CALL - THE HEALTH CARE FRAUD HOTLINE

202-418-3300

OR WRITE TO:

United States Office of Personnel Management

Office of the Inspector General Fraud Hotline

1900 E Street NW Room 6400

Washington, DC20415-1100

Identification cards

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 866-351-5946 or you may request replacement cards through the website at www.healthamerica.cvty.com.

Where you get covered care

You get care from "Plan providers" and "Plan facilities." You will only pay copayments 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 at www.healthamerica.cvty.com or you may call the plan for assistance.

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 at www.healthamerica.cvty.com.

What you must do to get covered care

It depends on the type of care you need. First, you and each family member must

choose a Primary Care Physician. This decision is important since your Primary

Care Physician provides or arranges for most of your health care. You can complete

a PCP Selection Card and mail it or you can call us.

Primary care

Your Primary Care Physician can be a family practitioner, internist or a pediatrician.

Your Primary Care Physician will provide most of your health care, or coordinate

your care to see a specialist.

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

Specialty care

Your primary care physician will refer you to a specialist for needed care. 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. You do not need a referral from your primary care physician to see a participating physician for maternity or gynecological care.

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 physician will work with us to develop a treatment plan that allows you to continue seeing your specialist. Your physician will use our criteria when creating your treatment plan. The participating network provider may have to get our prior approval for certain services.

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

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

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

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

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

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

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

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

Hospital care

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

If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at (866) 351-5946. If you are new to the FEHB Program, we will arrange for you to receive care.

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

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

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

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

These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such case, the hospitalized family member�s benefits under the new plan begin on the effective date of enrollment.

Circumstances beyond our control

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

Services requiring our prior approval

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

Inpatient hospital admissions

Extended Care/Skilled Nursing Facility

Outpatient surgeries

Home health care

Durable medical equipment

Out�of-network referral requests

Transplant requests

Complex diagnostic testing such as Magnetic Resonance Imaging,

Chiropractic care

Rehabilitative service

Infertility treatment

Oral surgery

Growth Hormone Therapy

Mental Health and Substance Abuse Treatment*

*You must contact ValueOptions before seeking mental health and substance abuse treatment. ValueOptions will help develop a treatment plan that you must follow. We will not cover services that ValueOptions has not approved.

Copayments

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

Example: When you see your primary care physician you pay a copayment of $15 per visit and when you see your specialist, you pay $25 per visit. If you go to the emergency room you pay $100 per visit.

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 them. The deductible amount for this plan is $1250 for self only coverage and $2500 for self and family coverage.

Traditional Medical Coverage - Your deductible must be satisfied before copayments occur.

Preventive Care Coverage - Your deductible does not apply for preventive care benefits as outlined in Section 5.1. However, you do have a copayment for covered preventive care services.

We do not pay for covered services that are subject to a deductible, until the deductible is met. You are responsible for paying your deductible. The deductible is a limit on the amount you must pay before you receive benefits. The Self and Family deductible must be satisfied by one family member or a combination of family members before we begin paying benefits.

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.

Coinsurance

Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance doesn�t begin until you meet your deductible.

Example: After you have satisfied the deductible, you pay $300 copay or 50% of the cost, whichever is less, for infertility services.

Your catastrophic protection out-of-pocket maximum

Self Only: Your annual out-of-pocket maximum is $4,000.

Self and Family: Your annual out-of-pocket maximum is $8,000.

Out-of-Pocket Maximum

The out-of -pocket maximum is the amount of out-of-pocket expenses that you will pay under a Self Only or a Self and Family coverage in a plan year. Out-of-pocket maximums apply on a calendar year basis only.

Expenses applicable to out-of-pocket maximums

Only the deductible and those out-of-pocket expenses resulting from the application of copayments may be used to satisfy the out-of-pocket maximums. We will not apply expenses you incur for non-covered services, expenses that exceed our maximum benefit limitations or allowable charges.

Once you have paid your deductible and satisfied your out-of-pocket maximum, we will cover eligible medical expenses at 100%. You no longer have copayments or coinsurance for covered services.

Differences between our allowance and the bill

You must use participating providersthat are part of our network. Our participating providers agree to accept our Plan allowance. When you use a network provider, your share of covered charges will only be your deductible, coinsurance and/or copayment. Our in network physicians will not bill you for any difference between the allowed amount and the total bill.

We will not cover services from non-participating provider unless we specifically authorize such care.

Summary

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

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 you do not qualify for an HSA, we will establish an HRA for you, and will credit your account each month for one-twelfth of the annual HRA allocation.  

With this Plan, we cover preventive care in full and you pay only your copay.  As you receive other non-preventive medical care, you must meet the Plan�s deductible before we pay benefits according to the benefit chart on page 17.  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.

Preventive care

You must use participating providers within our network. The Plan covers preventive care services, such as periodic health evaluations (e.g., annual physicals), screening services (e.g., mammograms), well-child care, and child and adult immunizations. We do not apply a deductible to these services. You only owe the copay as fully described in Section 5.1.  You do not have to meet the deductible before using these services.

Traditional medical care

You must use participating providers within our network. After you have paid the Plan�s deductible, we pay benefits under traditional medical care described in Section 5.2.  The Plan typically pays 100% for traditional medical care after you meet the deductible and you are only responsible for your copayment or coinsurance for covered services.  

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 5.3 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 $52.08per month for a Self-Only enrollment or $104.17 per month for a Self and Family enrollment.   In addition to our monthly contribution, you have the option to make additional tax-free contributions to your HSA, so long as total contributions do not exceed the limit established by law, which is $1,250 for Self Only enrollment and $2,500 for Self and Family enrollment. See maximum contribution information in Section 5.3. You can use funds in your HSA to help pay your health plan deductible, copayments, coinsurance,and other medical 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 Corporate Benefit Services of America (CBSA)

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 Flexible Spending Account Program � FSAFEDS in Section 12.

HRA

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

In 2005, we will give you an HRA credit of $625 per year for a Self-Only enrollment and $1,250 for a Self and Family enrollment.  You can use funds in your HRA to help pay your health plan deductible and/or for certain expenses that don�t count toward the deductible. 

HRA features include:

For our HDHP option, the HRA is administered by Corporate Benefits Services of America (CBSA)

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

Unused credits carryover from year to year

HRA credit does not earn interest

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

Catastrophic protection for out-of-pocket expenses

When you use network providers, your annual maximum for out-of-pocket expenses (deductibles, coinsurance and copayments) for covered services is limited to $4,000 for self only or $8,000 for Self and 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 out-of-network expenses or 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 Traditional medical coverage subject to the deductible, and Section 5.4Catastrophic protection for out-of-pocket expenses for more details.

Health education resources and account management tools

Section 5.5 describes the health education resources and account management tools available to you to help you manage your health care and your health care dollars.  

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

Preventive care services listed in this Section are not subject to the deductible. You only owe your copay for covered preventive care services.

You must use providers that are part of our network.

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.

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Professional services, such as:

Routine physical examinations

Routine screenings

Routine immunizations such as:

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

� Influenza vaccines, annually, age 50 and over at physicians discretion for those determined to be high risk.

� Pneumococcal vaccine, age 65 and over

Wellness programs

$15 per office visit to your Primary Care Physician or

$25 per office visit copay to a Specialist

Routine screenings, such as:

Blood test

Urinalysis

Nothing

Total Blood Cholesterol-once every three years

Colorectal Cancer Screening, including

� Fecal occult blood test

Nothing if you receive these services during yoru office visit; otherwise,

$15 per office visit to your Primary Care Physician or

$25 per office visit copay to a Specialist

� Sigmoidoscopy screening � every 5 years starting at age 50

Nothing

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

Nothing

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

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

� One per calendar year age 40 and above

Nothing

Routine pap test

$15 per office visit to your Primary Care Physician

$25 per office visit to a Specialist

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 ( through age 22)

Childhood immunizations recommended by the American Academy of Pediatrics

Examinations, such as:

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

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

$15 office visit copay for Primary Care Physician

$25 office visit copay for Specialist

Not covered:

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

Immunizations, boosters, and medications for travel.

All charges.

Annual eye refraction

All ages

$15 per office visit to a participating vision provider.

Not covered:

Eyeglasses or contact lenses

Eye exercises and orthoptics

Radial Keratotomy and other refractive surgery

All charges.

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Here are some important things you should keep in mind about your 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.

You must use providers that are part of our network.

Services described in this section are subject to the deductible. The deductible is $1,250 for self only or $2,500 for Self and 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 satisfy your deductible before we pay for Traditional Medical Coverage.

Preventive care services are not subject to the deductible. Please refer to Section 5.1 for information on preventive care services.

Under Traditional Medical Coverage, you are responsible for the copayment and/or coinsurance for a covered service after you satisfy the deductible.

You are protected by an annual catastrophic maximum on out-of-pocket expenses for covered services. After your coinsurance, copayments and deductibles total $4,000 for self or $8,000 for Self and 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. This plan does not include out of network coverage.

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

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You must satisfy your deductible before your Traditional Medical Coverage begins. The Self and Family deductible must be satisfied by one family member or a combination of family members. The deductible applies to almost all benefits in this Section. In the You pay column, we say "No deductible" when it does not apply. When you receive covered services from network providers, you are responsible for paying the allowable charges until you meet the deductible.

100% of allowable charges until you meet the deductible of $1,250 for self only or $2,500 for Self and Family enrollment. You may choose to pay deductible expenses from your HSA or HRA, or you can pay for them out-of-pocket.

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

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

Professional services of physicians

In physician�s office

Office medical consultations

Second surgical opinion

$15 per office visit to your Primary Care Physician

$25 per office visit to a Specialist

Professional services of physicians

In an urgent care center

During a hospital stay

In a skilled nursing facility

Nothing

At home

$15 per visit from your Primary Care Physician

$25 per visit from a Specialist

Tests, such as:

Blood tests

Urinalysis

Non-routine pap tests

Pathology

Non-routine mammograms

Nothing

X-rays

CT Scans/MRI

Ultrasound, (including prenatal ultrasound)

Electrocardiogram and EEG

$25 copay per visit

Not covered:

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

All charges.

Complete maternity (obstetrical) care, such as:

Prenatal care

Delivery

Postnatal care

Note: Here are some things to keep in mind:

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.

We cover routine nursery care of the newborn child during the covered portion of the mother�s maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment.

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

$15 per office visit to your Primary Care Physician

$25 per office visit to a Specialist

Note: You pay the office visit copay for your first visit only. We waive the office visit copay after your initial maternity care visit.

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

All charges.

A broad range of voluntary family planning services, limited to:

Surgically implanted contraceptives

Injectable contraceptive drugs

Intrauterine devices (IUDs)

Diaphragm fitting

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

$15 per office visit to your Primary Care Physician

$25 per office visit to a Specialist

Voluntary Sterilization

$50 per vasectomy

$100 per tubal ligation

Not covered: reversal of voluntary surgical sterilization and genetic counseling

All charges.

Diagnosis and treatment of infertility such as:

Artificial insemination:

� intravaginal insemination (IVI)

� intracervical insemination (ICI)

� intrauterine insemination (IUI)gs

$300 copay or 50% of the cost of the service, whichever is less

Not covered:

Fertility Drugs

Assisted reproductive technology (ART) procedures, such as:

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

� In vitro fertilization

Services and supplies related to excluded ART procedures

Cost of donor sperm

Cost of donor egg

All charges.

Testing and treatment

$15 per office visit to your Primary Care Physician

$25 per office visit to a Specialist

Allergy injection

Allergy serum

Nothing

Not covered: provocative food testing and sublingual allergy desensitization

All charges.

Treatment therapies

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 XX.

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 will only cover GHT when we preauthorize the treatment and determine that it is medically necessary. Your doctor will need to submit medical information to support that GHT is medically necessary. You must obtain authorization for GHT before you begin treatment because we only cover GHT services from the date we determine it is medically necessary. We do not cover GHT or related services and supplies if we determine it isn�t medically necessary. See Services requiring our prior approval in Section 3.

$15 per office visit to your Primary Care Physician

$25 per office visit to a Specialist

Up to two consecutive months per condition for 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 and if significant improvement can be expected within two consecutive months.

Cardiac rehabilitation is limited to treatment for therapy conditions that in the judgement of a participating physician and the Medical Director are subject to significant improvement through short-term therapy. We only cover one course of cardiac rehabilitation treatment per episode.

$15 per visit from your Primary Care Physician or

$25 per visit from a Specialist

Nothing per visit if the services are provided by a participating physical therapist

Nothing per visit during a covered inpatient hospital admission.

Not covered:

long-term rehabilitative therapy or rehabilitative therapy beyond two consecutive months per condition

Exercise programs

All charges.

Up to two consecutive months per condition for the services provided by a qualified speech therapist

$15 per office visit to your Primary Care Physician

$25 per office visit to a Specialist

Hearing testing (one per contract year)

$15 per office visit to your Primary Care Physician

$25 per office visit to a Specialist

Not covered:

All other hearing testing

Hearing aids, testing and examinations for them

All charges.

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

Nothing

Not covered:

Contact lenses

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 the "Not Covered" section under Orthopedic and prosthetic devices for information on podiatric shoe inserts.

$15 per office visit to your Primary Care Physician

$25 per office visit to a Specialist

Not covered:

Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and smilar 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

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

Internal prosthetic devices, such as artificial joints, limbs, pacemakers, and surgically implanted breast implant following mastectomy, when authorized in accordance with the plan�s policies and procedures. Note: See 5(b) for coverage of the surgery to insert the device.

Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome when rheumatoid arthritis, ankylosing spondylitis, or disseminated lupus erythmatosus.

Note: You must receive our preauthorization. Call us at (866) 351-5946 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:

Orthopedic and corrective shoes

Arch supports

Foot orthotics (except for diabetics)

Heel pads and heel cups

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

Cochlear implant devices

Replacement due to neglect

Any dental care involved with the treatment of tempormandibular joint (TMJ) pain dysfunction syndrome or joint disorders

Dental prosthesis

Lumbar supports

Wigs

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; base model necessary to cover your needs

crutches;

walkers;

Diabetes equipment such as blood glucose monitors, insulin infusion devices and orthotics

Note: You must receive our preauthorization. Call us at (866) 351-5946 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:

Disposable items such as incontinent pads, catheters, irrigation kits, electrodes, ace bandages, elastic stockings and dressings

Equipment which serves for comfort or convenience functions or is primarily for the convenience of a person caring for a member

Air conditioners

Corrective appliances that do not require prescription specifications or are used primarily for recreational sports

Humidifiers

Electric air cleaners

Exercise or fitness equipment

Elevators

Hot tubs

Hoyer lifts

Shower/bath bench

Routine servicing, e.g., testing, cleaning, regulating and checking of equipment

Special clothing of any type

Hearing devices of any type

Replacement due to neglect

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

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

Homemaker services

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

Services or supplies furnished by a person who is the spouse or relative of member or by non home health provider

All charges.

Medical Foods and Nutritional Therapy

Services for nutritional formulas as Medically Necessary for the therapeutic treatment of phenylketonuria, branched-chain ketonuria, galactosemia and homocystinuria as administered under the direction of a Participating Provider

Elemental Formula: Prior authorization is required. Covered services according to Plan guidelines for formulas made up of single amino acids and simple sugars and if the following requirements are met:

� You must require nutritional therapy to sustain life (that is, to meet 505 of your daily nutritional requirements) and adequate nutrition must not be possible with dietary adjustment and/ or oral supplements

� Your Physician must see you within thirty (30) days prior to initial Prior Authorization and any subsequent re-Authorization.

Nothing

Not covered:

Food or food supplements, vitamins or other nutritional and over-the �counter electrolyte supplements except as specified above.

All charges.

Chiropractic

Up to 15 visits per member per calendar year for

Manipulation of the spine and extremities or

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

$25 per office visit to a Specialist

Not covered: Visits that exceed 15 per calendar year

All charges.

Alternative Treatments

Biofeedback when approved in conjunction with an approved pain management program or for the treatment of urinary and or fecal incontinence

$15 per office visit to your Primary Care Physician

$25 per office visit to a Specialist

Not covered:

Naturopathic services

Acupuncture

Hypnotherapy

Biofeedback not shown as covered

All charges.

Educational classes and programs

Outpatient diabetes self-management training and education (including nutritional therapy) for persons with diabetes, when prescribed by a Plan Physician. Coverage includes:

visits medically necessary upon the diagnosis of diabetes;

visits where a Plan physician identifies and diagnoses a significant change in the patient�s symptoms or conditions that necessitates changes in a patient�s self-management; and

visits where a licensed physician identifies that a new medication or therapeutic process relating to the person�s treatment or diabetes management is medically necessary.

$15 per office visit to your Primary Care Physician

$25 per office visit to a Specialist

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

The deductible is $1,250 under Self Only and $2,500 under Self and Family. After you have satisfied the deductible, you traditional medical coverage begins.

You must use providers that are part of our participating provider network.

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 PRECERTIFICATION FOR SOME SURGICAL PROCEDURES. Please refer to the prior approval information in Section 3 to be sure which services require our prior approval.

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 or Body Mass Index (BMI) is greater than 40.

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

Treatment of Burns

Circumcisions for male newborns

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

Nothing

Voluntary sterilization

$50 copay for vasectomy and

$100 for tubal ligation

Not covered:

Reversal of voluntary sterilization

Routine treatment of conditions of the foot; see Foot care.

Cosmetic procedures

All charges.

Reconstructive surgery

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.

Nothing

Not covered:

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

Surgeries related to sex transformation

All charges.

Oral surgical procedures, limited to:

Reduction of fractures of the jaws or facial bones;

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

Removal of stones from salivary ducts;

Excision of leukoplakia or malignancies;

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

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

Excision of lesions of the mandible, mouth , lip, or tongue

Incision of accessory sinuses, mouth, salivary glands or duct;

Manipulation of dislocations of the jaw

Reconstruction or repair of the mouth or lips necessary to correct functional impairment caused by congenital condition and birth abnormalities;

Treatment of tumors

Extractions of impacted third molars when partially or totally covered by bone

Nothing

Not covered:

Oral implants and transplants

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

Orthodontia

Treatment of TMJ if dental related

Orthognathic or prognathic surgery when it is performed only to improve the appearance of a functioning structure

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

Note: Transplant services must be performed at a participating Center of Excellence. We approve and designate where all transplants must be performed including hospitals for specific transplant procedures. If you would like to know about a specific facility, please contact Member Services.

Note: We cover related medical and hospital expenses of the donor when the expenses are not covered by the donor�s insurance and when the transplant recipient is a HealthAmerica member approved for transplant services.

Nothing

Not covered:

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

Donor expenses related to donating organs or tissue to a non-member recipient

Implants of artificial organs

Experimental or investigational transplants

Transplants not listed as covered

All charges.

Professional services provided in �

Hospital (inpatient)

Hospital outpatient department

Skilled nursing facility

Ambulatory surgical center

Nothing

Professional services provided in �

Office

$15 per office visit to your Primary Care Physician

$25 per office visit to a Specialist

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

The deductible is $1,250 for Self Only enrollment and $2,500 for Self and Family enrollment. After you have satisfied your deductible, your Traditional Medical Coverage begins.

You must use providers that are part of our participating provider network.

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 10 about coordinating benefits with other coverage, including with Medicare.

YOUR NETWORK PHYSICIAN WILL PRECERTIFY YOUR HOSPITAL STAY. Please refer to the prior approval information in Section 3 to be sure which services require our prior approval.

Room and board, such as

Ward, semiprivate, or intensive care accommodations;

General nursing care; and

Meals and special diets.

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

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

Nothing

Not covered:

Custodial care

Non-covered facilities, such as nursing homes, schools

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

Private nurse 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

Packed red blood cells, cryoprecipitate, Factor VII, and platelets;

Other clotting factors or blood components such as Factor VIII or Factor IX, whether naturally or artificially derived are covered for acute traumatic events or when medically necessary.

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 by the member

All charges.

Skilled nursing facility (SNF) or Extended care benefits:

Up to 100 days per calendar year 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 us. Services include:

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 or convalescent care

All charges.

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

Nothing

Not covered: Independent nursing, homemaker services

All charges.

Local professional ambulance service when medically appropriate

Nothing

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 experience the sudden onset of a medical condition or injury with symptoms that you think may result in serious impairment, please go to the nearest emergency room or call 911. Otherwise if your symptoms allow, call your Primary Care Physician. Your primary care physician is available to advise you about an urgent or emergency situation 24 hours a day, seven days a week by phone. Your PCP�s phone number is on your ID card. Be sure to call your Primary Care Physician before going to a hospital emergency room or urgent care center whenever possible. If it is not possible, go straight to the nearest hospital emergency room or call 911 or the local emergency phone number. Be sure to tell the emergency room personnel that you are a HealthAmerica Plan member. Please be sure that you contact your PCP within 24 hours of being treated or admitted. Your PCP will make sure that:

Medical information about you is given to the hospital emergency room doctor;

Your care continues without delay; and

Your follow-up care is coordinated.

If you are outside the service area and a Plan doctor believes that your care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full. To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or provided by Plan providers.

Emergency care at a doctor�s office

$15 per office visit to your primary care physician or $25 per office visit to a specialist

Emergency care at an urgent care center or hospital

$75 per visit

Not covered:

Elective care or non-emergency care

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

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

All charges.

Professional ambulance, including air ambulance when medically appropriate.

Note: See 5.2(c) for non-emergency service.

Nothing

Not covered: non emergency services

All charges.

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

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

The deductible is $1,250 for Self Only enrollment and $2,500 for Self and Family enrollment. After you have satisfied your deductible, your Traditional Medical Coverage begins.

You must use providers that are part of our participating provider network. 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.

See Section 3, Services requiring our prior approval.

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.

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 psychiatrist, psychologists, or clinical social workers

Medication Management

Note: Psychiatrists, Psychologists, or Licensed Clinical Social Workers are specialty providers. The office visit copay for specialists applies to services from these providers.

$15 per office visit to your Primary Care Physician

$25 per office visit to a Specialist

Nothing for inpatient services

The following diagnostic tests:

Blood tests

Urinalysis

Pathology

$15 per office visit to your Primary Care Physician

$25 per office visit to a Specialist

Nothing for inpatient services

The following diagnostic tests including but not limited to:

X-rays

CT Scans

Ultrasound

Electrocardiogram

$25 per visit

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.

Evaluation or therapy on court order or as a condition of parole or probation, unless determined by a Plan doctor to be necessary and appropriate.

Testing for learning disabilities, school related issues, or for the purposes of obtaining or maintaining employment.

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:

ValueOptions, Inc. will coordinate your Mental Health and Substance Abuse services. If you need help, call your Primary Care Physician. Your doctor will work with Value Options to coordinate the care that you need. You may also call ValueOptions directly without referral from your Primary Care Physician.

If you need to seek mental health care services on an emergency basis, ValueOptions is available to you 24 hours a day, 7 days a week. Their normal business hours are from 8:00 am to 5:00 pm. You can reach ValueOptions toll free at (866) 834-1717, TDD (800) 334-1987.

We have a comprehensive network of professionals and facilities available for mental health and chemical dependency treatment. Please refer to the list of providers in the Mental Health/Chemical Dependency section of your Provider Directory. If you need a directory or assistance with finding a provider call (866) 351-5946

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

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.

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

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

Where you can obtain them. You may fill the prescription at a local Plan participating pharmacy or by mail at our participating mail-order pharmacy for a plan-approved maintenance medication. Our Plan pharmacies are listed in our directory.

We use a formulary. It is a list of approved medications. Our Prescription Drug Formulary is a list of drugs and other items that we approve for your use and which will be dispensed through participating pharmacies to members. We periodically review and modify our formulary. The list of approved drugs is available for review in the participating physician's office. You may also obtain them formulary list by contacting the Plan's Member Services Department or our website at www.healthamerica.cvty.com. We cover non-formulary drugs prescribed by a Plan doctor.

These are the dispensing limitations. You may obtain up to a 31-day supply or 100-unit supply; whichever is less, at a Plan Participating retail pharmacy. For commercially prepackaged drugs such as topicals, inhalers, and vials, you will pay one copay for each container. Selected products or prescription drugs may require prior approval from the Plan. These medications may include those that (1) are not suggested for first-line therapy (2) may require special tests before starting them (3) have very limited approval for use or (4) have specific quantity limits. Sexual dysfunction drugs have specific quantity limitations. When generic substitution is permissible, but you or your doctor choose the name brand drug over the generic drug, you pay the price difference between the generic drug and name brand drug as well as the appropriate copay per prescription unit or refill. Your prescription drug copay will never exceed the retail price of the drug. Plan members called to active military duty (or members in time of national crisis) who need to obtain prescribed medications should call us at 866-351-5946.

Prescriptions by Mail-Order. You can order up to a 3-month supply of approved maintenance medications through the mail and pay just two times the retail pharmacy copay. For commercially prepackaged drugs such as topicals, inhalers, and vials, you will pay one mail order copay for each three (3) containers. Maintenance medications are those that you must take for long-term conditions such as high blood pressure or high cholesterol. Simply ask your doctor to write your maintenance medication prescription for up to a 90-day supply. You will need to complete a mail order envelope (which you can obtain from Member Services) and mail it to the address on the front of the envelope. All maintenance medications are not available by mail-order. For a list of maintenance medications that you can obtain by mail, please contact us at (866) 351-5946.

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

When you have to file a claim. Prescription drugs prescribed for emergency services and filled by a Non-Participating pharmacy are covered only for a quantity sufficient to treat the acute phase of the illness/injury. Coverage for such prescription Drugs prescribed in relation to Emergency Services and provided by a Non-Participating pharmacy is limited to one hundred percent (100%) of the Reasonable and Customary Charge less applicable copayments and other appropriate charges as noted above such as when a brand drug is dispensed and an FDA approved generic is available. Members must submit claims for reimbursement of prescription drugs purchased from a Non-Participating pharmacy on a Direct Reimbursement Form (available from HealthAmerica�s Member Services Department). All claims for reimbursement must be received by HealthAmerica or its agent within ninety (90) days of the date of purchase of the prescription drugs. Claim forms are also available from our website (www.healthamerica.cvty.com) under the Downloadable Rx Forms Section.

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

Drugs and medicines that by Federal law of the United States require a physician�s prescription for their purchase, except those listed as Not Covered.

Full range of FDA approved contraceptives, including but not limited to oral, injectable or implantable contraceptives and contraceptive diaphragms

Insulin with a charge and copay for each vial

Plan approved diabetic supplies and pharmacological agents, or devices used to assist in insulin injection (injection aids) including insulin syringes and needles, blood glucose test strips and lancets

Self administered- injectable drugs- see note below.

Disposable needles and syringes for the administration of covered medications

Note: Self administered injectables include but are not limited to multiple sclerosis agents, colony stimulating factors, chronic medications for hepatitis C, rheumatoid medication, certain HIV drugs, osteoporosis agents, heparin products, etc. You cannot obtain a 90- day supply of these drugs and they are not available through our mail-order pharmacy. These agents require prior authorization and must be filled at our contracted or participating Specialty Pharmacy. This does not apply to Insulin, Glucagon, Bee Sting Kits (Antigen) and Imitrex.

Growth hormone therapy

Note: We will only cover GHT when we preauthorize the treatment and determine that it is medically necessary. Your doctor will need to submit medical information to support that GHT is medically necessary. You must obtain authorization for GHT before you begin treatment because we only cover GHT services from the date we determine it is medically necessary. See services requiring our prior approval in Section 3. You cannot obtain a 90- day supply of GHT and it is not available through our mail-order pharmacy.

Note: Please check section 5(a) when checking coverage for intravenous fluids and medications for home use, some injectable drugs, diabetic equipment (glucose monitor) and some FDA approved contraceptive devices.

At a Plan Retail Pharmacy:

$5 copay for generic formulary,

$35 copay for name brand formulary,

$50 copay non-formulary

or

Through our Mail Order Pharmacy:

$10 copay for generic,

$70 copay brand,

$100 copay for non-formulary

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

Note: For commercial containers through mail order, you pay the appropriate copay for each (3) containers.

Drugs for sexual dysfunction are subject to dose or quantity limitations. If it comes in pill form the limit is 4 pills per month, or 6 units per month for injectables or suppositories. Call the Plan for specific dose limitations.

Note: These drugs are not available by mail-order

$50 copay non-formulary

Not covered:

Drugs and supplies for cosmetic purposes

Drugs to enhance athletic performance

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

Vitamins, and minerals (both OTC and legend), except legend prenatal vitamins and liquid or chewable legend pediatric vitamins

Supplies such as dressings and antiseptics

Drugs to aid in smoking cessation

Drugs used for the primary purpose of treating infertility, including those given in connection with artificial insemination

Oral dental preparations and fluoride rinses

Drug therapy for weight loss (e.g. Xenical)

Nonprescription medicines

Drugs for investigational and experimental purposes

Food or food supplements, other nutritional and over-the-counter electrolyte supplements.

All charges.

Flexible benefits option

Under the flexible benefits option, we determine the most effective way to provide services. We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative benefit. Alternative benefits are subject to our ongoing review. By approving an alternative benefit, we cannot guarantee you will get it in the future. The decision to offer an alternative benefit is solely ours, and we may withdraw it at any time and resume regular contract benefits. Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.

Services for deaf and hearing impaired

Telecommunications Device for the Deaf and hearing impaired members who have access to a TDD-Compatible telephone. Members call (800) 207-1262 from 7am-6pm Monday-Friday or from 9 am �1pm on Saturday.

Complex Case Management

Complex Case Management programs promote quality of care to reduce the likelihood of extended, more costly health care. Our specially trained nurse case managers work directly with the patients and their doctors. Some of the programs include Cardiovascular, Endocrinology, Oncology, Trauma/Medical-Surgical

High risk pregnancies

This program is set up to identify women at risk for developing complications that may affect their pregnancy. The program promotes quality of care to reduce the likelihood of extended, more costly health care and focus on patients at risk, early intervention, coordination of care between patient and health care team, continuing education and regular follow up to ensure the patient is following the plan of care properly. For more information call (866) 351-5946

Centers of excellence

HealthAmerica has a nationally recognized organ transplant network through Coventry�s Transplant Centers of Excellence to coordinate care for members who may need a transplant. The network provides you and your family with access to the hospitals across the country, which specialize in specific transplant procedures. For information and access to these Centers of Excellence call Member Services. Care provided outside the Centers of Excellence network will not be covered unless approved by the Plan.

Student out of area benefits

Limited coverage is available to dependent students up to the age of 22 who:

are the dependents of Federal Government subscribers who live in the HealthAmerica service area.

attend a secondary school, college, university or licensed trade school full time; and

temporarily live outside Pennsylvania, but in the USA for the purpose of attending school;

This limited benefit provides coverage outside Pennsylvania at non-participating providers for the treatment of an unexpected illness or injury. Covered benefits include such things as: emergency care, physician services for illness and injury, outpatient rehabilitation, diabetic education and training, therapeutic injections, dialysis lab, radiology, durable medical equipment and corrective appliances, allergy serum and services, initial doctor visit to diagnose a pregnancy. Some benefits require authorization.

Benefits Not Covered: Any benefit not listed above as a covered benefit; any benefit no considered to be medically necessary; elective care service. Additionally, mental health and substance abuse services must be provided by a participating provider. When in the HealthAmerica service area, students must use participating providers. Dependent student coverage is subject to the Exclusions and Limitations as outlined in this brochure. If you have questions please contact the plan at 1-866-351-5946.

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. We will only cover services that you receive within 24 hours of the accident.

Note: We do not cover services rendered more than 24 hours after the accidental injury whether or not the treatment is a continuation or completion of a treatment plan initiated at time of injury.

Nothing:

Not covered:

Services provided after the initial 24 hours post

Orthodontia and all other dental related services

Services provided by non-participating dentists

Other dental services shown as not covered.

All Charges

We have no other dental benefits.

All charges

Administrator

The Plan will establish an HSA for you with Corporate Benefits Services of America (CBSA), this HDHP�s fiduciary (an administrator, trustee or custodian as defined by Federal tax code and approved by IRS.)

HSA Administrator:

Corporate Benefit Services of America (CBSA)

P.O. Box 270520

Golden Valley, MN 55427

Phone 800-566-9311 or 800-260-6627

Web site:

http://services.cbsainc.com/eehome.asp

Fiduciary (Corporate Office)

Wells Fargo Bank, NA

420 Montgomery Avenue

San Francisco, CA 94104

The Plan will establish an HRA with Corporate Benefits Services of America when you are ineligible for an HSA and enroll in this HDHP.

HRA Administrator:

Corporate Benefit Services of America (CBSA)

P.O. Box 270520

Golden Valley, MN 55427

Phone 800-566-9311 or 800-260-6627

Web site:

http://services.cbsainc.com/eehome.asp

Fees

None

None.

Eligibility

You must be enrolled in HealthAmerica�s High Deductible Health Plan.

You must have no other health insurance coverage (does not apply to specific injury, accident, disability, dental, vision or long-term care coverage).

You must not be enrolled in Medicare Part A or Part B.

You must not be claimed as a dependent on someone else�s tax return.

You must complete and return all banking paperwork.

Eligibility is determined on the first day of the month

You must be enrolled in HealthAmerica�s High Deductible Health Plan.

Your eligibility is determined on the first day of the month.

You are not eligible to have an HSA.

You must complete and return all paperwork

Funding

Self Only coverage

$52.08 monthly contribution from premium

$625.00 annual premium pass through by HDHP directly into account

$52.08 monthly credit

$625.00 annual credit provided by the HDHP upon effective date

Self and Family
coverage

$104.17 monthly contribution from premium

$1,250.00 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.

$104.17 monthly credit

$1,250.00annual credit provided by the HDHP upon 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

The maximum that can be contributed to your HSA 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 $1,250 Self Only and $2,500 Self and Family.

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).

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

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

Self Only coverage

For each month you are eligible for HSA contributions,

The HDHP will make a premium pass through of $52.08 per month. You may make a maximum annual contribution of $625.00.

The HDHP will make a premium pass-through of $52.08 per month. You may make a maximum annual contribution of $625.00

Self and Family
coverage

The HDHP will make a premium pass through of $104.17 per month. You may make a maximum annual contribution of $1,250.00.

The HDHP will make a premium pass through of $104.17 per month. Your annual maximum contribution cannot exceed $1,250.00

Access funds

You can access your HSA by the following methods

Debit card

Withdrawal form

You may obtain a withdrawal form directly from the CBSA website or by calling CBSA directly (800-566-9311 or 800-260-6627). Using a withdrawal form, you have access to funds from your HSA for qualified medical expenses. Submit your completed withdrawal form to us by mail:

Corporate Benefit Services of America, Inc.

P.O. Box 270520

Golden Valley, MN 55427.

Alternatively, you may fax the form to CBSA

920-260-6627. CBSA will process the HSA disbursement request and you will receive a check.

For qualified medical expenses under your HDHP, you will be automatically reimbursed when claims are submitted through HealthAmerica HDHP.

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.

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 HRA account

Account owner

FEHB enrollee

HealthAmerica Pennsylvania, Inc.

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 as long as you remain enrolled in the HealthAmerica Pennsylvania, Inc., HDHP.

HSAs

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 CBSA 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 enrolled in 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 CBSA at (800) 566-9311. 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, become enrolled 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 enroll in Medicare, 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 enrolled in Medicare.

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 quarterly 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 detailing your reimbursement amount and your remaining balance.

Minimum reimbursements from your HSA

You will be reimbursed the full amount provided that you have available funds in your money market account. In most instances, funds will not be disbursed until your reimbursement totals at least $25.

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, even if you have not elected to enroll 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

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

Health education resources

Visit the Health Information section of our website at www.healthamerica.cvty.com for information to help you take command of your health. This section is organized in simple, user-friendly, sections:

Assess Your Health � where you will find a simple, free, online health risk assessment tool to benchmark your wellness, and better understand your overall health status and risks.

About Your Health � for information about a specific condition or general preventive guidelines.

Patient Safety

WebMD � our link to this health site also provides wellness and disease information to help improve health.

Prescription Drug educational materials are also accessible through our website, through a link to our pharmacy benefit manager, Caremark. There, you will find Detailed information about a wide range of prescription drugs; A drug interaction tool to help easily determine if a specific drug can have any adverse interactions with each other, with over-the-counter drugs, or with herbals and vitamins; Facts about why FDA-approved generic drugs should be a first choice for effective, economical treatment.

Another key health information tool that we make available to you is our online quality tools, powered by HealthShare�. You can review the frequency of procedures performed by a provider, knowing the correlation between frequency of service and quality of outcomes. We post additional quality outcome information, such as re-admission rates within 30 days, post operative complications,a nd even death rates. (This new feature will be available in 2005).

We also publish an e-newsletter to keep you informed on a variety of issues related to your good health. Visit our Web site at www.healthamerica.cvty.com for back editions of this publication, Living Well.

In addition, we augment our health education tools with access to our Nurse Advisor Services. Experienced RNs are available through an inbound call center 24x7x365 to assist you and help you to maximize your benefits, by providing clinical and economic information to make an informed decision on how to proceed with care. (This new feature will be available in 2005).

Account management tools

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

If you have an HSA,

You will receive a quarterly statement by mail,outlining your account balance and activity for the month.

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

If you have an HRA,

Your will receive a quarterly statement by mail outlining your account balance and activity.

You may access your account and review your activity on a daily basis online, by accessing My Online Services, at www.healthamerica.cvty.com.

Consumer choice information

As a member of this HDHP, you must seek care from our participating provider network. Our provider search function on our Web site (www.healthamerica.cvty.com) is updated every week. It lets you easily search for a participating physician based on the criteria you choose, such as provider specialty, gender, secondary languages spoken, or hospital affiliation. You can even specify the maximum distance you�re willing to travel and, in most instances, get driving directions and a map to the offices of identified providers.

Pricing information for medical care is available at www.healthamerica.cvty.com. There, you will find our Health Services Pricing Tools which provide average cost information for some of the most common categories of service. The easy-to-understand information is sorted by categories of service including physician office visits, diagnostic tests, surgical procedures and hospitalization.

Pricing information for prescription drugs is available through our link to the Web site of our pharmacy benefit manager, Caremark (which you can access via www.healthamerica.cvty.com). Through a password- protected account, you will have the ability to estimate prescription costs before ordering.

Link to online pharmacy through the Web site of our pharmacy benefit manager, Caremark (which you can access via www.healthamerica.cvty.com).

Educational materials on the topics of HSAs, HRAs and HDHPs are available at www.healthamerica.cvty.com.

Care support

Our complex case management programs offer special assistance to members with intricate, long-term medical needs. Our disease management program fosters a proactive approach to managing care from prevention through treatment and management. Your physician can help arrange for participation in these programs, or you can simply contact our Customer Service Department.

Patient safety information is available online at www.healthamerica.cvty.com.

Medical and hospital benefits

In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form. Your facility will file on the UB-92 form. For claims questions and assistance, call us at (866) 351-5946.

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

Covered member�s name and ID number;

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

Dates you received the services or supplies;

Diagnosis;

Type of each service or supply;

The charge for each service or supply;

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

Receipts, if you paid for your services.

Submit your claims to:

Harrisburg- HealthAmerica

Attn: Member Services Department

3721 TecPort Drive, P.O. Box 67103

Harrisburg, PA 17106

Pittsburgh- HealthAmerica

Attn: Member Services Department

Cranberry Business Park

120 East Kensinger

Cranberry Township PA 16066

HSA or HRA

Please see section 5.3 Savings � HSAs and HRAs for information on filing for qualified medical expenses.

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.{Edit to reflect Plan specific records HDHP/fiduciary keeps, deductible & catastrophic maximums, when family maximums are met, etc.}

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.

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: {Plan address}; and

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

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

2

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

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

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

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

3

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

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

We will write to you with our decision.

4

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

You must write to OPM within:

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

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

120 days after we asked for additional information.

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

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 this plan and Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. Tell us if you are enrolled in Medicare Part A or B. Medicare will determine who is responsible for paying first for medical services. If Medicare pays first, we coordinate our payment for covered services. Under your FEHB coverage, we do not waive any of the copayments.

Claims process when you have the Original Medicare Plan � You should not have to file a claim form when you have both our Plan and the Original Medicare Plan. In some cases, you may need to file a claim form when you have both our Plan and Medicare.

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. To find out if you need to do something to file your claim, call us at (866) 351-5946.

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

Payer chart is on next page.

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

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

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

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

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

You have FEHB coverage through your spouse who is an annuitant

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

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

for Part B services

for other services

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

*

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

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

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

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

This Plan was the primary payer before eligibility due to ESRD

for 30-month coordination period

Medicare was the primary payer before eligibility due to ESRD

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

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

Medicare Advantage

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

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

This Plan and our Medicare Advantage plan: You may enroll in our Medicate Advantage plan and also remain enrolled in our FEHB plan. In this case, we do not waive any of our copayments, coinsurance, or deductibles for your FEHB coverage.

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

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

TRICARE and CHAMPVA

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

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

Workers� Compensation

We do not cover services that:

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

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

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

Medicaid

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

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

When other Government agencies are responsible for your care

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

When others are responsible for injuries

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

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

Calendar year

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

Coinsurance

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

Copayment

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

Covered services

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

Custodial care

Care provided by non-medical personnel that does not attempt to cure your condition but will

help you perform daily living activities. Some examples of custodial care include helping you

walk, dress, bathe, eat or take your medication.

Deductible

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

Experimental or investigational services

We gather appropriate information to determine whether a procedure, service, or supply is experimental or investigational. The gathered information includes all appropriate medical records, reviews of current medical and scientific evidence publications, as well as information from government regulatory bodies. Appropriate medical professionals participate in the extensive evaluation process to determine whether a procedure is/is not considered experimental or investigational. After the determination is made, you will be notified of our decision. You can obtain a copy of our Experimental procedures Determinations Policy by contacting the plan.

Group health coverage

Group health coverage is protection that provides payment of benefits for covered sickness or injury.

Medical necessity

A service or treatment which is appropriate and consistent with diagnoses, and which in accordance with accepted standards of practice in the medical community of the area in which the health services are rendered, could not have been omitted without adversely affecting the member�s condition or the quality of medical care rendered.

Plan allowance

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

We determine the allowance with each participating provider based upon negotiated charges contained within the provider�s contractual agreement. The negotiated charge represents the amount a participating provider must accept as payment in full for covered services provided to Plan members.

Us/We

Us and We refer to HealthAmerica

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 Benefit Plan�s Basic Option.

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

When benefits and premiums start

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

When you retire

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

When FEHB coverage ends

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

Your enrollment ends, unless you cancel your enrollment, or

You are a family member no longer eligible for coverage.

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

Spouse equity coverage

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

Temporary Continuation of Coverage (TCC)

If you leave Federal service, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after 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 claim as a dependent on your Federal Income Tax return (and who is mentally or physically incapable of self care).

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

Enroll during Open Season

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

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

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

What is SHPS?

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

Who is eligible to enroll?

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

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

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

How much should I contribute to my FSA?

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

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

What can my HCFSA pay for?

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

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

Tax savings with an FSA

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

If your taxable income is:

$50,000

$50,000

And you deposit this amount into an FSA:

$2,000

-$0-

Your taxable income is now:

$48,000

$50,000

Subtract Federal & Social Security taxes:

$13,807

$14,383

If you spend after-tax dollars for expenses:

-$0-

$2,000

Your real spendable income is:

$34,193

$33,617

Your tax savings:

$576

-$0-

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

Tax credits and deductions

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

Health care expenses

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

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

Dependent care expenses

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

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

Does it cost me anything to participate in FSAFEDS?

No. Section 1127 of the National Defense Authorization Act (Public Law 108-136) requires agencies that offer FSAFEDS to employees to cover the administrative fee(s) on behalf of their employees. However, remember that participating in FSAFEDS can cost you money if you don�t spend your entire account balance by the end of the Plan Year, resulting in the forfeiture of funds remaining in your account (the IRS "use-it-or-lose-it" rule).

Contact us

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

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

The Federal Long Term Care Insurance Program can help protect you from the potentially high cost of long term care. This coverage gives you options regarding the type of care you receive and where you receive it. With FLTCIP coverage, you won�t have to worry about relying on your loved ones to provide or pay for your care.

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

You don�t have to wait for an open season to apply. The Federal Long Term Care Insurance Program accepts applications from eligible persons at any time. You will have to complete a full underwriting application, which asks a number of questions about your health. However, if you are a new or newly eligible employee, you (and your spouse, if applicable) have a limited opportunity to apply using the abbreviated underwriting application, which asks fewer questions. Newly married spouses of employees also have a limited opportunity to apply using abbreviated underwriting.

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

To find out more and to request an application

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

Medical services provided by physicians:

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

After the deductible you pay

$15 office visit copay for primary care physician

$25 office visit copay for specialist

22

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

Nothing

35

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

Nothing

36

Emergency care at a hospital or urgent care center, including doctors services............................................................................................................

$75 copay per visit

38

Care provided at the doctors office ............................................................

$15 per visit Primary Care Physician or $25 per visit to a Specialist

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

Regular cost sharing

39

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

After you meet the deductible,

$5 copay for generic formulary drugs, $35 copay for name brand formulary drugs, and $50 copay for non-formulary

41

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

Accidental injury benefit

After the deductible you pay

Nothing

46

Special features: High Risk Pregnancy, Centers of Excellence, Member Services TDD, Complex Case Management, Student Out of Area Coverage

45

Protection against catastrophic costs

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

Nothing after $4,000 self only or $8,000 self and family enrollment per year. Some costs do not count toward this protection

53

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

High Option

Self Only

Y61

$113.92

$ 37.97

$246.83

$ 82.27

$134.80

$ 17.09

High Option

Self and Family

Y62

$280.07

$ 93.35

$606.81

$202.27

$331.41

$ 42.01

High Option

Self Only

YW1

$128.69

$ 42.90

$278.84

$ 92.94

$152.29

$ 19.30

High Option

Self and Family

YW2

$290.33

$ 96.77

$629.04

$209.68

$343.55

$ 43.55

High Option

Self Only

YN1

$131.08

$59.68

$284.01

$129.30

$154.74

$ 36.02

High Option

Self and Family

YN2

$298.23

$132.93

$646.17

$288.01

$352.08

$ 79.08

High Option

Self Only

9N1

$131.08

$52.68

$284.01

$114.14

$154.74

$ 29.02

High Option

Self and Family

9N2

$298.23

$116.22

$646.17

$251.81

$352.08

$ 62.37