Sixth Street SW, Canton, Ohio 44710; 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 x, 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 enrolled in 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.

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 1-800-344-8858 or see our Web site at www.aultcare.com.

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 member are eligible for Medicare solely due to disability and you�

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

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

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

Medicare Advantage

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

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

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

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

TRICARE and CHAMPVA

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

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

Workers' Compensation

We do not cover services that:

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

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

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

Medicaid

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

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

When other Government agencies are responsible for your care

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

When others are responsible for injuries

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

If you do not seek damages you must agree to let us try. This is called subrogation. 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 15.

Copayment

A copayment is a fixed amount of money you pay when you receive covered services. See page 15.

Covered services

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

Custodial care

Care provided primarily for maintenance of the patient or which is designed essentially to assist the patient in meeting his activities of daily living and which is not primarily provided for its therapeutic value in the treatment of an illness, disease, bodily injury or condition.

Custodial care includes, but is not limited to, help in walking, bathing, dressing, feeding, preparation of special diets and supervision over self-administration of oral medications

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 15.

Experimental or investigational services

The Plan's Utilization Management team gathers information from various sources before making an independent evaluation to determine medical appropriateness and/or the experimental/investigational nature of new technology, i.e., the application of existing technology or new medical procedures, drugs, or devices. The Plan's decision is made in good faith, following a detailed factual background investigation of the claim and proposed service and interpretation of the Plan provisions. Sources the Plan may use include the Federal Drug Administration, Medicare guidelines, published scientific articles, and related medical society guidelines. If the plan decides that a service or supply is not medically appropriate and/or is experimental/investigational, that service or supply will not be eligible.

Group health coverage

Coverage provided by the Company for the Plan participant and dependants, if applicable.

Medical necessity

A service or supply given by a Provider that is required to diagnose or treat your condition, illness or injury and which we determine is:

Appropriate with regard to standards of good medical practice;

Not solely for the convenience of you or a provider;

The most appropriate supply or level or service which can be safely provided to you. When applied to the care of an Inpatient, this means that the services cannot be safely provided to you as an Outpatient.

Us/We

Us and We refer to AultCare Health Plan

You

You refers to the enrollee and each covered family member.

No pre-existing condition limitation

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

Where you can get information about enrolling in the FEHB Program

See www.opm.gov/insure/archive/health for enrollment as well as:

Information on the FEHB Program and plans available to you

A health plan comparison tool

A list of agencies who participate in Employee Express

A link to Employee Express

Information on and links to other electronic enrollment systems

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

When you may change your enrollment;

How you can cover your family members;

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

When your enrollment ends; and

When the next open season for enrollment begins.

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

Types of coverage available for you and your family

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

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

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

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

Children's Equity Act

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

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

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

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

If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self and Family in the Blue Cross and Blue Shield Service 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 your 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 as a dependent on your Federal Income Tax return (and who is mentally or physically incapable of self care).

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

Enroll during Open Season

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

Online: visit www.FSAFEDS.comand 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 of 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 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 15 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:

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.

Paperless Reimbursement �This plan participates in the FSAFEDS paperless reimbursement program. When you enroll for your HCFSA, you will have the opportunity to enroll for paperless reimbursement. If you do, we will send FSAFEDS the information they need to reimburse you for your out-of-pocket costs so you can avoid filing paper claims.

{Note to Plan: delete this section if you do not participate in paperless reimbursement.}

Dependent care expenses

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

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

Does it cost me anything to participate in FSAFEDS?

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

Contact us

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

E-mail: FSAFEDS@shps.net

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

TTY: 1-800-952-0450

It's important protection

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

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

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

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

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

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

To find out more and to request an application

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

Medical services provided physicians:

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

$10 per office visit

20

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

Nothing

31

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

Nothing

32

In-area..............................................................................................................

Nothing

33

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

Nothing

33

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

Regular cost sharing

34

Generic.............................................................................................................

$10 copayments

36

Brand name formulary...................................................................................

$20 copayments

Brand name non-formulary...........................................................................

$35 copayments

Accidental injury benefit�������������������

Nothing

38

Preventive dental care��������������������

30%

One exam every two years������������������

$10 per office visit

25

Eyewear�������������������������

Various payments

� Special features: Aultman Healthline, I Can Cope, Common Ground

37

Benefits

You Pay

Page

Medical services provided by physicians:

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

In-network: 20% of plan allowance

Out-of-network: 40% of our allowance plus amount over our allowance.

48

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

In-network:20% of plan allowance

57

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

Out-of-network: 40% of our allowance plus amount over our allowance.

58

Accidental injury....................................................................................

In-network: 20% of plan allowance

60

Medical emergency................................................................................

Out-of-network: 40% of our allowance plus amount over our allowance.

60

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

In-network: regular cost sharing.

Out-of-network: Benefits are limited

62

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

20% of plan allowance

64

Special features: Aultman Healthline, I Can Cope, Common Ground

66

Protection against catastrophic costs

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

In-network: Nothing after $2,000/Self Only or $4,000/Family enrollment per year.

Out-of-network: $8,000/Self only or $16,000/Family enrolment per year.

Some costs do not count toward this protection

73

Non-Postal Premium

Postal Premium

Biweekly

Monthly

Biweekly

Type of

Enrollment

Code

Gov't

Share

Your

Share

Gov't

Share

Your

Share

USPS

Share

Your

Share

Stark, Carroll, Holmes, Tuscarawas and Wayne counties and Canton metropolitan area in Ohio

High Option

Self Only

3A1

$121.10

$40.37

$262.39

$87.46

$143.30

$18.17

High Option

Self and Family

3A2

$297.29

$99.10

$644.14

$214.71

$351.80

$44.59

HDHP Option

Self Only

3A4

$126.40

$42.13

$273.86

$91.29

$149.57

$18.96

HDHP Option

Self and Family

3A5

$253.27

$84.42

$548.75

$182.91

$299.70

$37.99