73-081

A Health Maintenance Organization Serving: Southeastern Wisconsin You must live in one of the following service areas to enroll in this Plan and must enroll in the area where you live. Enrollment in this Plan is limited; see page 9 for requirements.

Enrollment code: WH1 Self Only WH2 Self and Family

Service Area: Services from Plan providers are available only in the following area: Milwaukee and Waukesha counties in Wisconsin

Visit the OPM website at http:// www. opm. gov/ insure The Plans web site address is http:// www. fhpc. org

Family Health Plan 1999

Authorized for distribution by the:

United States Office of Personnel Management

RI 73- 081

Family Health Plan

Family Health Plan, 11524 W. Theodore Trecker Way, Milwaukee, WI 53214, has entered into a contract (CS 1906) with the Office of Personnel Management (OPM) as authorized by the Federal Employees Health Benefits (FEHB) law, to provide a comprehensive medical plan herein called Family Health Plan or the Plan.

This brochure is the official statement of benefits on which you can rely. A person enrolled in the Plan is entitled to the benefits stated in this brochure. However if conflicts are discovered between the language of this brochure and the contract, the contract will control. If enrolled for Self and Family, each eligible family member is also entitled to these benefits.

Premiums are negotiated with each plan annually. Benefit changes are effective January 1, 1999, and are shown on page (22) the inside back cover of this brochure.

Table of Contents Page Inspector General Advisory on Fraud................................................................................................................... 3

General Information............................................................................................................................................... 3- 6

Confidentiality; If you are a new member; If you are hospitalized when you change plans; Your responsibility; Things to keep in mind; Coverage after enrollment ends (Former spouse coverage; Temporary continuation of coverage; and Conversion to individual coverage)

Facts about this Plan............................................................................................................................................... 7- 9

Information you have a right to know; Who provides care to Plan members; Role of a primary care doctor; Choosing your doctor; Referrals for specialty care; Authorizations; For new members; Hospital care; Out- of- pocket maximum; Deductible carryover; Submit claims promptly; Other considerations; The Plans service area

General Limitations................................................................................................................................................. 9- 10

Important notice; Circumstances beyond Plan control; Arbitration of claims; Other sources of benefits

General Exclusions................................................................................................................................................... 11 Benefits...................................................................................................................................................................... 11- 16

Medical and Surgical Benefits; Hospital/ Extended Care Benefits; Emergency Benefits, Mental Conditions/ Substance Abuse Benefits; Prescription Drug Benefits

Other Benefits........................................................................................................................................................... 17

Dental care; Vision care

How to Obtain Benefits............................................................................................................................................ 18 How Family Health Plan Changes January 1999................................................................................................. 19

Program- wide changes Changes to this Plan

Summary of Benefits............................................................................................................................................... 22

Inspector General Advisory: Stop Health Care Fraud!

Fraud increases the cost of health care for everyone. Anyone who intentionally makes a false statement or a false claim in order to obtain FEHB benefits or increase the amount of FEHB benefits is subject to prosecution for FRAUD. This could result in CRIMINAL PENALTIES. Please review all medical bills, medical records and claims statements carefully. If you find that a provider, such as a doctor, hospital or pharmacy, charged your plan for services you did not receive, billed for the same service twice, or misrepresented any other information, take the following actions:

Call the provider and ask for an explanation - sometimes the problem is a simple error. If the provider does not resolve the matter, or if you remain concerned, call your plan at (414) 256- 0040 and explain the situation. If the matter is not resolved after speaking to your plan (and you still suspect fraud has been committed), call or write:

THE HEALTH CARE FRAUD HOTLINE 202/ 418- 3300

The Office of Personnel Management Office of the Inspector General Fraud Hotline

1900 E. Street, N. W. Room 6400 Washington, D. C. 20415

The inappropriate use of membership identification cards, e. g., to obtain services for a person who is not an eligible family member or after you are no longer enrolled in the Plan, is also subject to review by the Inspector General and may result in an adverse administrative action by your agency.

General Information Confidentiality Medical and other information provided to the Plan, including claim files, is kept confidential

and will be used only: 1) by the Plan and its subcontractors for internal administration of the Plan, coordination of benefit provisions with other plans, and subrogation of claims; 2) by law enforcement officials with authority to investigate and prosecute alleged civil or criminal actions; 3) by OPM to review a disputed claim or perform its contract administration functions; 4) by OPM and the General Accounting Office when conducting audits as required by the FEHB law; or 5) for bona fide medical research or education. Medical data that does not identify individual members may be disclosed as a result of the bona fide medical research or education.

If you are a Use this brochure as a guide to coverage and obtaining benefits. There may be a delay before you

new member receive your identification card and member information from the Plan. Until you receive your ID card, you may show your copy of the SF 2809 enrollment form or your annuitant confirmation letter from OPM to a provider or Plan facility as proof of enrollment in this Plan. If you do not receive your ID card within 60 days after the effective date of your enrollment, you should contact the Plan.

If you made your open season change by using Employee Express and have not received your new ID card by the effective date of your enrollment, call the Employee Express HELP number to request a confirmation letter. Use that letter to confirm your new coverage with Plan providers.

If you are a new member of this Plan, benefits and rates begin on the effective date of your enrollment, as set by your employing office or retirement system. As a member of this Plan, once your enrollment is effective, you will be covered only for services provided or arranged by a Plan doctor except in the case of emergency as described on page 14. If you are confined in a hospital on the effective date, you must notify the Plan so that it may arrange for the transfer of your care to Plan providers. See If you are hospitalized on page 4.

FEHB plans may not refuse to provide benefits for any condition you or a covered family member may have solely on the basis that it was a condition that existed before you enrolled in a plan under the FEHB Program.

General Information continued

If you change plans or options, benefits under your prior plan or option cease on the effective date of your enrollment in your new plan or option, unless you or a covered family member are confined in a hospital or other covered facility or are receiving medical care in an alternative care setting on the last day of your enrollment under the prior plan or option. In that case, the confined person will continue to receive benefits under the former plan or option until the earliest of (1) the day the person is d i s c h a rged from the hospital or other covered facility (a move to an alternative care setting does not constitute a discharge under this provision), or (2) the day after the day all inpatient benefits have been exhausted under the prior plan or option, or (3) the 92nd day after the last day of coverage under the prior plan or option. However, benefits for other family members under the new plan will begin on the effective date. If your plan terminates participation in the FEHB Program in whole or in part, or if the Associate Director for Retirement and Insurance orders an enrollment change, this continuation of coverage provision does not apply; in such case, the hospitalized family members benefits under the new plan begin on the effective date of enrollment.

It is your responsibility to be informed about your health benefits. Your employing office or retirement system can provide information about: when you may change your enrollment; who family members are; what happens when you transfer, go on leave without pay, enter military service, or retire; when your enrollment terminates; and the next open season for enrollment. Your employing office or retirement system will also make available to you an FEHB Guide, brochures and other materials you need to make an informed decision.

The benefits in this brochure are effective on January 1 for those already enrolled in this Plan; if you changed plans or plan options, see If you are a new member above. In both cases, how ever, the Plans new rates are effective the first day of the enrollees first full pay period that begins on or after January 1 (January 1 for all annuitants).

Generally, you must be continuously enrolled in the FEHB Program for the last five years before you retire to continue your enrollment for you and any eligible family members after you retire.

The FEHB Program provides Self Only coverage for the enrollee alone or Self and Family coverage for the enrollee, his or her spouse, and unmarried dependent children under age 22. Under certain circumstances, coverage will also be provided under a family enrollment for a disabled child 22 years of age or older who is incapable of self- support.

A member with Self Only coverage who is expecting a baby or the addition of a child may change to a Self and Family enrollment up to 60 days after the birth or addition. The effective date of the enrollment change is the first day of the pay period in which the child was born or became an eligible family member. The enrollee is responsible for his or her share of the Self and Family premium for that time period; both parent and child are covered only for care received from Plan providers, except for emergency benefits.

You will not be informed by your employing office (or your retirement system) or your Plan when a family member loses eligibility.

You must direct questions about enrollment and eligibility, including whether a dependent age 22 or older is eligible for coverage, to your employing office or retirement system. The Plan does not determine eligibility and cannot change an enrollment status without the necessary information from the employing agency or retirement system.

An employee, annuitant, or family member enrolled in one FEHB plan is not entitled to receive benefits under any other FEHB plan.

Report additions and deletions (including divorces) of covered family members to the Plan promptly.

If you are an annuitant or former spouse with FEHB coverage and you are also covered by Medicare Part B, you may drop your FEHB coverage and enroll in a Medicare prepaid plan when one is available in your area. If you later change your mind and want to reenroll in FEHB, you may do so at the next open season, or whenever you involuntarily lose coverage in the Medicare prepaid plan or move out of the area it serves.

If you are hospitalized

Your responsibility

Things to keep in mind

General Information continued

Most Federal annuitants have Medicare Part A. If you do not have Medicare Part A, you may enroll in a Medicare prepaid plan, but you will probably have to pay for hospital coverage in addition to the Part B premium. Before you join the plan, ask whether they will provide hospital benefits and, if so, what you will have to pay.

You may also remain enrolled in this Plan when you join a Medicare prepaid plan. Contact your local Social Security Administration (SSA) office for information on local Medicare prepaid plans (also known as Coordinated Care Plans or Medicare HMOs) or request it from SSA at 1- 800/ 638- 6833. Contact your retirement system for information on dropping your FEHB enrollment and changing to a Medicare prepaid plan.

Federal annuitants are not required to enroll in Medicare Part B (or Part A) in order to be covered under the FEHB Program nor are their FEHB benefits reduced if they do not have Medicare Part B (or Part A ) .

When an employees enrollment terminates because of separation from Federal service or when a family member is no longer eligible for coverage under an employee or annuitant enrollment, and the person is not otherwise eligible for FEHB coverage, he or she generally will be eligible for a free 31- day extension of coverage. The employee or family member may also be eligible for one of the following:

When a Federal employee or annuitant divorces, the former spouse may be eligible to elect coverage under the spouse equity law. If you are recently divorced or anticipate divorcing, contact the e m p l o y e e s employing office (personnel office) or retirees retirement system to get more facts about electing coverage.

If you are an employee whose enrollment is terminated because you separate from service, you may be eligible to temporarily continue your health benefits coverage under the FEHB Program in any plan for which you are eligible. Ask your employing office for RI 79- 27, which describes TCC, and for RI 70- 5, the FEHB Guide for individuals eligible for TCC. Unless you are separated for gross misconduct, TCC is available to you if you are not otherwise eligible for continued coverage under the Program. For example, you are eligible for TCC when you retire if you are unable to meet the five- year enrollment requirement for continuation of enrollment after retirement.

Your TCC begins after the initial free 31- day extension of coverage ends and continues for up to 18 months after your separation from service (that is, if you use TCC until it expires 18 months following separation, you will only pay for 17 months of coverage). Generally, you must pay the total premium (both the Government and employee shares) plus a 2 percent administrative charg e . If you use your TCC until it expires, you are entitled to another free 31- day extension of coverage when you may convert to nongroup coverage. If you cancel your TCC or stop paying premiums, the free 31- day extension of coverage and conversion option are not available.

Children or former spouses who lose eligibility for coverage because they no longer qualify as family members (and who are not eligible for benefits under the FEHB Program as employees or under the spouse equity law) also may qualify for TCC. They also must pay the total premium plus the 2 percent administrative charge. TCC for former family members continues for up to 36 months after the qualifying event occurs, for example, the child reaches age 22 or the date of the divorce. This includes the free 31- day extension of coverage. When their TCC ends (except by cancellation or nonpayment of premium), they are entitled to another free 31- day extension of coverage when they may convert to nongroup coverage.

NOTE: If there is a delay in processing the TCC enrollment, the effective date of the enrollment is still the 32nd day after regular coverage ends. The TCC enrollee is responsible for premium payments retroactive to the effective date and coverage may not exceed the 18 or 36 month period noted above.

Coverage after enrollment ends Former spouse coverage

Temporary continuation of coverage (TCC)

General Information continued

Separating employees - Within 61 days after an employees enrollment terminates because of separation from service, his or her employing office must notify the employee of the opportunity to elect TCC. The employee has 60 days after separation (or after receiving the notice from the employing office, if later) to elect TCC.

Children - You must notify your employing office or retirement system when a child becomes eligible for TCC within 60 days after the qualifying event occurs, for example, the child reaches age 22 or marries.

Former spouses - You or your former spouse must notify the employing office or retirement system of the former spouses eligibility for TCC within 60 days after the termination of the marriage. A former spouse may also qualify for TCC if, during the 36- month period of TCC eligibility, he or she loses spouse equity eligibility because of remarriage before age 55 or loss of the qualifying court order. This applies even if he or she did not elect TCC while waiting for spouse equity coverage to begin. The former spouse must contact the employing office within 60 days of losing spouse equity eligibility to apply for the remaining months of TCC to which he or she is entitled.

The employing office or retirement system has 14 days after receiving notice from you or the former spouse to notify the child or the former spouse of his or her rights under TCC. If a child wants TCC, he or she must elect it within 60 days after the date of the qualifying event (or after receiving the notice, if later). If a former spouse wants TCC, he or she must elect it within 60 days after any of the following events: the date of the qualifying event or the date he or she receives the notice, whichever is later; or the date he or she loses coverage under the spouse equity law because of remarriage before age 55 or loss of the qualifying court order.

Important: The employing office or retirement system must be notified of a childs or former spouses eligibility for TCC within the 60- day time limit. If the employing office or retirement system is not notified, the opportunity to elect TCC ends 60 days after the qualifying event in the case of a child and 60 days after the change in status in the case of a former spouse.

When none of the above choices are available - or chosen - when coverage as an employee or family member ends, or when TCC coverage ends (except by cancellation or nonpayment of premium), you may be eligible to convert to an individual, nongroup contract. You will not be required to provide evidence of good health and the plan is not permitted to impose a waiting period or limit coverage for preexisting conditions. If you wish to convert to an individual contract, you must apply in writing to the carrier of the plan in which you are enrolled within 31 days after receiving notice of the conversion right from your employing agency. Afamily member must apply to convert within the 31- day free extension of coverage that follows the event that terminates coverage, e. g., divorce or reaching age 22. Benefits and rates under the individual contract may differ from those under the FEHB Program.

Notification and election requirements

Conversion to individual coverage

Facts about this Plan

This Plan is a comprehensive medical plan, sometimes called a health maintenance organization (HMO). When you enroll in an HMO, you are joining an organized system of health care that arranges in advance with specific doctors, hospitals and othe providers to give care to members and pays them directly for their services. Benefits are available only from Plan providers except during a medical emergency. Members are required to select a personal doctor from among participating Plan primary care doctors. Services of a specialty care doctor can only be received by referral from the selected primary care doctor. There are no claim forms when Plan doctors are used.

Your decision to join an HMO should be based on your preference for the plans benefits and delivery system, not because a particular provider is in the plans network. You cannot change plans because a provider leaves the HMO.

Because the Plan provides or arranges your care and pays the cost, it seeks efficient and effective delivery of health services. By controlling unnecessary or inappropriate care, it can afford to offer a comprehensive range of benefits. In addition to providing comprehensive health services and benefits for accidents, illness and injury, the Plan emphasizes preventive benefits such as office visits, physicals, immunizations and well- baby care. You are encouraged to get medical attention at the first sign of illness.

All carriers in the FEHB Program must provide certain information to you. If you did not receive information about this Plan, you can obtain it by calling the carrier at 414 256- 0040 or you may write to the carrier at the address on the inside front cover of this brochure. You may also contact the carrier by fax at 414 256- 0069. Information that must be made available to you includes: Disenrollment rate for 1997 State and Federal licensing or certification compliance status Types of accreditations held by the plan and dates received Whether the carrier meets State and Federal requirements for fiscal solvency, confidentiality,

and transfer of medical records Family Health Plan is a staff model health maintenance organization. Family Health Plan hires its own family doctors, technicians, nurses, pharmacists, counselors, and many other professionals who serve Family Health Plan members only. As a member of Family Health Plan, you are eligible to take advantage of the many services this team can provide.

When you join Family Health plan you select one of our health centers and then choose a primary care doctor on our staff at that health center to be your and your familys personal doctor. Family Health Plans delivery system is based on the family practice doctors, so all family members are encouraged to select the same family practice doctor.

The first and most important decision each member must make is the selection of a primary care doctor. The decision is important since it is through this doctor that all other health services, particularly those of specialists, are obtained. It is the responsibility of your primary care doctor to obtain any necessary authorizations from the Plan before referring you to a specialist or making arrangements for hospitalization. Services of other Plan providers are covered only when there has been a referral by the members primary care doctor. Awoman, at her request, may see a Plan OB/ GYN for her annual routine exam.

The Plans provider directory lists primary care doctors (generally family practitioners and internists), with their locations and phone numbers, and notes whether or not the doctor is accepting new patients. Directories are updated on a regular basis and are available at the time of enrollment or upon request by calling the Marketing Department at (414) 256- 0040; you can also find out if your doctor participates with this Plan by calling this number.

If you are interested in receiving care from a specific provider who is listed in the directory, call the provider to verify that he or she still participates with the Plan and is accepting new patients. Important note: When you enroll in this plan, services (except for emergency benefits) are provided through the Plans delivery system; the continued availability and/ or participation of any one doctor, hospital, or other provider, cannot be guaranteed.

Should you decide to enroll, you will be asked to complete a primary care doctor selection form and send it directly to the Plan, indicating the name of the primary care doctors you select for you and each member of your family. Members may change their doctor selection by notifying the Plan 30 days in advance. 7

Information you have a right to know

Who provides care to Plan members

Role of a primary care doctor

Choosing your doctor

Facts about this Plan continued

In the event a member is receiving services from a doctor who terminates a participation agreement, the Plan will provide payment for covered services until the Plan can make reasonable and medically appropriate provisions for the assumption of such services by a participating doctor.

The HMO Group (THMOG) Reciprocity Program provides Family Health Plan members two levels of reciprocity, expanded care and travel care. Members visiting an area covered by a THMOG home plan can obtain routine and urgent care through the home plan for up to one year. If members know they are going to visit a THMOG plan area, they can complete the necessary forms in advance. Travel care is available to members who are traveling out of the area for a short period of time and an urgent situation arise. If you would like more information about receiving care away from home, please call the Member Service Department at 414- 256- 5713.

Except in a medical emerg e n c y, or when a primary care doctor has designated another doctor to see patients when he or she is unavailable, you must contact your primary care doctor for a referral before seeing any other doctor or obtaining special services. Referral to a participating specialist is given at the primary care doctors discretion; if specialists or consultants are required beyond those participating in the Plan, the primary care doctor will make arrangements for appropriate referrals.

When you receive a referral from your primary care doctor, you must return to the primary care doctor after the consultation. All follow- up care must be provided or authorized by the primary care doctor. On referrals, the primary care doctor will give specific instructions to the consultant as to what services are authorized. If additional services or visits are suggested by the consultant, you must first check with your primary care doctor. Do not go to the specialist unless your primary care doctor has arranged for and the Plan has issued an authorization for the referral in advance. If your medical condition requires frequent visits to a Plan specialist, your primary care doctor will develop a treatment plan that allows an appropriate number of visits while allowing your doctor to monitor your progress and adjust the treatment plan if necessary.

Authorizations Your primary care doctor must provide you with an authorization before you may be hospitalized, referred for specialty care or obtain follow- up care from a specialist.

For new members If you are already under the care of a specialist who is a Plan participant, you must still obtain referral from a Plan primary care doctor for the care to be covered by the Plan. If the doctor who originally referred you prior to your joining the Plan is now your primary care doctor you need only call to explain that you now belong to this Plan and ask that a referral form be sent to the specialist for your next appointment.

Hospital care If you require hospitalization, your primary care doctor or authorized specialist will make the necessary arrangements and continue to supervise your care.

Your out- of- pocket expenses for benefits under the Plan are limited to the stated copayments required for certain dental and prescription benefits.

If you changed to this Plan during open season from a plan with a deductible and the effective date of the change was after January 1, any expenses that would have applied to that plans deductible will be covered by your old plan if they are for care you got in January before the effective date of your coverage in this Plan. If you have already met the deductible in full, your old plan will reimburse these covered expenses. If you have not met it in full, your old plan will first apply your covered expenses to satisfy the rest of the deductible and then reimburse you for any additional covered expenses. The old plan will pay these covered expenses according to this years benefits; benefit changes are effective January 1.

Reciprocity Referrals for specialty care

Out- of- pocket maximum

Deductable carryover

Facts about this Plan continued

When you are required to submit a claim to this Plan for covered expenses, submit your claim promptly. The Plan will not pay benefits for claims submitted later than December 31 of the calendar year following the year in which the expense was incurred, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.

Plan providers will follow generally accepted medical practice in prescribing any course of treatment. Before you enroll in this Plan, you should determine whether you will be able to accept treatment or procedures that may be recommended by Plan providers.

The service area for this Plan, where Plan providers and facilities are located, is described below. You may enroll in this Plan if you live or work inside the service area or live in the geo graphic area described below. Benefits for care outside the service area are limited to emergency services, as described on page 14.

Milwaukee and Waukesha counties as well as the following zip codes in Walworth, Racine, Washington and Ozaukee counties. Walworth Racine Washington Ozaukee 53105 53105 53012 53112 53119 53108 53017 53024 53120 53120 53022 53092 53138 53126 53027 53217 53148 53130 53033 53149 53139 53037 53157 53149 53076 53176 53150 53077

53167 53086 53182 53185 53402

If you or a covered family member move outside the service area, you may enroll in another approved plan. It is not necessary to wait until you move or for the open season to make such a change; contact your employing office or retirement system for information if you are anticipating a move.

General Limitations Important notice Although a specific service may be listed as a benefit, it will be covered for you only if, in the

judgement of your Plan doctor, it is medically necessary for the prevention, diagnosis, or treatment of your illness or condition. No oral statement of any person shall modify or otherwise affect the benefits, limitations and exclusions of this brochure, convey or void any coverage, increase or reduce any benefits under this Plan or be used in the prosecution or defense of a claim under this Plan. This brochure is the official statement of benefits on which you can rely, based on text included in the contract between OPM and this Plan and is intended to be a complete statement of benefits available to FEHB members. You should use this brochure to determine your entitlement to benefits. H o w e v e r, if conflicts are discovered between the language of this brochure and the contract, the contract will control.

In the event of major disaster, epidemic, war, riot, civil insurrection, disability of a significant number of Plan providers, complete or partial destruction of facilities, or other circumstances beyond the Plans control, the Plan will make a good faith effort to provide or arrange for covered s e r v i c e s . However, the Plan will not be responsible for any delay or failure in providing service due to lack of available facilities or personnel.

Any claim for damages for personal injury, mental disturbance or wrongful death arising out of the rendition or failure to render services under this contract must be submitted to binding arbitration.

Submit claims promptly

Other considerations

The Plans Service Area

Circumstances beyond Plan control

Arbitration of claims

General Limitations continued

This section applies when you or your family members are entitled to benefits from a source other than this Plan. You must disclose information about other sources of benefits to the Plan and complete all necessary documents and authorizations requested by the Plan.

Medicare If you or a covered family member is enrolled in this Plan and Medicare Part Aand/ or Part B, the Plan will coordinate benefits according to Medicares determination of which coverage is primary. H o w e v e r, this Plan will not cover services, except those for emergencies, unless you use Plan providers. You must tell your Plan that you or your family member is eligible for Medicare. Generally, that is all you will need to do, unless your Plan tells you that you need to file a Medicare claim.

This coordination of benefits (double coverage) provision applies when a person covered by this Plan also has, or is entitled to benefits from, any other group health coverage, or is entitled to the payment of medical and hospital costs under no- fault or other automobile insurance that pays benefits without regard to fault. Information about the other coverage must be disclosed to this Plan.

When there is double coverage for covered benefits, other than emergency services from non- Plan providers, this Plan will continue to provide its benefits in full, but is entitled to receive payment for the services and supplies provided, to the extent that they are covered by the other coverage, no- fault or other automobile insurance or any other primary plan.

One plan normally pays its benefits in full as the primary payer, and the other plan pays a reduced benefit as the secondary payer. When this Plan is the secondary payer, it will pay the lesser of (1) its benefits in full, or (2) a reduced amount which, when added to the benefits payable by the other coverage, will not exceed reasonable charges. The determination of which health coverage is primary (pays its benefits first) is made according to guidelines provided by the National Association of Insurance Commissioners. When benefits are payable under no- fault automobile insurance, including no- fault, the no- fault automobile insurer is primary (pays its benefits first) if it is legally obligated to provide benefits for health care expenses without regard to other health benefits coverage the enrollee may have. This provision applies whether or not a claim is filed under the other coverage. When applicable, authorization must be given this Plan to obtain information about benefits or services available from the other coverage, or to recover overpayments from other coverages.

CHAMPUS If you are covered by both this Plan and the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), this Plan will pay benefits first. As a member of a prepaid plan, special limitations on your CHAMPUS coverage apply; your primary provider must authorize all care. See your CHAMPUS Health Benefits Advisor if you have questions about CHAMPUS coverage.

Medicaid If you are covered by both this Plan and Medicaid, this Plan will pay benefits first. The Plan will not pay for services required as the result of occupational disease or injury for which any medical benefits are determined by the Office of Workers Compensation Programs (OWCP) to be payable under workerscompensation (under section 8103 of title 5, U. S. C.) or by a similar agency under another Federal or State law. This provision also applies when a third party injury settlement or other similar proceeding provides medical benefits in regard to a claim under workerscompensation or similar laws. If medical benefits provided under such laws are exhausted, this Plan will be financially responsible for services or supplies that are otherwise covered by this Plan. The Plan is entitled to be reimbursed by OWCP (or the similar agency) for services it provided that were later found to be payable by OWCP.

Facilities of the Department of Veterans A ffairs, the Department of Defense, and the Indian Health Service are entitled to seek reimbursement from the Plan for certain services and supplies provided to you or a family member to the extent that reimbursement is required under the Federal statutes governing such facilities.

The Plan will not provide benefits for services and supplies paid for directly or indirectly by any other local, State, or Federal Government agency.

If a covered person is sick or injured as a result of the act or omission of another person or party, the Plan requires that it be reimbursed for the benefits provided in an amount not to exceed the amount of the recovery, or that it be subrogated to the persons rights to the extent of the benefits received under this Plan, including the right to bring suit in the persons name. If you need more information about subrogation, the plan will provide you with its subrogation procedures.

Other sources of benefits

Group health insurance and automobile insurance

Workers compensation

DVA facilities, DoD facilities, and Indian Health Service

Other Government agencies

Liability insurance and third party actions

General Exclusions

All benefits are subject to the limitations and exclusions in this brochure. Although a specific service may be listed as a benefit, it will not be covered for you unless your Plan doctor determines it is medically necessary to prevent, diagnose or t reat your i l l n e s s o r c o n d i t i o n . The following are excluded:

Care by non- Plan doctors or hospitals except for authorized referrals or emergencies (see Emergency Benefits)

Expenses incurred while not covered by this Plan Services furnished or billed by a provider or facility barred from the FEHB Program Services not required according to accepted standards of medical, dental, or psychiatric practice Procedures, treatments, drugs or devices that are experimental or investigational; Procedures, services, drugs and supplies related to sex transformations; and Procedures, services, drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest.

Medical and Surgical Benefits What is covered Acomprehensive range of preventive, diagnostic and treatment services is provided by Plan doctors

and other Plan providers. This includes all necessary office visits; you pay nothing. Within the Service Area, house calls will be provided if in the judgement of the Plan doctor such care is necessary and appropriate; you pay nothing for a doctors house call or for home visits by nurses and health aides.

Plan doctors also provide all necessary medical or surgical care in a hospital or extended care facility, at no additional cost to you.

The following services are included: Preventive care, including well- baby care and periodic check ups Mammograms are covered as follows: for women age 35 through 39, one mammogram during these five years; for women 40 through 49, one mammogram every one or two years; for women age 50 through 64, one mammogram every year; and for women age 65 and above, one mammogram every two years. In addition to routine screening, mammograms are covered when prescribed by the doctor as medically necessary to diagnose or treat your illness.

Routine immunizations and boosters Consultations by specialists Diagnostic procedures, such as laboratory tests and X- rays Complete obstetrical (maternity) care for all covered females, including prenatal, delivery and postnatal care by a Plan doctor. The mother, at her option, may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a caesarean delivery. Inpatient stays will be extended if medically n e c e s s a r y. If enrollment in the Plan is terminated during pregnancy, benefits will not be provided after coverage under the Plan has ended. Ordinary nursery care of the newborn child during the covered portion of the mothers hospital confinement for maternity will be covered under either a Self Only or Self and Family enrollment; other care of an infant who requires definitive treatment will be covered only if the infant is covered under a Self and Family Enrollment.

Voluntary sterilization and family planning services Diagnosis and treatment of diseases of the eye

Medical and Surgical Benefits continued Allergy testing and treatment, including test and treatment materials (such as allergy serum) The insertion of internal prosthetic devices, such as pacemakers and artificial joints. Cornea, heart, kidney and liver transplants; 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 Hodgkins lymphoma, advanced non- Hodgkins lymphoma, advanced neuroblastoma, breast cancer; multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors. Related medical hospital expenses of the donor are covered when the recipient is covered by this Plan.

Women who undergo mastectomies may, at their option, have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

Dialysis Chiropractic services Chemotherapy, radiation therapy, and inhalation therapy Surgical treatment of morbid obesity Orthopedic devices, such as braces except for orthotic fittings and devices for the feet Prosthetic devices, such as artificial limbs, and lenses following cataract removal Durable medical equipment, such as wheelchairs and hospital beds Home health services of nurses and health aides, including intravenous fluids and medications when prescribed by your Plan doctor, who will periodically review the program for continuing appropriateness and need

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS Limited Benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures

for congenital defects, such as cleft lip and cleft palate, and for medical or surgical procedures occurring within or adjacent to the oral cavity or sinuses including, but not limited to, treatment of fractures and excision of tumors and cysts. Medically necessary diagnostic procedures and medically necessary surgical or nonsurgical treatment, including but not limited to intraoral splint therapy devices, for the correction of temporomandibular disorders, TMJ, caused by congenital, developmental, or acquired deformity, disease or injury. Coverage is limited to procedures or devices used to control or eliminate infection, pain, disease, or dysfunction. All other procedures involving the teeth or areas surrounding the teeth are not covered, including shortening of the mandible or maxillae for cosmetic purposes.

Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an injury or surgery that has produced a major effect on the members appearance, and if the condition can reasonably be expected to be corrected by such surg e r y.

S h o rt- term rehabilitative therapy (physical, speech and occupational) is provided on an inpatient or outpatient basis for up to two c o n s e c u t i v e months per condition if significant improvement can be expected within two months; you pay nothing. Speech therapy is limited to treatment of certain speech impairments of organic origin. Occupational therapy is limited to services that assist the member to achieve and maintain self- care and improved functioning in other activities of daily living.

Diagnosis and treatment of infert i l i t y is covered, including hyper- ovulatory drugs (example: Clomid, up to six months of treatment, or Pergonal, up to two (2) menstrual cycle attempts per lifetime); you pay nothing. The following types of artificial insemination are covered: intravaginal insemination (IVI); intracervical insemination (ICI) and intrauterine insemination (IUI); you p a y nothing; cost of donor sperm is not covered. Other assisted reproductive technology (ART) procedures, such as in vitro fertilization and embryo transfer, are not covered.

Medical and Surgical Benefits continued

Cardiac rehabilitation following a heart transplant, bypass surgery, or a myocardial infarction is provided.

Physical examinations that are not necessary for medical reasons, such as those required for obtaining or continuing employment or insurance, attending school or camp, or travel

Reversal of voluntary, surgically- induced sterility Plastic Surgery primarily for cosmetic purposes Hearing aids Long- term rehabilitative therapy Homemaker services Transplants not listed as covered

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS Hospital/ Extended Care Benefits What is covered

Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor. You pay nothing. All necessary services are covered, including:

Semiprivate room accommodations; when a Plan doctor determines it is medically necessary, the doctor may prescribe private accommodations or private duty nursing care

Specialized care units, such as intensive care or cardiac care units

Extended care The Plan provides a comprehensive range of benefits for up to 30 days per confinement when f u l l - t i m e skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor. You pay nothing. All necessary services are covered, including:

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

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

Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor.

Limited benefits

Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need for hospitalization for reasons totally unrelated to the dental procedure; the Plan will cover the hospitalization, but not the cost of the professional dental services unless such services are covered under the Plans dental benefits. Conditions for which hospitalization would be covered include hemophilia and heart disease; the need for anesthesia, by itself, is not such a condition.

Hospitalization for medical treatment of substance abuse is limited to emergency care, diagnosis, treatment of medical conditions, and medical management of withdrawal symptoms (acute detoxification) if the Plan doctor determines that outpatient management is not medically appropriate. See page 15 for nonmedical substance abuse benefits.

What is not Custodial care, rest cures, domiciliary or convalescent care

covered Personal comfort items, such as telephone and television

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 13

What is not covered

Inpatient dental procedures

Acute inpatient detoxification

Emergency Benefits

Amedical 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 the Plan may determine are medical emergencies - what they all have in common is the need for quick action.

If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (e. g., the 911 telephone system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a family member should notify the Plan within 48 hours. It is your responsibility to ensure that the Plan has been timely notified.

If you need to be hospitalized in a non- Plan facility, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If you are hospitalized in non- Plan facilities and Plan doctors believe care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

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

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

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

You pay . . . Nothing for emergency services which are covered benefits of the Plan. Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

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

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

You pay . . . Nothing for emergency services which are covered benefits of this Plan.

What is covered Emergency care at a doctors office or an urgent care center Emergency care as an outpatient or inpatient at a hospital, including doctorsservices Ambulance service approved by the Plan

What is not Elective care or nonemergency care

covered Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area Medical and hospital costs resulting from a normal full- term delivery of a baby outside the Service Area

What is a medical emergency?

Emergencies within the service area

Emergencies outside the service area

Emergency Benefits continued

With your authorization, the Plan will pay benefits directly to the providers of your emergency care upon receipt of their claims. Physician claims should be submitted on the HCFA1500 claim form. If you are required to pay for the services, submit itemized bills and your receipts to the Plan along with an explanation of the services and the identification information from your ID card.

Payment will be sent to you (or the provider if you did not pay the bill), unless the claim is denied. If it is denied, you will receive notice of the decision, including the reasons for the denial and the provisions of the contract on which denial was based. If you disagree with the Plans decision, you may request reconsideration in accordance with the disputed claims procedure described on page 18.

Mental Conditions/ Substance Abuse Benefits Mental conditions

What is covered To the extent shown below, the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions, including the treatment of mental illness or disorders:

Diagnostic evaluation Psychological testing Psychiatric treatment (including individual and group therapy) Hospitalization (including inpatient professional services)

Outpatient All medically necessary outpatient mental health care, subject to plan approval you pay nothing

care for each covered visit.

Inpatient All medically necessary inpatient mental health care, subject to plan approval you pay nothing

care for each covered visit.

What is not Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject

covered to significant improvement through relatively short- term treatment Psychiatric 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

Psychological testing when not medically necessary to determine the appropriate treatment of a short- term psychiatric condition

Substance abuse What is covered This Plan provides medical and hospital services such as acute detoxification services for the

medical, non- psychiatric aspects of substance abuse, including alcoholism and drug addiction, the same as for any other illness or condition and, to the extent shown below, the services necessary for diagnosis and treatment.

Outpatient Up to 20 outpatient visits to Plan providers for treatment each calendar year; you pay nothing for

care each covered visit - all charges thereafter. An additional, up to five outpatient visits are provided for college students who live out of the service area but in Wisconsin, upon approval by the Plan.

Inpatient Up to 30 days per calendar year for substance abuse rehabilitation (intermediate care) program in

care an alcohol detoxification or rehabilitation center approved by the Plan; you pay nothing during the benefit period - all charges thereafter.

Transitional treatment up to a maximum of 24 visits or substance abuse services worth $2,700 per contract year, approved by the medical director and subject to the contract year maximum limit for substance abuse services can be substituted.

What is not covered Treatment that is not authorized by a Plan doctor.

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 15

Filing claims for non- Plan providers

Prescription Drug Benefits What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be

dispensed for up to a 31- day supply or 100 unit supply, whichever is less; 240 milliliters of liquid (8 oz.); 60 grams of ointment, creams or topical preparation; or one commercially prepared unit (i. e., one inhaler, one vial ophthalmic medication or insulin). You pay nothing for formulary drugs. All non- formulary prescription drugs require a $10 copayment per 31 day supply or dispensing unit.

Covered medications and accessories include: Drugs for which a prescription is required by law Oral and injectable contraceptive drugs Insulin Diabetic supplies including insulin syringes, needles, chem strips and test tape Implanted time- release medications, such as Norplant Disposable needles and syringes needed to inject covered prescribed medication Hyper- ovulatory drugs are covered under the infertility treatment benefit on page 12. Intravenous fluids and medication for home use, implantable drugs, and some injectable drugs are covered under Medical and Surgical Benefits.

What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available Drugs obtained at a non- Plan pharmacy except for out- of- area emergencies Vitamins and nutritional substances that can be purchased without a prescription Medical supplies such as dressings and antiseptics Drugs for cosmetic purposes Drugs to enhance athletic performance Contraceptive devices; diaphragms Smoking cessation drugs and medication, including nicotine patches

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Other Covered Benefits Dental care

What is This Plan provides the following comprehensive program of dental coverage through participating

covered Plan dentists. The emphasis is on prevention, with preventive and diagnostic dental services provided with no copayment. For all other dental services, you pay 50% of charg e s .

The following list summarizes the dental services provided by participating Plan dentists.

DIAGNOSTIC

X- rays including bite wings and panoramic (once a year; oral examination and treatment plan; vitality test; and oral cancer exam) Study model

PREVENTIVE

Prophylaxis, annual topical application of fluoride; preventive dental instruction

RESTORATIVE (fillings)

Amalgam- one surface Amalgam- two surface Amalgam- three surface Amalgam- four or more surfaces Plastic or composite- single surface Plastic or composite- two surfaces Plastic or composite- three surfaces

ORAL SURGERY

Post- operative treatment; extraction (simple) Alveoplasty per quadrant Impaction (soft tissue) Impaction (partial bony) Impaction (complete bony)

Dental medical emergencies within the service area are covered; you pay 50% of charges. Out- of- area (service received outside of 50 mile radius of the dental clinic) is covered at 50% of charges up to $50 per person per year maximum.

Accidental injury Restorative services and supplies necessary to promptly repair (but not replace) sound natural

benefit teeth are covered. You pay nothing.

What is not Other dental services not shown as covered

covered Vision care

What is In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases

covered of the eye, annual eye refractions (to provide a written lens prescription for eyeglasses) obtained from Plan providers. You pay nothing.

What is not Corrective lenses or frames or contact lenses (including the fitting of the lenses)

covered Eye exercises

PROSTHODONTICS

Complete upper or lower Cast chrome partial- upper or lower Acrylic partial- upper or lower Repair broken denture Reline upper or lower complete denture or partial

CROWN (caps)

Crown- Metal full or 3/ 4 cast Crown- Porcelain/ metal

PERIODONTICS (gum treatment)

Treatment of diseases of gums and bones supporting teeth (per quadrant)

ENDODONTICS

Root canal anterior Root canal bicuspid Root canal molar Apicoectomy, per root

ORTHODONTICS (braces)

Limited to age 19; You pay 50% of charges up to a lifetime maximum of $1,150.00 per person. The Plan pays in full thereafter.

How to Obtain Benefits Questions If you have a question concerning Plan benefits or how to arrange for care, contact the Plans

Membership Services Office at (414) 256- 0040 and TDD (414) 423- 7731 or you may write to the Plan at 11524 W. Theodore Trecker Way, Milwaukee, WI 53214. You may also contact the Plan by fax at (414) 256- 0069.

Disputed claims review Plan reconsideration If a claim for payment or services is denied by the Plan, you must ask the Plan, in writing and

within six months of the date of the denial, to reconsider its denial before you request a review by OPM. (This time limit may be extended if you show you were prevented by circumstances beyond your control from making your request within the time limit.) OPM will not review your request unless you demonstrate that you gave the Plan an opportunity to reconsider your claim. Your written request to the Plan must state why, based on specific benefit provisions in this brochure, you believe the denied claim for payment or service should have been paid or provided.

Within 30 days after receipt of your request for reconsideration, the Plan must affirm the denial in writing to you, pay the claim, provide the service, or request additional information reasonably necessary to make a determination. If the Plan asks a provider for information it will send you a copy of this request at the same time. The Plan has 30 days after receiving the information to give its decision. If this information is not supplied within 60 days, the Plan will base its decision on the information it has on hand.

If the Plan affirms its denial, you have the right to request a review by OPM to determine whether the Plans actions are in accordance with the terms of its contract. You must request the review within 90 days after the date of the Plans letter affirming its initial denial.

OPM review You may also ask OPM for a review if the Plan fails to respond within 30 days of your written request for reconsideration or 30 days after you have supplied additional information to the Plan. In this case, OPM must receive a request for review within 120 days of your request to the Plan for reconsideration or of the date you were notified that the Plan needed additional information, either from you or from your doctor or hospital.

This right is available only to you or the executor of a deceased claimants estate. Providers, legal counsel, and other interested parties may act as your representative only with your specific written consent to pursue payment of the disputed claim. OPM must receive a copy of your writ ten consent with their request for review.

Your written request for an OPM review must state why, based on specific benefit provisions in this brochure, you believe the denied claim for payment or service should have been paid or provided. If the Plan has reconsidered and denied more than one unrelated claim, clearly identify the documents for each claim.

Your request must include the following information or it will be returned by OPM: A copy of your letter to the Plan requesting reconsideration; Acopy of the Plans reconsideration decision (if the Plan failed to respond, provide instead (a) the date of your request to the Plan or (b) the dates the Plan requested and you provided additional information to the Plan);

Copies of documents that support your claim, such as doctorsletters, operative reports, bills, medical records, and explanation of benefit (EOB) forms; and

Your daytime phone number. Medical documentation received from you or the Plan during the review process becomes a permanent part of the disputed claim file, subject to the provisions of the Freedom of Information Act and the Privacy A c t .

Send your request for review to: Office of Personnel Management, Office of Insurance Programs, Contracts Division IV, P. O. Box 436, Washington, DC 20044.

You (or a person acting on your behalf) may not bring a lawsuit to recover benefits on a claim for treatment, services, supplies or drugs covered by this Plan until you have exhausted the OPM review procedure, established at section 890.105, title 5, Code of Federal Regulations (CFR). If OPM upholds the Plans decision on your claim, and you decide to bring a lawsuit based on the denial, the lawsuit must be brought no later than December 31 of the third year after the year in which the services or supplies upon which the claim is predicated were provided. Pursuant to section 890.107, title 5, CFR, such a lawsuit must be brought against the Office of Personnel Management in Federal court.

Federal law exclusively governs all claims for relief in a lawsuit that relates to this Plans benefits or coverage or payments with respect to those benefits. Judicial action on such claims is limited to the record that was before OPM when it rendered its decision affirming the Pans denial of the benefit. The recovery in such a suit is limited to the amount of benefits in dispute.

Privacy Act statement - If you ask OPM to review a denial of a claim for payment or service, OPM is authorized by chapter 89 of title 5, U. S. C., to use the information collected from you and the Plan to determine if the Plan has acted properly in denying you the payment or service, and the information so collected may be disclosed to you and/ or the Plan in support of OPMs decision on the disputed claim.

How Family Health Plan Changes January 1999

Do not rely on this page; it is not an official statement of benefits. Several changes have been made to comply with the Presidents mandate to implement the recommendations of the Patient Bill of Rights. If your medical condition requires frequent visits to a Plan specialist, your primary care doctor will develop a treatment plan that allows an appropriate number of visits. Amedical emergency is defined as a 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. The diagnosis, evaluation and medical management of certain mental conditions while covered under this Plans Medical and Surgical Benefits provisions. Examples include attention deficit disorder and Gilles de la To u r e t t e s syndrome. Related drug costs will be covered under this Plans Prescription Drug Benefits, and any costs for psychological testing or psychotherapy will be covered under this P l a n s Mental Conditions Benefits.

Limited coverage is provided for the treatment of temporomandibular joint syndrome TMJ. Providers, legal counsel, and other interested parties may act as your representative in pursuing payment of a disputed claim only with your written consent. Any lawsuit to recover benefits on a claim for treatment, services, supplies or drugs covered by this Plan must be brought against the O ffice of Personnel Management in Federal court and only after you have exhausted the OPM review procedure.

Program- wide changes

Changes To this Plan:

Notes

Summary of Benefits for Family Health Plan - 1999

Do not rely on this chart alone. All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set forth in the brochure. This chart merely summarizes certain important expenses covered by the Plan. If you wish to enroll or change your enrollment in this Plan, be sure to indicate the correct enrollment code on your enrollment form (codes appear on the cover of this brochure). ALL SERVICES COVERED UNDER THIS PLAN, WITH THE EXCEPTION OF EMERGENCY CARE, ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS.

Benefits Plan pays/ provides Page Hospital Comprehensive range of medical and surgical services without dollar or day limit. Includes in

hospital doctor care, room/ and board, general nursing care, private room and private nursing care if medically necessary, diagnostic tests, drugs and medical supplies, use of operating room, intensive care and complete maternity care. You pay nothing................................................... 13

Extended care All necessary services, for up to 30 days per confinement. You pay nothing.......................... 13

Mental conditions All medical necessary inpatient, mental health care, subject to plan approval.

You pay nothing........................................................................................................................... 15

Substance abuse Up to 30 days per year in a substance abuse program. You pay nothing................................... 15 Comprehensive range of services such as diagnosis and treatment of illness or injury, including specialists care; preventive care, including well- baby care, periodic check- ups and routine immunizations; laboratory tests and X- rays; complete maternity care. You pay nothing for office visits or house calls by a doctor.................................................................................. 11, 12

Home health care All necessary visits by nurses and health aides. You pay nothing....................................... 11, 12

Mental conditions All medically necessary outpatient mental health care, subject to plan approval.

You pay nothing......................................................................................................................... 15

Substance abuse Up to 20 outpatient visits per year. You pay nothing................................................................. 15

Emergency care Reasonable charges for services and supplies required because of a medical emerg e n c y. You pay

nothing to the hospital for each emergency room visit and any charges for services that are not covered by this Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 4

Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy. You pay nothing for formulary drugs. All non- formulary drugs require a $10 copayment. ........................................................... 16

Dental care Accidental injury benefit; you pay nothing; emergency dental care; preventive dental care; comprehensive range of restorative, orthodontic and other services.

You pay nothing for preventive and diagnostic services; 50% of charges for all other covered services......................................................................................................................................... 17

Vision care One refraction annually. You pay nothing.................................................................................. 17

Out- of- pocket maximum Your out- of- pocket expenses for benefits covered under this Plan are limited to the stated copayments which are required for certain dental and prescription benefits only........................ 8

Inpatient care

Outpatient care

1999 Rate Information for Family Health Plan

Non- Postal rates apply to most non- Postal enrollees. If you are in a special enrollment category, refer to the FEHB Guide for that category or contact the agency that maintains your health benefits enrollment.

Postal rates apply to most career U. S. Postal Service employees, but do not apply to non- career Postal employees, Postal retirees, certain special Postal employment categories or associate members of any Postal employee organization. If you are in a special Postal employment category, refer to the FEHB Guide for that category.

Non- Postal Premium Postal Premium Biweekly Biweekly Monthly Type of Enrollment Code Govt

Share Govt Share USPS

Share Your Share Your

Share Your Share Self Only WH1 $72.06 $34.49 $156.13 $74.73 $84.98 $21.57 Self and Family WH2 $160.39 $115.79 $347.51 $250.88 $183.29 $92.89