RI-47 cover 99.q

A Health Maintenance Organization Serving: Metropolitan Washington, DC, Area and Metropolitan Baltimore, Maryland Area Enrollment in this Plan is limited; see page 8 for requirements.

Enrollment code: E31 Self only E32 Self and family

Important Notice: A copay will apply to office visits and outpatient surgery visits. Visit the OPM website at http:// www. opm. gov/ insure

and this Plans National website at http:// www. kaiserpermanente. org

United States Office of Personnel Management

Authorized for distribution by the:

RI 73- 047 Kaiser Foundation Health Plan

of the Mid- Atlantic States, Inc.

8/ 98- 8/ 01 This Plan has full accreditation from NCQA. See the 1999 Guide for more

information on NCQA.

1999

For changesin benefits see page

22.

Kaiser Foundation Health Plan of the Mid- Atlantic States, Inc.

Kaiser Foundation Health Plan of the Mid- Atlantic States, Inc., 2101 East Jefferson Street, Rockville, MD 20849 has entered into a contract (CS 1763) 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 Kaiser Permanente 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. 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 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; Conversion to individual coverage and Certificate of Creditable coverage)

Facts about this Plan ...................................................................................................................................................... 6- 8 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; Experimental/ investigational determinations; Other considerations; The Plans service areas

General Limitations ....................................................................................................................................................... 8- 9

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

General Exclusions ....................................................................................................................................................... 9- 10 Benefits ........................................................................................................................................................................ 10- 16

Medical and Surgical Benefits; Hospital/ Extended Care Benefits; Travel Benefits/ Benefits Available Away From Home; Emergency Benefits; Mental Conditions/ Substance Abuse Benefits; Prescription Drug Benefits

Other Benefits............................................................................................................................................................. 16- 19

Dental care; Vision care

Non- FEHB Benefits ......................................................................................................................................................... 20 How to Obtain Benefits.............................................................................................................................................. 21- 22 How Kaiser Foundation Health Plan of the Mid- Atlantic States, Inc. Changes January 1999 ............................... 22 Summary of Benefits ....................................................................................................................................................... 23 Rate Information ............................................................................................................................................................. 24

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 301/ 468- 6000 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

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.

Use this brochure as a guide to coverage and obtaining benefits. There may be a delay before you 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 pages 13- 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 12.

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.

Confidentiality If you are a new member

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 discharged 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, however, 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.

An enrollee 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.

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.

If you are hospitalized

Your responsibility

Things to keep in mind

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 employees 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 charge. 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.

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.

Coverage after enrollment ends

Former spouse coverage

Temporary continuation of coverage (TCC)

Notification and election requirements

General Information continued

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. A family 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.

Under Federal law, if you lose coverage under the FEHB Program, you should automatically receive a Certificate of Group Health Plan Coverage from the last FEHB Plan to cover you. This certificate, along with any certificates you receive from other FEHB plans you may have been enrolled in, may reduce or eliminate the length of time a preexisting condition clause can be applied to you by a new non- FEHB insurer. If you do not receive a certificate automatically, you must be given one on request.

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 other providers to give care to members and pays them directly for their services. Benefits are available 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.

Information you have a right to know

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 (301) 468- 6000 or you may write the Carrier at Kaiser Foundation Health Plan of the Mid- Atlantic States, Inc., 2101 E. Jefferson Street, P. O. Box 6103, Rockville, Medical Director 20849- 6103 You may also contact the Carrier by fax at 301- 816- 7482 at its website at http:// www. kaiserpermanente. org, or by email at kaiseronline. org.

Information that must be made available to you includes: Disenrollment rates for 1997. Compliance with State and Federal licensing or certification requirements and the dates met. If noncompliant, the reason for noncompliance.

Accreditations by recognized accrediting agencies and the dates received. Carriers type of corporate form and years in existence. Whether the carrier meets State, Federal and accreditation requirements for fiscal solvency, confidentiality and transfer of medical

records. Kaiser Foundation Health Plan of the Mid- Atlantic States, Inc., is a Federally qualified Health Maintenance Organization. The Plan has been delivering prepaid health services to Washington, D. C., area residents since December 1972. Presently it serves nearly 550,000 members in the Washington, D. C., and Baltimore, Maryland metropolitan areas.

This Plan offers comprehensive health care coverage on a prepaid group practice basis through Plan Medical Centers and other designated locations conveniently located throughout the Washington, D. C., and Baltimore, Maryland metropolitan areas. Except in emergencies, all care is provided at these facilities or otherwise arranged by the Plan. Health Plan contracts with the Mid- Atlantic Permanente Medical Group, P. C. ( Plan doctors), an independent multi- specialty group of physicians, to provide or arrange all necessary physician care for Plan members. These Plan doctors are members of American Specialty Boards or are Board eligible. Medical care is provided through Plan doctors and other qualified medical personnel working together at Plan Medical Centers and other designated locations. Other necessary medical services are also available at Plan Medical Centers. Plan doctors also arrange any necessary specialty care. Hospital care is provided at local community hospitals.

The first and most important decision each member must make is the selection of a primary care doctor. Primary care doctors include internists, family practitioners, gynecologists and pediatricians. 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

Conversion to individual coverage

Role of a primary care doctor Who provides care

to Plan members?

Certificate of Creditable Coverage General Information continued

Plan providers are covered only when there has been a referral by the members primary care doctor with the following exception: a woman may see her Plan gynecologist for her annual routine examination without a referral.

The Plans provider directory lists primary care doctors (general practitioners, pediatricians, gynecologists 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 Member Services Department at 301/ 468- 6000 or 1- 800- 777- 7902; 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.

If you enroll, you will be asked to select a primary care doctor for you and each member of your family and inform your Plan of your choice. You are free to see other Plan doctors if your primary care doctor is not available, and to receive care at other Kaiser Permanente facilities. Members may change their doctor selection by notifying the Plan at any time.

If you are receiving services from a Plan doctor who terminates his or her association with the Plan, 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 another Plan doctor.

Except in a medical emergency or for follow- up or continuing care services, you must contact your primary care doctor for a referral before seeing any other doctor or obtaining special services. Referral to a Plan specialist is given at the primary care doctors discretion; if specialists or consultants are required beyond those who are Plan doctors, the primary care doctor will make arrangements for appropriate referrals.

If you have a chronic, complex, or serious medical condition that causes you to see a Plan specialist frequently, your primary care doctor will develop a treatment plan with you and your health plan that allows an adequate number of direct access visits with that specialist. The treatment plan will permit you to visit your specialist without the need to obtain further referrals.

When you receive a referral from your primary care doctor, you must return to the primary care doctor after the consultation. On referrals, your 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.

The Plan will provide benefits for covered services only when the services are medically necessary to prevent, diagnose or treat your illness or condition. Your Plan doctor must obtain the Plans determination of medical necessity before you may be hospitalized, referred for specialty care or obtain follow- up care from a specialist.

If you are already under the care of a specialist who is a Plan participant, you must still obtain a referral from a Plan primary care doctor for the care to be covered by the Plan.

If you are selecting a new primary care doctor and want to continue with this specialist, you must schedule an appointment so that the primary care doctor can decide whether to treat the condition directly or refer you to a specialist.

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

Copayments are required for a few benefits. However, copayments will not be required for the remainder of the calendar year after your out- of- pocket expenses for services provided or arranged by the Plan reach $1,500 per Self Only enrollment or $3,000 per Self and Family enrollment. This copayment maximum does not include costs of prescription drugs, cosmetic services, chiropractic and acupuncture services, the $25 charges paid for follow up or continuing care and all mental conditions services except the first 20 outpatient visits.

You should maintain accurate records of the copayments made, as it is your responsibility to determine when the copayment maximum is reached. You are assured a predictable maximum in out- ofpocket costs for covered health and medical needs. Copayments are due when service is rendered, except for emergency care.

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

Choosing your doctor

Facts about this Plan continued

Referrals for specialty care

Authorizations For new members

Hospital care Out- of- pocket maximum

Deductible carryover

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.

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.

A service is investigational if it is: (1) not approved by the FDA; or (2) the subject of a new drug or new device application on file with the FDA; or (3) part of a Phase I or Phase II clinical trial, as the experimental or research arm of a Phase III clinical trial; or is intended to evaluate the safety, toxicity, or efficacy of the service; or (4) provided pursuant to a written protocol that evaluates the services safety, toxicity, or efficacy; or (5) subject to the approval or review of an Institutional Review Board; or (6) provided pursuant to informed consent documents that describe the service as experimental or investigational. The Plan and its Medical Group carefully evaluate if a particular therapy is either proven to be safe and effective or offers a degree of promise with respect to improving health outcomes. The primary source of evidence about health outcomes of any intervention is peer- reviewed medical literature.

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 must live or work in the service area to enroll in this Plan.

The District of Columbia; the Maryland counties of Montgomery, Prince Georges, and the portions of Charles, Calvert and Frederick Counties served by the following zip codes: Charles County 20601, 20602, 20603, 20604, 20612, 20616, 20617, 20637, 20640, 20646, 20658, 20675, 20695; Calvert County 20639, 20689, 20714, 20732, 20736, 20754; Frederick County 21702, 21705, 21709, 21710, 21714, 21716, 21717, 21718, 21754, 21755, 21758, 21762, 21769, 21770, 21774, 21777, 21790, 21793; the City of Baltimore, and the counties of Baltimore, Carroll, Hartford, Howard and Anne Arundel counties; the Virginia cities of Alexandria, Fairfax, Falls Church, Manassas, Manassas Park, as well as the Virginia counties of Arlington, Fairfax, Loudoun, and Prince William.

Benefits for care outside the service area are limited to emergency services, follow- up or continuing care services and services from other Kaiser Permanente plans, as described on page 13.

If you or a covered family member travels frequently or lives away from home part of the year, you should be aware that benefits for care outside the service area are restricted to follow- up or continuing care services, services from other Kaiser Permanente plans and emergency care benefits as described on pages 13- 14. The service area is the area within which the Plans providers are most accessible. For this Plan, the service area is the same as the enrollment area listed on the front cover of this brochure (the area in which you must live or work to enroll in this Plan).

If you or a covered family member move outside the service area, (or if you no longer work there) 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

Although a specific service may be listed as a benefit, it will be covered for you only if, in the judgment 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.

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 services. However, the Plan will not be responsible for any delay or failure in providing service due to lack of available facilities or personnel.

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.

The Plans service areas Other

considerations Submit claims

promptly

Facts about this Plan continued

Circumstances beyond Plan control

Other sources of benefits Experimental/

investigational determinations

Important notice

General Limitations continued

If you or a covered family member is enrolled in this Plan and Medicare Part A and/ or Part B, the Plan will coordinate benefits according to Medicares determination of which coverage is primary. However, this Plan will not cover services, except those for emergencies, follow- up or continuing care, unless you use Plan providers. You must tell your Plan that you or your family member is eligible for Medicare. Generally, this 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 automobile insurance, including nofault, the 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.

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 care provider must authorize all care. See your CHAMPUS Health Benefits Advisor if you have questions about CHAMPUS coverage.

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 workers compensation (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 workers compensation 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 (or the agency).

Facilities of the Department of Veterans Affairs, 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.

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 treat your illness or condition as discussed under Authorizations on page 7. The following are excluded:

Medicare Group health insurance and automobile insurance

CHAMPUS Medicaid Workers compensation

DVA facilities, DoD facilities and Indian Health Service

Other Government agencies

Liability insurance and third party actions

Care by non- Plan doctors or hospitals except for authorized referrals or emergencies and services received under the Travel Benefit (see Emergency Benefits and Benefits Available Away From Home); 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

A comprehensive range of preventive, diagnostic and treatment services is provided by Plan doctors and other Plan providers. This includes all necessary office and outpatient surgery visits. You pay a $5 per office visit charge for the following: Preventive care, including office visits for children over 3 years of age. Pediatric visits for children up to age 3 are provided at no charge. Mammograms are covered as follows: for women age 35 through 39, one mammogram during

these five years; for women age 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 at no charge. 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 at no charge Complete obstetrical (maternity) care for all covered females, including prenatal, delivery and

post- natal care by a Plan doctor. Copays are waived for scheduled prenatal visits and the first post- partum visit. 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 necessary. 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 Allergy testing and treatment, including testing and treatment materials (such as allergy serum) The insertion of covered internal prosthetic devices, such as pacemakers and artificial joints. Cornea, heart, heart- lung, kidney, simultaneous pancreas- kidney, liver and lung (single and double) transplants; allogeneic (donor) bone marrow transplants; autologous bone marrow transplants

(autologous stem cell and peripheral stem cell support) for the following conditions: acute lymphocytic on non- lymphocytic leukemia, advanced Hodgkins lymphoma, advanced non- Hodgkins lymphona, advanced neuroblastoma, breast cancer; multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors. Transplant services are not available for ovarian carcinoma. Transplants are covered when approved by the Medical Group. Related medical and hospital expenses of the donor are covered. 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 (office visit charges will be waived if you enroll in Medicare Part B and assign your

Medicare benefits to the Plan) Chemotherapy, radiation and inhalation therapy Surgical treatment of morbid obesity Home health services of doctors, 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; at no charge. Medical management of mental health conditions, including drug therapy evaluation and maintenance

Medical food and low protein modified food products for the treatment of inherited metabolic disease will be covered if the medical food and low protein modified food products are: (a) prescribed and pre- authorized as medically necessary for the therapeutic treatment of inherited metabolic diseases; and (b) administered under the direction of a physician; at no charge

What is covered

10 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

General Exclusions continued

All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other plan providers.

If you do not pay any of the charges required for services at the time you receive the services, you will be billed for those charges. You will also be required to pay an administrative charge of $10 for each service for which a bill is sent.

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. All other procedures involving the teeth or intra- oral areas surrounding the teeth are not covered (except as shown on pages 16- 18 under Dental care) including shortening of the mandible or maxillae for cosmetic purposes, correction of malocclusion, and any dental care involved in treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

Cleft lip and Cleft palate: Coverage shall include benefits for inpatient or outpatient expenses arising orthoodontics, oral surgery, and orthologic, audiological, and speech/ language treatment for the management of the birth defect cleft lip or cleft palate or both.

General Anesthesia for Dental Care: General anesthesia and associated hospital or ambulatory charges in conjunction with dental care for members age 7 or younger or is developmentally disabled; or is extremely uncooperative, fearful, or uncommunicative child age 17 or younger with dental needs that treatment should not be delayed or deferred. Coverage does not apply to care for temporal mandibular joint disorders.

Qualified Medical Clinical Trials: Clinical trials that provide treatment for life threatening conditions; or is for prevention, early dectection, and treatment studies of cancer. If the treatment or studies are being conducted in a Phase I, II, III, or IV clinical trial for cancer; or Phase II, III, or IV clinical trial for any other life threatening condition. Coverage may be provided for a Phase I clinical trial for these conditions on a case by case basis.

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 surgery.

Short- term rehabilitative therapy (physical, speech and occupational) is provided on an inpatient or outpatient basis for up to two consecutive months per condition if significant improvement can be expected within two months, you pay $5 per visit. 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. You may receive outpatient or inpatient therapy as part of a specialized therapy program in a specialized rehabilitation facility for up to two months per condition; you pay nothing.

Diagnosis and treatment of infertility is covered; you pay 50% of non- member rates. The following types of artificial insemination are covered: intravaginal insemination (IVI); intracervical insemination (ICI) and intrauterine insemination (IUI); cost of donor sperm and donor eggs and services related to their procurement and storage is not covered. Other assisted reproductive technology (ART) procedures, such as in vitro fertilization, gamete and zygote intrafallopian transfer, are not covered. Infertility services are not available when either member of the family has been voluntarily surgically sterilized. Drugs used for covered infertility treatments are provided under the Prescription Drug Benefit. Drugs related to non- covered infertility treatments are not covered.

Durable medical equipment (DME) for use in the members home will be provided for up to three months following a hospital confinement. Other durable medical equipment, such as wheelchairs, hospital beds and oxygen in the home is not covered.

Alternative therapy services Chiropractic and acupuncture services will be provided as a component of the Plans complementary and alternative medicine services, when your primary care physician, in consultation with the Plans Complementary and Alternative Medicine Department, determine that such care is appropriate. Chiropractic and acupuncture services are provided for up to 20 visits per therapy, per calendar year. You pay $15 per visit.

Blood Products, including gamma globulin and anti- hemophiliac factors Physical examinations that are not necessary for medical reasons, such as those required for

obtaining or continuing employment or insurance or governmental licensing Reversal of voluntary, surgically- induced sterility Surgery primarily for cosmetic purposes External and internally implanted hearing aids

11 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Medical and Surgical Benefits continued

Limited benefits What is not covered

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS Homemaker services

Long- term rehabilitative therapy Transplants not listed as covered Any eye surgery solely for the purpose of correcting refractive defects of the eye, such as nearsightedness myopia), farsightedness (hyperopia) and astigmatism. Orthopedic and prosthetic devices, such as braces, foot orthotics, artificial limbs and lenses following cataract removal Devices, equipment, supplies and prosthetics related to sexual dysfunction. ardiac rehabilitation Whole blood and packed red blood cells

Hospital/ Extended Care Benefits

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

Prescribed drugs and their administration, blood products and the administration of blood, biologicals, supplies, and equipment ordinarily provided or arranged as part of inpatient services

The Plan provides a comprehensive range of benefits for up to 100 days per calendar year when fulltime skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate. You pay nothing. All necessary services are covered, including:

Bed, board and general nursing care Prescribed drugs and their administration, biologicals, supplies, and equipment ordinarily provided or arranged by the skilled nursing facility

Supportive and palliative care for a terminally ill member is covered in the home. You pay nothing. Services include short- term 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.

Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor. You pay nothing.

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 and anesthesiology cost, but not the cost of the professional dental services. Conditions for which hospitalization may 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.

Personal comfort items, such as telephone and television Custodial care, or care in an intermediate care facility Whole blood and packed red blood cells

What is covered Hospital care

Extended care

Medical and Surgical Benefits continued

Hospice care Ambulance service

Acute inpatient detoxification Limited benefits

Inpatient dental procedures

What is not covered

Benefits Available Away From Home

When you are outside the service area of this Plan, you may still receive covered health care services. There are two types of coverage provided under your enrollment in this Plan.

When you are in the service area of another Kaiser Permanente plan, you are entitled to receive virtually all the benefits described in this brochure at any Kaiser Permanente medical office or medical center and from any Kaiser Permanente provider. You pay the charge required by the Plan you visit for services provided to federal enrollees in that Plans service area. If the Kaiser Permanente plan in the area you are visiting has a benefit that is different from the benefits of this Plan, you are not entitled to receive that benefit. Some services covered by this Plan, such as artificial reproductive services and the services of specialized rehabilitation facilities, will not be available in other Kaiser Permanente service areas. If a benefit is limited to a specific number of visits or days, you are entitled to receive only the number of visits or days covered by the plan in which you are enrolled.

If you are seeking routine, non- emergent or non- urgent services, you should call the Kaiser Permanente member services department in that service area and request an appointment. You may obtain routine follow- up or continuing care from these Plans, even when you have obtained the original services in the service area of this Plan. If you require emergency services as the result of an unexpected or unforeseen illness that requires immediate attention, you should go directly to the nearest Kaiser Permanente facility to receive care.

At the time you register for services, you will be asked to pay the copayment required under your enrollment in this plan.

If you plan to travel to an area with another Kaiser Foundation Health Plan and wish to obtain more information about the benefits available to you from that Kaiser Foundation Health Plan, please call the Member Services Office at (310) 468- 6000 in the Washington D. C. area or 1- 800- 777- 7902 in the Baltimore, Maryland area.

Benefits Available While You Travel

If you are outside the service area of this Plan by more than 100 miles, or outside the service area of any other Kaiser Permanente Plan, the following health care services will be covered:

Follow- up care care necessary to complete a course of treatment following receipt of covered outof- plan emergency care, or emergency care received from Plan facilities, if the care would otherwise be covered and is performed on an outpatient basis. Examples of covered follow- up care include the removal of stitches, a catheter or a cast.

Continuing care care necessary to continue covered medical services normally obtained at Plan facilities, as long as care for the condition has been received at Plan facilities within the previous 90 days and the services would otherwise be covered. Services must be performed on an outpatient basis. Services include scheduled well- baby care, prenatal visits, medication monitoring, blood pressure monitoring and dialysis treatments. The following services are not covered: hospitalization, infertility treatments, childbirth services, and transplants. Prescription drugs are not covered. However, you may have prescriptions filled by mail through this Plans Prescription Drug Benefit.

If you have any questions about how to use these benefits, call the travel benefit Information Line at 800/ 390- 3509. You may obtain the travel benefits for Federal Employees brochure by calling this number.

You should pay the provider at the time you receive the service. Submit a claim to the Plan for the services on the Plans Claim for Follow- up/ Continuing care medical Services Form, with necessary supporting documentation. Submit itemized bills and your receipts to the Plan along with an explanation of the services and the identification information from your ID card. Submit claims to Kaiser Foundation Health Plan of the Mid- Atlantic States, Inc., P. O. Box 6233, Rockville, Maryland, 20849- 6233. If the services are covered under this Travel Benefit, you will be reimbursed the reasonable charges for the care, up to a maximum of $1200 per calendar year. You pay $25 for each follow- up or continuing care visit. This amount will be deducted from the payment the Plan makes to you.

Emergency Benefits

A medical emergency is the sudden and unexpected onset of a condition or an injury that 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

Services From Other Kaiser Permanente Plans

What is a medical emergency?

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 the Plans 24- hour emergency number 1- 800- 677- 1112. Emergency care is available through Kaiser Permanente 24 hours a day, 7 days a week.

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 must notify the Plan within 48 hours. It is your responsibility to ensure that the Plan has been 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.

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

$35 per hospital emergency room visit for emergency services that are covered benefits of this Plan. If the emergency results in admission to a hospital, the charge is waived.

You may obtain emergency and urgent care services from Kaiser Permanente medical facilities and providers when you are in the service area of another Kaiser Permanente plan. The facilities will be listed in the local telephone book under Kaiser Permanente. You may also obtain information about these facilities by calling (301) 468- 6000.

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.

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

$35 per hospital emergency room visit for emergency services that are covered benefits of this Plan. If the emergency results in admission to a hospital, the charge is waived.

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

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

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 HCFA 1500 claim form. Submit claims to Kaiser Foundation Health Plan of the Mid- Atlantic States, Inc., P. O. Box 6233, Rockville, Maryland, 20849- 6233. 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 8.

Emergency Benefits continued

Emergencies outside the service area

Plan pays . . . You pay . . .

What is covered What is not covered

Filing claims for non- Plan providers

Emergencies within the service area

Mental Conditions/ Substance Abuse Benefits

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) Medical management visits, including drug evaluation and maintenance Hospitalization (including inpatient professional services)

Unlimited visits to Plan doctors, consultants, or other psychiatric personnel; you pay nothing for visits 1 through 5; you pay $10 for an individual visit and $5 for a group visit for visits 6 through 20; thereafter,

you pay $30 for an individual visit and $5 for a group visit. If you do not pay any of the charges required for services at the time you receive the services, you will be billed for those charges. You will also be required to pay an administrative charge of $10 for each service for which a bill is sent.

Unlimited number of days each calendar year; you pay nothing. Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject 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 that is not medically necessary to determine the appropriate treatment of a

short- term psychiatric condition 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 visits to Plan providers for treatment; you pay nothing for each visit. Acute detoxification; the Plan provides unlimited number of days for rehabilitative services in a hospital or specialized facility; you pay nothing.

Treatment that is not authorized by a Plan doctor Substance abuse treatment on court order or as a condition of parole or probation, unless determined by a Plan doctor to be necessary and appropriate

Prescription Drug Benefits

Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 90- day supply, based upon the prescribed dosage and standard manufacturers package size. You pay $7 per prescription unit or refill for drugs purchased at a Plan pharmacy.

Dental prescriptions are limited to formulary products for pain relief and antibiotics only. The Plan uses a formulary to determine which prescribed drugs will be provided to members. If the physician specifically prescribes a nonformulary drug, and does not prescribe a substitution, the nonformulary drug will be covered. If you request the nonformulary drug when your physician has prescribed a substitution, the nonformuarly drug is not covered. However, you may purchase the nonformulary drug from a Plan pharmacy at prices charged to members for non- covered drugs.

The following drugs are provided at the $7 charge (unless another charge is specifically identified): Drugs for which a prescription is required by law Oral contraceptive drugs, diaphragms and intrauterine devices (you pay $100 for an IUD) Implanted time release drugs; you pay a one- time payment equal to the $7 per prescription

charge times one half the expected number of months the medication will be effective, not to exceed $200. There will be no refund of any portion of these copayments if the implanted time release medication is removed before the end of its expected life. Injectable contraceptive drugs Insulin

15 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

What is covered Mental Conditions Outpatient care What is not covered

Inpatient care What is covered Substance abuse What is not covered

Outpatient care Inpatient care

What is covered

Diabetic test strips Self injectable drugs, other than ovulation stimulants (you pay $7 per prescribed therapeutic

course of treatment) Ovulation stimulants (you pay 25% of the average wholesale price)

The Plan provides the following at no charge Disposable needles and syringes needed for injecting covered prescribed drugs Amino acid modified products used in the treatment of inborn errors of amino acid metabolism

(PKU) Immunosuppressant drugs required after a covered transplant Intravenous fluids and medications for home use Chemotherapy drugs

Drugs to treat sexual dysfunction have dispensing limitations. You pay 50% of charges. Contact the Plan for details.

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 Drugs related to non- covered services, including infertility services Smoking cessation drugs Contraceptive devices, except diaphragms and intrauterine devices

Other Benefits

The following dental services are covered when provided by participating Plan general dentists. You pay copayments when services are performed by a general dentist. Services of a specialist can only be received by referral from a Plan general dentist. Higher copayments may apply for services received from a specialist.

Preventative and diagnostic services:

Initial and periodic examinations, bitewing X- rays, cleaning of teeth (prophylaxis) every six months, topical fluoride treatments, and preventive care training: You pay a $30 copayment per member per visit.

Schedule of dental services and fees:

16 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Prescription Drug Benefits continued

What is covered Dental Care

What is not covered Limited Benefits

Dental Services

PROCEDURE NAME You Pay*

ADA Diagnostic: 0210 Intraoral- Coml Ser Incl Bitewings $30/ 33 0330 Panoramic X- Rays 25/ 28 0460 Pulp Vitality Tests 14 0470 Diagnostic Casts 29

ADA Preventative: 1351 Sealant- Per Tooth 15 1510 Space Maintainer- Fixed Unilateral 164 1515 Space Maintainer- Fixed Bilateral 164 1520 Space Maintainer- Removable Unilateral 202 1525 Space Maintainer- Removable Bilateral 126 1550 Recementation of Space Maintainer 19

PROCEDURE NAME You Pay*

ADA Restorative: 2110 Amalgam- One Surface Primary $24 2120 Amalgam- Two Surfaces Primary 31 2130 Amalgam- Three Surfaces Primary 35 2131 Amalgam- Four+ Surfaces Primary 45

2140 Amalgam- One Surface Permanen 27 2150 Amalgam- Two Surfaces Permanent 35 2160 Amalgam- Three Surfaces Permanent 43 2161 Amalgam- Four+ Surfaces Permanent 51 2330 Resin- One Surface Anterior 33 2331 Resin- Two Surfaces Anterior 43 2332 Resin- Three Surfaces Anterior 52 2335 Resin- 3+ Surf or Involving Incisal Angle 56

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 17

Other Benefits continued

PROCEDURE NAME You Pay*

2510 Inlay- Metallic- One Surface 290 2520 Inlay- Metallic- Two Surfaces 315 2530 Inlay- Metallic- Three Surfaces 350 2540 Onlay- Metallic- Per- Tooth In Add To Inlay 385 2610 Inlay- Porcelain/ Ceramic- One Surface 445 2620 Inlay- Porcelain/ Ceramic- Two Surfaces 445 2630 Inlay- Porcelain/ Ceramic- Three Surfaces 445 2640 Onlay- Porcelain/ Ceramic- Per Tooth- Inlay 445 2710 Crown- Resin- Laboratory 210 2740 Crown- Porcelain/ Ceramic Substrate 470 2750 Crown- Porc Fused to Hi Noble Metal 450 2751 Crown- Porc Fused to Predom Base Metal 400 2752 Crown- Porc Fused to Noble Metal 425 2790 Crown- Full Cast High Noble Metal 455 2791 Crown- Full Cast Predom Base Metal 395 2792 Crown- Full Cast Noble Metal 415 2810 Crown- 3/ 4 Cast Metallic 465 2910 Recement Inlay 30 2920 Recement Crown 30 2930 Prefab Stainlss Steel Crwn- Prim Tooth 95 2931 Prefab Stainlss Steel Crwn- Perm Tooth 100 2932 Prefabreinted Resin Crown 140 2940 Sedative Fillings 30 2950 Crown Buildup- including any Pins 90 2951 Pin Reten- Per Tooth in Add to Resto 20 2952 Cast Post & Core in Add to Crown 130 2954 Prefab Post & Core in Add to Crown 115 2970 Temporary Crown (Fractured Tooth) 75 2980 Crown Repair 75

ADA Endodontics: 3110 Pulp Cap- Direct EXCL Final Rest $20/ 21 3120 Pulp Cap- Indirect EXCL Final Rest 20/ 21 3220 Therapeutic Pulpotomy Excl Final Rest 50/ 60 3310 One Canal Excl Final Restoration 214/ 270 3320 Two Canals Excl Final Restoration 249/ 420 3330 Three Canals Excl Final Restoration 265/ 520 3350 Apexification- Per Treatment 105/ 146 3410 Apicoectomy/ Periadicular Surg- Ant.. 132/ 340 3421 Apico/ Perirad Surg- Bicus First Root 132/ 415 3425 Apico/ Perirad Surg- Molar First Root 132/ 435 3426 Apico/ Perirad Srg- Molar Ea Add Root 44/ 165 3430 Retrograde Filling- Per Root. 93/ 175 3450 Root Amputation- Per Root 93/ 225 3920 Hemisect W Rt Tem- W/ O Canal Ther 112/ 200

ADA Periodontics: 4210 Gingivectomy/ Gingivoplasty- Per Quad $198/ 265 4221 Gingivectomy/ Gingivoplasty- Per Tooth 53/ 80 4220 Gingival Curettage- Per- Quad 60/ 125 4240 Gingival Flap Incl Rt Plan- Per Quad 198/ 340 4249 Crn Length- Hard/ Soft Tissue By Rep 232/ 320 4250 Muco- Gingival Surgery- Per Quad 232/ 330 4260 Oss Surg & Flap Ent/ Clos- Per Quad 331/ 590 4268 Guid Tis Rgen Inc Sur Re- ent By Rep 320/ 320 4270 Pedicle Soft Tissue Graft Procedure 159/ 375 4271 Free Soft Tissue Graft & Donor Site 232/ 455 4320 Provisional Splinting- lntracoronal 95/ 116

PROCEDURE NAME You Pay*

4321 Provisional Splinting- Extracoronal 66/ 120 4341 Root Planing- Per Quad 60/ 125 4910 Periodontal Maintenance 40/ 60

ADA Prosthetics Removable: 5110 Complete Uppr or Low (5120) Denture $495 5120 Complete Denture Lower 495 5130 Immediate Upper or Lower (5140) Denture 495 5211 U Par- Acry Bs & Conv Clasps & Rests 340 5212 L Par- Acry Bs & Conv Clasps & Rests 420 5213 U Par Rs Cst Bs W Acry Sdls & C & R 535 5214 L Par Bs Cst Bs W Acry Sdls & C & R 535 5281 Rm Uni Par D- l Pc- Bs Cst- Clsp- Per Unit 40 5410 Adjust Dent- Compl/ Part Upper, Lower 65 5510 Repair Broken Compl Denture Base 50 5520 Repair Miss/ Brkn T- Compl Dent EAT 40 5610 Repair Acrylic Saddle or Base 50 5620 Repair Cast Framework 55 5630 Repair or Replace Broken Clasp 45 5640 Replace Broken Teeth- Per Tooth $45 5650 Add Tooth to Existing Partial Denture65 5660 Add Clasp to Existing Partial Denture 90 5710 Rebase Dent- Compl/ Part Upper, Lower 175 5730 Reline Dent- Compl/ Part- Up Lo Chairside 120 5750 Reline Dent- Compl/ Part- Up Lo Lab 140 5825 Dent Temp Partial- Stayplate U/ L 195 5850 Tissue Conditioning- Per Dent Uni 45 5851 Tissue Conditioning Lower- Denture 50

ADA Prosthetics Fixed: 6210 Pontic- Cast High Noble Metal $445 6211 Pontic Cast Predom Base Metal 410 6212 Pontic- Cast Noble Metal 410 6240 Pontic- Porc Fused to Hi Noble Metal 440 6241 Pontic- Porc Fused to Predom Base Metl 385 6242 Pontic- Porc Fused to Noble Metal 415 6520 Inlay- Metallic- Two Surfaces 315 6530 Inlay- Metallic- 3 or More Surfaces 350 6540 Onlay- Metallic- Per Tooth- Inlay 385 6545 Cast Metal Retainer for Acid Etch Brdg 200 6750 Crown- Porc Fused to Hi Noble Metal 450 6751 Crown- Porc Fused to Predom Base Metl 375 6752 Crown- Porc Fused to Noble Metal 405 6780 Crown- 3/ 4 Cast High Noble Metal 425 6790 Crown- Full Cast Hi Noble Metal 455 6791 Crown- Full Cast Predom Base Metal 405 6792 Crown- Full Cast Noble Metal 415 6930 Recement Bridge 35

ADA Oral Surgery: 7110 Single Tooth Extraction $40/ 45 7120 Each Additional Tooth Extraction 35/ 40 7130 Root Removal- Exposed Roots 25/ 35 7210 Surgical Removal of Erupted Tooth 50/ 90 7220 Rem Impacted Tooth- Soft Tissue 46/ 115 7230 Rem Impacted Tooth- Partial Bony 60/ 145 7240 Rem Impacted Tooth Complete Bony 99/ 170 7250 Surg Rem Resid T Roots- Cutting Proc 53/ 95

PROCEDURE NAME You Pay*

7260 Oroantral Fistula Closure 152/ 190 7270 Tooth Replantation 93/ 215 7280 Surg Expos Imp/ Unerup Tooth- Ortho 112/ 185 7281 Surg Expos Imp/ Unerup Tooth- Aid Erup 79/ 150 7285 Biopsy of Oral Tissue Hard 66/ 115

ADA Oral Surgery: 7286 Biopsy of Oral Tissue Soft $66/ 100 7291 Transseptial Fiberotomy 30/ 30 7310 Alveolopl In Conj W Extract- Per Quad 53/ 105 7320 Alveoloplasty No Extract- Per Ouad 66/ 120 7410 Radical Excision- Lesion to 1.25 Cm 79/ 150 7420 Radical Excision- Lesion over 1.25 Cm 126/ 225 7430 Exc Benign Tumor- Lesion to 1.25 Cm 99/ 160 7431 Exc Benign Tumor- Lesion Over 1.25 Cm 132/ 265

ADA Oral Surgery: 7450 Rem Odon & Cyst/ Tum- Les to 1.25 Cm 99/ 160 7451 Rem Odont Cyst/ Tum- Les > 1.25 Cm 132/ 165 7460 Rem NonOdont Cyst/ Tum- Les to 1.25 Cm 99/ 160 7461 Rem NonOdont Cyst/ Tum- Les 1.25 Cm 132/ 265 7470 Removal Exostosis- Maxilla or Mandible 172/ 250 7480 Part Ostectomy Gutter or Sauceri 265/ 265 7510 I& D Abscess- lntraoral Soft Tissue $53/ 70 7520 I& D Abscess- Extraoral Soft Tissue 53/ 70 7550 Sequestrectomy for Osteomyelitis 145/ 145 7510 I& D Abscess- Intraoral Soft Tissue 53/ 70 7530 Rem Frn Bdy/ Skn/ Subcut Areo Tissue 107/ 160 7910 Suture Simple Wounds up to 5 Cm 35/ 35

PROCEDURE NAME You Pay*

7911 Suture of Complex Wounds 70/ 70 7960 Frenectomy Frenec/ Frenot- Sep Proc 86/ 185 7970 Exc of Hyperplastic Tissue- Per Arch 53/ 85 7971 Excision of Pricoronal Gingiva .60/ 140

ADA Orthodontics: 8440 Orthodontic Fully Banded (2Yr) Case 2375

ADA Additional Procedures: 9110 Palliative Tx- Emer Treat Dent Pain- Minor $25 9220 General Anesthesia 66/ 165 9221 Gen Aneth Each Addl 15 min 33/ 110 9230 Analgesia (Nitrous Oxide) 15/ 20 9240 Intravenous Sedation (Per 2 Hour) 99/ 160 9310 Consultation (Per Session) 40/ 44 9910 Application of Desensitizing Medication 25/ 25 9940 Occlusal Guards By Report 145/ 240 9951 Occlusal Adjustment- Limited 33/ 51 9952 Occlusal Adjustment- Complete 132/ 218 9980 Sterilization Surcharge (Per Visit) .5/ 5 9990 After Hours Surcharge 25/ 25 9999 Broken Appointment Fee (Per 2 Hr) 15/ 15

*When two copayments are listed, the amount on the left is due when service is provided by a general Dentist; the amount on the right is due when service is provided by a Specialist.

Lab fees for biopsies and excisions are to be paid by the patient. Orthodontic benefits for ages 19 and under; adult orthodontics are not covered.

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 18 There will be a $25 surcharge for covered dental services provided after- hours and a $15 broken appointment fee applies to each one half

hour of scheduled appointment time. For a complete listing of participating Plan dentists please call the Kaiser Dental Plan in the Washington area 301/ 986- 5600, 1- 800/ 638- 8847 in the Baltimore area or call the Plans Member Services Department.

Restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth are covered up to a maximum benefit amount per accident of $2,000. A sound natural tooth is one that has not been weakened by existing dental pathology, such as decay or periodontal disease, one that has been previously restored by a crown, inlay, onlay, porcelain restoration or treatment by endodontics. The need for these services must result from an accidental injury from an external force (not chewing). The accident must be reported to a Plan provider within 72 hours of the event. Services must be provided within the 12- month period immediately following the injury and must start within 60 days of the accident. You must pay $5 per office visit. Coverage under this benefit is for the most cost- effective procedure that, in the opinion of the Plan dental provider, would produce a satisfactory result. No benefits will be available to replace teeth that have been knocked out, or that have been so severely damaged that, in the opinion of the Plan dental provider, restoration is impossible.

Hospitalization for dental procedures, except as covered under Hospital/ Extended Care BenefitsLimited benefits Replacement of dentures or bridge work due to loss or theft or accidental injury Dental procedures or services for cosmetic purposes Other dental services not shown as covered Laboratory fees for biopsies and excisions Fully banded orthodontics for members ages 20 and over

In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye, this Plan provides certain vision care benefits from Plan providers.

Routine eye examinations, including lens prescription for eyeglasses. You pay $10 per examination.

Other Benefits continued

Accidental injury benefit

What is not covered

Vision care What is covered

19 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS Eyeglasses including frames and lenses, and the initial fitting and purchase of contact lenses. You

pay all charges less 25% off the usual and customary charges on all purchases of eyeglass lenses and frames and less 15% off the usual and customary charge on the cost of the initial fitting and purchase of contact lenses. Members may apply the above discounts to purchases of lenses and frames as often as they wish.

Eye exercises Cost of eyewear not purchased at Plan facilities

What is not covered Other Benefits continued

NON- FEHB BENEFITS AVAILABLE TO PLAN MEMBERS

This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare. As indicated on Page 5, annuitants and former spouses with FEHB coverage and Medicare Parts A & B may elect to either drop their FEHB coverage and enroll in a Medicare prepaid plan or remain enrolled in FEHB Program and simultaneously enroll in the Medicare Prepaid plan when one is available in their area. Those members who choose to disenroll from the FEHB Program may then later re- enroll in the FEHB Program.

Most Federal annuitants have Medicare Part A (hospital coverage). Those without Medicare Part A may join this Medicare prepaid plan after they have elected to purchase Medicare Part A in addition to continuing to pay their Part B premium. Before you drop your FEHB coverage and apply for coverage in the Medicare Prepaid plan, please contact us so we may help you determine your Medicare A & B eligibility.

If you are interested in dropping your FEHB enrollment please contact your retirement system for more information. For information on the Medicare Prepaid Plan please contact us at the numbers listed below based on your resident:

The District of Columbia and the following cities and counties in Virginia: Alexandria, Arlington, Fairfax, Fairfax City, Falls Church Loudoun, Manassas, Manassas Park, Prince William please call (800) 281- 8797. The following cities and counties in the State of Maryland: Baltimore,

Baltimore City, and the following zip codes within Anne Arundel county: 20794, 21060, 21076, 21077, 21090, 21108, 21122, 21144, 21146, 21226 and 21240 please call (800) 203- 2808. The following counties in the State of Maryland, Montgomery, Prince

Georges, and the following zip codes within Charles county: 20601, 20602, 20603, 20604, 20612, 20616, 20617, 20637, 20640, 20643, 20646, 20658, 20675 and 20695 please call (800) 229- 5591.

Benefits on this page are not part of the FEHB contract CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Medicare Prepaid Plan Enrollment

How to Obtain Benefits

If you have a question concerning Plan benefits or how to arrange for care, contact the Plans Membership Service Office at 301/ 468- 6000 in Rockville, MD or 1- 800- 777- 7902 in the Baltimore area or you may write to the Plan at 2101 East Jefferson Street, Box 6103, Rockville, MD 20849- 6103. You may also access the Plans National Web site at http:// www. kaiserpermanente. org. You may also contact the Plan by fax at (301) 816- 7482.

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.

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 written 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; A copy 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 doctors letters, 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 Act.

Send your request for review to: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3, 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.

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Questions Disputed claims review

OPM review Plan

reconsideration

22 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 Plans denial of the benefit. The recovery in such a suit is limited to the amount of benefits in dispute.

Privacy Act statement C 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.

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

How to Obtain Benefits continued

How Kaiser Foundation Health Plan of the Mid- Atlantic States, Inc. Changes January 1998

Do not rely on this page; it is not an official statement of benefits. Program- wide changes Several changes have been made to comply with the Presidents mandate to implement the recommendations of the Patient Bill of Rights. Women may see their Plan gynecologist as a primary care doctor (See page 7). If you have a chronic, complex, or serious medical condition that causes you to frequently see a Plan specialist,

your primary care doctor will develop a treatment plan with you and your health plan that allows an adequate number of direct access visits with that specialist, without the need to obtain further referrals (See page 7 for details). A medical emergency is defined as 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 (See page 13). The medical management of mental conditions will be covered under this Plans Medical and Surgical Benefits

provisions. 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 Plans Mental Conditions Benefit.

Changes to this Plan: The copayment for office visits and outpatient surgery visits has increased from $0 to $5, except for scheduled prenatal visits, the first post partum visit, and pediatric visits for children up to age 3 (See page 10). A charge of $10 will be added to any office visit charge that is not paid at the time the member receives services

(See page 11). An out- of- pocket maximum of $1,500 for Self Only and $3,000 for Self and Family has been added (See page 7). The copayment for short- term physical therapy visits has increased from $0 to $5 (see page 11). Chiropractic and acupuncture services will be covered up to 20 visits per therapy, per calendar year with a $15

copay per visit (See page 11). Diagnosis and treatment of infertility will be covered with a 50% copay (See page 11). Drugs to treat sexual dysfunction are covered under this Plans Prescription Drug Benefit (See page 16). Devices, equipment, supplies and prosthetics related to the treatment of sexual dysfunction are not covered (See

page 12). Blood products, including gamma globulin and anti- hemophiliac factors will be covered with no copay (See page 11). A travel benefit that covers follow- up and continuing care will be added up to a maximum of 1,200 per calendar

year (See page 13). Dialysis services will be provided at the office visit charge of $5. However, if a member is covered by Part B of

medicare and assigns to the Plan the right to collect payment from medicare for these services, the office visit charge will be waived (See page 10). Accidental dental benefits will be provided with a $5 copay per visit up to a maximum of $2,000 per accident (See

page 18).

Summary of Benefits for Kaiser Foundation Health Plan of the Mid- Atlantic States, Inc. - 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, FOLLOWUP AND CONTINUING CARE AND CARE RECEIVED FROM OTHER KAISER PERMANENTE PLANS 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Extended care All necessary services, for up to 100 days per calendar year. You pay nothing . . . . . .12

Mental conditions Diagnosis and treatment of acute psychiatric conditions for unlimited number of days of inpatient care per calendar year. You pay nothing . . . . . . . . . . . . . . . . . . . . . .15

Substance abuse Inpatient rehabilitation services. You pay nothing for unlimited number of days in a hospital or specialized facility per calendar year . . . . . . . . . . . . . . . . . . . . . . . . . . .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 $5 per office visit; nothing per house call by a doctor . .10- 11

Home health care All necessary visits by nurses and health aides. You pay nothing per visit . . . . . . . . .10

Mental conditions Unlimited visits per year. You pay nothing for the first five visits, then $10 for individual visits, $5 for group visits 6- 20; then $30 for individual visits; $5 for group visits for the remainder of the calendar year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Substance abuse Outpatient counseling and treatment; you pay nothing . . . . . . . . . . . . . . . . . . . . . . . .15 Reasonable charges for services and supplies required because of a medical emergency.

You pay $35 per emergency room visit, except for services that are not covered benefits of this Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13- 14

Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy. You pay $7 per prescription unit or refill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15- 16

Accidental injury benefit; you pay nothing. Preventive dental care, comprehensive range of restorative, orthodontic, and other services. You pay copays for these services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16- 18

Refractions including lens prescription: You pay $10 per examination. Eyeglasses including frames and lenses, and the initial fitting and purchase of contact lenses (see page 18) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18- 19

Copayments will not be required for the remainder of the calendar year after your out- of- pocket expenses for services provided or arranged by the Plan reach $1500 per Self only enrollment or $3000 per Self and Family enrollment . . . . . . . . . . . . . . . .7

Inpatient care Outpatient care Emergency care Prescription drugs Dental care

Vision care Out- of- pocket maximum

1999 Rate Information for Kaiser Foundation Health Plan of the Mid- Atlantic States, Inc. 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 Monthly Biweekly Type of Govt Your Govt Your USPS Your Enrollment Code Share Share Share Share Share Share

Self Only E31 $65.50 $21.83 $141.92 $ 47.30 $ 77.51 $ 9.82 Self and Family E32 $160.39 $55.27 $347.51 $119.75 $183.29 $32.37