Postmasters 1999

A Managed Fee- for- Service Plan with a Preferred Provider Organization

and a Point of Service Product Sponsored by: the National League of Postmasters of the United States.

Who may enroll in this Plan: All Federal employees and annuitants who are eligible to enroll in the Federal Employees Health Benefits Program and who are, or become, members or League Benefit Members of the National League of Postmasters of the United States.

To become a member or League Benefit Member: To be eligible for membership in the League, you must be an active or retired employee of the Federal government or the United States Postal Service.

Annuitants (retirees) may enroll in this Plan.

Membership dues: New League Benefit Members will be billed separately $35 for annual dues when the Plan receives notice of enrollment. Continuing members will be billed by the League for the annual membership dues.

Postmaster members must pay dues based on level of office. Dues are paid by payroll deduction or annually at the option of the Postmaster. Continuing Postmaster members are billed annually for membership dues.

Enrollment code for this Plan: HIGH OPTION STANDARD OPTION 361 Self only 364 Self only 362 Self and family 365 Self and family

Visit the OPM website at http:// www. opm. gov/ insure Postmasters Benefit Plan 1999

RI 71- 13

Authorized for distribution by the:

United States Office of Personnel Management

For changesin benefitssee page 43.

Postmasters Benefit Plan

The National League of Postmasters of the United States, Washington, D. C., (Carrier) has entered into Contract No. CS 1071 with the Office of Personnel Management (OPM) to provide a health benefits plan (Plan) authorized by the Federal Employees Health Benefits (FEHB) law. The FEHB contract specifies the manner in which it may be modified or terminated.

This brochure is the official statement of benefits on which you can rely. It describes the benefits, exclusions, limitations, and maximums of the Postmasters Benefit Plan for 1999 and until amended by future benefit negotiations between OPM and the Carrier. It also describes procedures for obtaining benefits. You should use this brochure to determine your entitlement to benefits. Oral statements cannot modify the benefits described in this brochure.

An enrollee does not have a vested right to receive the benefits in this brochure in 2000 or later years, and does not have a right to benefits available prior to 1999 unless those benefits are contained in this brochure.

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 which may 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, pharmacy, etc., 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 (doctor, hospital, etc.) 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 Carrier at 703/ 683- 5585 and explain the

situation. If the matter is not resolved after speaking to your Carrier (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 benefits 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.

When you need help with Plan benefits, or getting your ID card, call your Plan at 703/ 683- 5585. The Fraud Hotline cannot help you with these.

Using This Brochure

The Table of Contents and Index will help you find the information you need to make the best use of your benefits. To get the best value for your money, you should read Facilities and Other Providers. It will help you understand how your choice of doctors and hospitals will affect how much you pay for services under this Plan.

This brochure explains all of your benefits. Its important that you read about your benefits so you will know what to expect when a claim is filed. Most of the benefit headings are self- explanatory. Other Medical Benefits and Additional Benefits, on the other hand, both include a variety of unrelated benefits. What is different about these benefits is how they are paid: Other Medical Benefits are paid after you satisfy the calendar year deductible and Additional Benefits are generally not subject to the calendar year deductible.

You will find that some benefits are listed in more than one section of the brochure. This is because how they are paid depends on which provider bills for the service. For example, physical therapy is paid one way if it is billed by an inpatient facility and paid another way when it is billed by a doctor, physical therapist or outpatient facility.

The last part of the brochure contains information useful to you under certain circumstances. For example, if you have to go to the hospital you need to read Precertification; hospital stays must be precertified for all payable benefits to apply. If you are enrolled in Medicare, take a look at This Plan and Medicare. And, the Enrollment Information section tells you about several FEHB enrollment requirements that could affect your future coverage.

How This Plan Works

Table of Contents

How This Plan Works

Page Help Contain Costs ....................................................................................................................................................... 5

Ways you and the Carrier can work together to keep costs down

Facilities and Other Providers ................................................................................................................................. 5- 7 Medical personnel and facilities covered by this Plan and how your choice of provider will affect what you pay for benefits

Cost Sharing................................................................................................................................................................. 7- 8 What you need to know about deductibles, coinsurance and copayments, your share of covered health care expenses, and the maximum amounts this Plan will pay for certain types of care

General Limitations ................................................................................................................................................. 9- 10 How the Plan works if you have other health care coverage or receive health care services through another Government program; limit on your costs if you are 65 or older and dont have Medicare

General Exclusions ...................................................................................................................................................... 11 What is not covered by this Plan

Benefits

Inpatient Hospital Benefits ................................................................................................................................... 12- 13 Your benefits for inpatient hospital care (see below for mental conditions/ substance abuse care)

Surgical Benefits ..................................................................................................................................................... 13- 15 Your benefits for doctors services for inpatient and outpatient surgery and related procedures

Maternity Benefits ................................................................................................................................................. 16- 17 Your benefits for prenatal care and childbirth

Mental Conditions / Substance Abuse Benefits ........................................................................................................ 17 Your benefits for outpatient, inpatient and other facility care for mental conditions, alcoholism, and drug abuse

Other Medical Benefits (deductible applies) ........................................................................................................ 18- 19 Your benefits for doctors home, office and inpatient visits, routine screening services, ambulance service, home nursing services, allergy treatment and injections, infertility treatment, chemotherapy, radiation therapy, lab tests and X- rays, renal dialysis, physical, occupational and speech therapy

Additional Benefits (no deductible) ............................................................................................................................ 20 Your benefits for chiropractic services, hospice care, immunizations, services for accidental injury, well child care and durable medical equipment (e. g. crutches and hospital beds) and emergency room

Prescription Drug Benefits ................................................................................................................................... 21- 22 Your benefits for prescription drugs and supplies you get from pharmacies or by mail order

Dental Benefits ....................................................................................................................................................... 23- 26 Your benefits for dental care

How to Claim Benefits .......................................................................................................................................... 27- 29 Getting your claims paid when your provider does not file them for you; how to ask OPM to review a claims dispute between you and the Carrier

Protection Against Catastrophic Costs ..................................................................................................................... 30 The maximum amount of covered expenses you can expect to pay for covered health care

Table of Contents continued

Page

Other Information

Information you have a right to know ..................................................................................................................... 31

Precertification ............................................................................................................................................................ 32 Hospital stays must be precertified to avoid a $500 benefit reduction

This Plan and Medicare ........................................................................................................................................ 32- 34 Information you need if you are covered by Medicare

Enrollment Information ........................................................................................................................................ 34- 37 Your enrollment in the Federal Employees Health Benefits Program and ,Coverage after enrollment ends (Former spouse coverage; Temporary continuation of coverage; Conversion to individual coverage; and Certificate of Credible Coverage)

Definitions ............................................................................................................................................................... 38- 40 Explanations of some of the terms used in this brochure

Index ............................................................................................................................................................................. 41 List of covered benefits and services, alphabetized, with page numbers

Non- FEHB Benefits .................................................................................................................................................... 42 Other services available to members of this Plan

How This Plan Changes

How the Postmasters Benefit Plan Changes January 1999 ................................................................................... 43

Summary of Benefits

High Option ................................................................................................................................................................. 46

Standard Option ........................................................................................................................................................... 47

How This Plan Works

Help Contain Costs

FEHB plans are expected to manage their costs prudently. All FEHB plans have cost containment measures in place. All fee- for- service plans include two specific provisions in their benefits packages: precertification of all inpatient admissions and the flexible benefits option. Some include managed care options, such as PPOs, to help contain cost.

As a result of your cooperative efforts, the FEHB Program has been able to control premium costs. Please keep up the good work and continue to help keep costs down.

Precertification evaluates the medical necessity of proposed admissions and the number of days required to treat your condition. You are responsible for ensuring that the precertification requirement is met. You or your doctor must check with First Health Group Corp., before being admitted to the hospital. If that doesnt happen, your Plan will reduce benefits by $500. Be a responsible consumer. Be aware of your Plans cost containment provisions. You can avoid penalties and help keep premiums under control by following the procedures specified on page 31 of this brochure.

Under the flexible benefits option, the Carrier has the authority to determine the most effective way to provide services. The Carrier may identify medically appropriate alternatives to traditional care and coordinate the provision of Plan benefits as a less costly alternative benefit. Alternative benefits are subject to ongoing review. The Carrier may decide to resume regular contract benefits at its sole discretion. Approval of an alternative benefit is not a guarantee of any future alternative benefits. The decision to offer an alternative benefit is solely the Carriers and may be withdrawn at any time. It is not subject to OPM review under the disputed claims process.

This Plan offers all of its Standard Option members the opportunity to limit out- of- pocket expenses for the cost of most care to modest copayments (copays) by 1) selecting a POS primary care physician, 2) accepting POS managed care provisions and 3) receiving care from providers who participate in the Plans POS provider network. See How to Obtain POS Benefits (page 29) for more details and to select a primary care physician.

This Plan offers most of its members the opportunity to reduce out- of- pocket expenses by choosing providers who participate in the Plans preferred provider organization (PPO). Consider the PPO cost savings when you review Plan benefits and check with First Health Group Corp., to see whether PPO providers are available in your area.

You can help Precertification Flexible benefits option

POS (Point- of- Service)

PPO Facilities and Other Providers Covered facilities

An out- of- hospital facility such as medical, cancer, dialysis, or surgical center or clinic, and licensed outpatient facilities accredited by the Joint Commission on Accreditation of Healthcare Organizations for treatment of substance abuse.

A facility whose staff must include a doctor and registered nurse (R. N.) and may include social workers, clergymen/ counselors, volunteers, clinical psychologists and physical or occupational therapists who are able to provide care 24 hours a day.

(l) An institution that is accredited as a hospital under the hospital accreditation program of the Joint Commission on Accreditation of Healthcare Organizations, or

(2) Any other institution that is operated pursuant to law, under the supervision of a staff of doctors, with 24- hour- a- day nursing service and that is primarily engaged in providing for sick and injured inpatients: general care and treatment through medical, diagnostic and major surgical facilities, all of which facilities must be provided on its premises or under its control, or specialized care and treatment through medical and diagnostic facilities (including X- ray and laboratory) on its premises, under its control, or through a written agreement with a hospital (as defined above) or with a specialized provider of those services.

Free- standing ambulatory facility

Hospice Hospital

An institution that: (1) meets the hospital definition as stated; or (2) provides a program for the treatment of alcohol or drug abuse and meets one of the following requirements: (a) is affiliated with a hospital under a contractual agreement with an established patient referral system; (b) is licensed, certified or approved as an alcohol or drug abuse rehabilitation facility by the State; or is accredited as such a facility by the Joint Commission on Accreditation of Healthcare Organizations.

An institution that (1) is operated pursuant to law and primarily engaged in providing the following services for patients recovering from an illness or injury: room, board and 24- hour- a day nursing service by professional nurses; (2) is under the full- time supervision of a doctor or registered nurse (R. N.); (3) maintains adequate medical records; and (4) has the services of a doctor available under an established agreement for 24 hours a day, if not supervised by a doctor.

For purposes of this Plan, covered providers include: A licensed doctor of medicine (M. D.) or a licensed doctor of osteopathy (D. O.). Other covered providers include: a licensed doctor of podiatry (D. P. M.); a licensed dentist (D. D. S. or D. M. D.); licensed chiropractor (D. C.); licensed or registered physical, occupational and speech therapists (R. P. T., R. S. T., R. O. T. and S. P.) practicing within the scope of their license. Other covered providers include a qualified clinical psychologist, clinical social worker, optometrist, nurse midwife, nurse practitioner/ clinical specialist and nursing school administered clinic. For purposes of this FEHB brochure, the term doctor includes all of these providers when the services are performed within the scope of their license or certification.

Within States designated as medically underserved areas, any licensed medical practitioner will be treated as a covered provider for any covered services performed within the scope of that license. For 1999, the States designated as medically underserved are: Alabama, Idaho, Louisiana, Mississippi, New Mexico, North Dakota, South Carolina, South Dakota, and Wyoming.

The Standard Option of this Plan provides POS benefits for many, but not all, covered services. POS managed care provisions affect inpatient admissions, care provided by specialists, and the use of CAT scans and MRIs. A POS primary care physician must be selected prior to receiving care. PPO and Non- PPO benefits are available to enrollees who: 1) do not select a POS primary care physician, 2) receive care from a non- POS provider or 3) do not comply with the managed care provisions of the POS program.

The Plans POS program allows members to choose from among three levels of benefits at the time they need to access medical care. Non- PPO benefits are available for all covered services and all covered providers. Members who wish to reduce their out- of- pocket costs can choose to receive care from PPO providers, if they are available in the members area. Now all members can reduce their out- of- pocket costs by selecting a POS primary care physician and accepting POS managed care provisions. When POS primary care physicians are available in a members area, the member must select from among existing POS primary care physicians. If there is no POS primary care physician available in a members area, a qualified physician in the members area can be designated as the members POS primary care physician. The POS benefits provision is available for Inpatient Hospital Benefits, Surgical Benefits, Maternity Benefits and Other Medical Benefits. See How to Obtain POS Benefits (page 29) for details about selecting a Primary Care Physician and POS managed care provisions.

If a POS Primary Care Physician or a specialist indicates the need for a hospital admission, the member must speak with a Referral Management Coordinator (RMC) at 1- 800- 654- 6530 to 1) identify the hospitals that qualify for POS benefits and 2) precertify the admission.

Benefits under this Plan are available from facilities, such as hospitals, and from providers, such as doctors and other health care personnel, who provide covered services. This Plan covers two types of facilities and providers: (1) those who participate in a preferred provider organization (PPO) and (2) those who do not. Who these health care providers are, and how benefits are paid for their services, are explained below. In general, it works like this.

PPO facilities and providers have agreed to provide most services to Plan members at a lower cost than youd usually pay a non- PPO provider. Although PPOs are not available in all locations or for all services, when you use these providers you help contain health care costs and reduce what you pay out of pocket. The selection of PPO providers is solely the Carriers responsibility; continued participation of any specific provider cannot be guaranteed. While PPO providers agree with the Carrier to provide covered services, final decisions about health care are the sole responsibility of the doctor and patient and are independent of the terms of the insurance contract.

PPO benefits apply only when you use a PPO provider. Provider networks may be more extensive in some areas than others. The availability of every specialty in all areas cannot be guaranteed. If no PPO provider is available, or you do not use a PPO provider, the standard non- PPO benefits apply.

Skilled nursing facility

Covered providers Coverage in medically underserved areas

POS arrangements (Standard Option)

This Plans POS (Standard Option)

PPO arrangements Facilities and Other Providers continued

Rehabilitation Facility

Facilities and Other Providers continued

When you use a PPO hospital, keep in mind that the professionals who provide services to you in the hospital, such as radiologists, anesthesiologists and pathologists, may not all be preferred providers. If they are not they will be paid by this Plan as non- PPO providers.

Non- PPO facilities and providers do not have special agreements with the Carrier. The Plan makes its regular payments toward their bills, and youre responsible for any balance.

The Plan provides a national network of Preferred Provider Organizations (PPO) through a company called First Health Group Corp. This PPO network, First Health Medical Network, offers hospitals and doctors in numerous geographic areas; however, the number or type of providers may be insufficient in some geographic areas. Network providers have agreed to provide services to Plan enrollees and their dependents at negotiated rates. PPO benefits are available for inpatient and outpatient hospital services, inpatient and outpatient services of doctors, surgical procedures and anesthesia. The Carrier is solely responsible for the selection of PPO providers and any questions regarding PPO providers should be directed to the Plan. The continued participation of any specific PPO provider cannot be guaranteed. The patient can confirm the current sufficiency or limitation of the PPO network, in the area where they intend to receive care, by calling toll- free, the PPO InfoLine. The PPO InfoLine offers Plan members a toll- free number 1- 800/ 654- 6530, to obtain up- to- date information on the current status of providers within the Network. The PPO InfoLine operates 24 hours a day, 7 days a week. The Plan is not responsible for benefits in excess of the non- PPO level of benefits based on the patient not confirming the current sufficiency of PPO providers.

If you need hospital services, and a PPO hospital is available in your area, you may choose between a PPO provider and a non- PPO provider at the time of service. The rates that have been negotiated with the PPO Providers will result in savings to you through a higher level of benefit payment. When a

High Option enrollee uses one of the PPO hospitals, there is no room and board inpatient deductible. There is a $350 (PPO) room and board deductible for Standard Option. The Plan will also pay covered Other charges at 100% under High Option and 95% under Standard Option.

In addition to savings on the PPO hospitals, the Plan offers a PPO Doctors Network. Participating providers will provide discounted charges. The Plan will pay 95% of the discounted charges (after any deductibles).

The enrollees identification card will identify the patient as a participant of the First Health Group Corp., PPO network and will alert medical care providers that the enrollee participates in the Preferred Provider network (PPO). If an enrollee elects to use a non- PPO provider the Plan will provide its usual coverage as outlined in this brochure. Note: Some discounts can be obtained from network providers even though PPO benefits may not apply (see page 17 and 19 for services not covered under PPO benefits). When you phone for an appointment, please remember to verify that the physician is still a PPO provider.

This Plans PPO

Cost Sharing Deductibles

Calendar year

A deductible is the amount of expense an individual must incur for covered services and supplies before the Plan starts paying benefits for the expense involved. A deductible is not reimbursable by the Plan and benefits paid by the Plan do not count toward a deductible. When a benefit is subject to a deductible, only expenses allowable under that benefit count toward the deductible.

The calendar year deductible is the amount of expenses an individual must incur for covered services and supplies each calendar year before the Plan pays certain benefits. The deductible is $200 (PPO) or $275 (Non- PPO) for the High Option and $200 (PPO) or $350 (Non- PPO) for the

Standard Option. Under High Option, only charges for services covered under Other Medical Benefits would apply to this deductible. Under Standard Option, only charges for services covered under Surgical Benefits, and Other Medical Benefits would apply to this deductible. Standard Option is subject to a separate deductible for mental conditions inpatient hospital visits and outpatient care.

If you change options in this Plan during the calendar year, the amount of covered expenses already applied toward the deductible of your old option will be credited to the deductible of your new option.

The calendar year prescription drug deductible for participating and non- participating pharmacies is $100 for High Option. Under Standard Option, the calendar year prescription drug deductible is $50 for participating pharmacies and the Mail Order Drug Program and $100 for non- participating pharmacies.

Drug

Cost Sharing continued

Dental Family limit

The deductible for Inpatient Hospital Benefits is $150 for the High Option and $350 (PPO) or $600 (Non- PPO) for the Standard Option per person per admission; when confined in a PPO hospital the deductible will be waived for High Option (see page 12). The High Option and Standard Option

deductible for mental conditions is $500 per admission. The High Option and Standard Option

deductible for substance abuse is $500 per person per year. The High Option deductible for Basic and Major Dental Benefits is $30 per person per calendar year. There is no Standard Option deductible for Dental Benefits.

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

There is a separate calendar year deductible of $200 (PPO) or $275 (Non- PPO) per person under the

High Option and $200 (PPO) or $350 (Non- PPO) per person under the Standard Option. Under a family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the deductible for all family members reach $400 (PPO) or $550 (Non- PPO) under High Option and $400 (PPO) or $700 (Non- PPO) under

Standard Option during a calendar year. If two or more persons under the same family enrollment are injured in the same accident, only one deductible need be satisfied that calendar year by those injured.

Coinsurance is the stated percentage of covered charges you must pay after you have met any applicable deductible. The Plan will base this percentage on either the billed charge or the reasonable and customary charge, whichever is less. For instance, when a Plan pays 80% of reasonable and customary charges for a covered service, you are responsible for 20% of the reasonable and customary charges, i. e., the coinsurance. In addition, you may be responsible for any excess charge over the Plans reasonable and customary allowance. For example, if the provider ordinarily charges $100 for a service but the Plans reasonable and customary allowance is $95, the Plan will pay 80% of the allowance ($ 76). You must pay the 20% coinsurance ($ 19), plus the difference between the actual charge and the reasonable and customary allowance ($ 5), for a total member responsibility of $24. Remember, if you use preferred providers, your share of covered charges (after meeting any deductible) is limited to the stated coinsurance amount.

When inpatient claims are paid according to a Diagnostic Related Group (DRG) limit (for instance, for admissions of certain retirees who do not have Medicare - see page 10), the Plan will consider 30% of the total covered amount as room and board charges and 70% as other charges and will apply your coinsurance accordingly.

A copayment is the stated amount the Plan requires you to pay for a covered service, such as $10 per prescription by mail or $20 per office visit charge at a PPO provider.

If a provider routinely waives (does not require you to pay) your share of the charge for services rendered, the Plan is not obligated to pay the full percentage of the amount of the providers original charge it would otherwise have paid. A provider or supplier who routinely waives coinsurance, copayments or deductibles is misstating the actual charge. This practice may be in violation of the law. The Plan will base its percentage on the fee actually charged. For example, if the provider ordinarily charges $100 for a service but routinely waives the 20% coinsurance, the actual charge is $80. The Plan will pay $64 (80% of the actual charge of $80).

Both Options - The Plan will pay up to $100 for enrollment in one smoking cessation program per member per lifetime.

Carryover Coinsurance

When hospital charges are limited by law

Copayments If provider waives your share

Lifetime maximums

Hospital

General Limitations Medicare

All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable when determined by the Carrier to be medically necessary. Coverage is provided only for services and supplies that are listed in this brochure. 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 the Plan or be used in the prosecution or defense of a claim under the Plan. This brochure is the official statement of benefits on which you can rely.

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 Carrier and complete all necessary documents and authorizations requested by the Carrier.

If you or a covered family member is enrolled in this Plan and Part A, Part B or Parts A and B of Medicare, the provisions on coordination of benefits with Medicare described on page 32 apply.

Coordination of benefits (double coverage) 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 Carrier.

When there is double coverage, one plan normally pays its benefits in full as the primary payer, and the other plan pays a reduced benefit as the secondary payer. When this Plan is the secondary payer, it will pay the lesser of (1) its benefits in full, or (2) a reduced amount that, when added to the benefits payable by the other coverage, will not exceed 100% of the reasonable and customary allowance.

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 (NAIC). When benefits are payable under automobile insurance, including no- fault, 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 Carrier 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.

If you are covered by both this Plan and Medicaid, this Plan will pay benefits first. The Plan will not pay for benefits or 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, medical benefits may be provided for services or supplies covered by this Plan. The Plan is entitled to be reimbursed by OWCP (or similar agency) for benefits paid by the Plan 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.

Subrogation applies when you are sick or injured as a result of the act or omission of another person or party. Subrogation means the Plans right to recover any payments made to you or a family member by a third partys insurer, because of an injury or illness caused by a third party. Third party means another person or organization. If, as a result of an illness or injury for which the Plan has paid or may pay benefits, you institute a suit or claim against a third party, the Plan will take an assignment from you of the money damages paid or payable to you by any third party on the suit or claim. This means the Plan will assert a lien against any monies you receive as a result of your claim regardless of the year instituted, whether you receive money by court order or as an out- of- court settlement or any other type of settlement. The lien will apply to money proceeds

Other sources of benefits

Group health insurance and automobile insurance

Medicaid CHAMPUS

Workers compensation

DVA facilities, DoD facilities, and Indian Health Services Other Government agencies

Liability insurance and third party actions

General Limitations continued

in the full amount of the Plan benefits paid or payable to you or any covered member of your family, and it will act only to reimburse the Plan for its payment of such benefits. Upon notification, the Plan will provide you with the necessary forms and will insist on execution of the assignment before paying any benefits on account of the injury or illness. Failure to notify the Plan promptly that you have instituted such a suit or claim against a third party may result in an overpayment of benefits by the Plan that is subject to recoupment. If you need more information about subrogation, the Plan will provide you with its subrogation procedures.

The Carrier will make reasonably diligent efforts to recover benefit payments made erroneously but in good faith and may apply subsequent benefits otherwise payable to offset any overpayments.

The information in these following paragraphs applies to you when 1) you are not covered by either

Medicare Part A (hospital insurance) or Part B (medical insurance), or both, 2) you are enrolled in this Plan as an annuitant or as a former spouse or family member covered by the family enrollment of an annuitant or former spouse, and 3) you are not employed in a position which confers FEHB coverage.

If you are not covered by Medicare Part A, are age 65 or older or become age 65 while receiving inpatient hospital services, and you receive care in a Medicare participating hospital, the law (5 U. S. C. 8904( b)) requires the Plan to base its payment on an amount equivalent to the amount Medicare would have allowed if you had Medicare Part A. This amount is called the equivalent Medicare amount. After the Plan pays, the law prohibits the hospital from charging you for covered services after you have paid any deductibles, coinsurance, or copayments you owe under the Plan. Any coinsurance you owe will be based on the equivalent Medicare amount, not the actual charge. You and the Plan, together, are not legally obligated to pay the hospital more than the equivalent Medicare amount. The Carriers explanation of benefits (EOB) will tell you how much the hospital can charge you in addition to what the Plan paid. If you are billed more than the hospital is allowed to charge, ask the hospital to reduce the bill. If you have already paid more than you have to pay, ask for a refund. If you cannot get a reduction or refund, or are not sure how much you owe, call the Plan at 703/ 683- 5585 for assistance.

Claims for physician services provided for retired FEHB members, age 65 and older who do not have Medicare Part B are also processed in accordance with 5 USC 8904 (b). This law mandates the use of Medicare Part B limits for covered physician services for those members who are not covered by Medicare Part B. The Plan is required to base its payment on the Medicare- approved amount (which is the Medicare fee schedule for the service), or the actual charge, whichever is lower. If your doctor is a member of the Plans preferred provider organization (PPO) and participates with Medicare, the Plan will base its payment on the lower of these two amounts and you are responsible only for any deductible and the PPO copayment or coinsurance. If you go to a PPO doctor who does not participate with Medicare, you are responsible for any deductible and the copayment or coinsurance. In addition, unless the doctors agreement with the Carrier specifies otherwise, you must pay the difference between the Medicare- approved amount and the limiting charge (115% of the Medicare- approved amount). If your physician is not a Plan PPO doctor but participates with Medicare, the Plan will base its regular benefit payment on the Medicare- approved amount. For instance, under this Plans high option surgery benefit, the Plan will pay 85% of the Medicare- approved amount. You will only be responsible for any deductible and coinsurance equal to 15% of the Medicare- approved amount. If your physician does not participate with Medicare, the Plan will still base its payment on the Medicare- approved amount. However, in most cases you will be responsible for any deductible, the coinsurance or copayment amount, and any balance, up to the limiting charge amount (115% of the Medicare- approved amount). Since a physician who participates with Medicare is only permitted to bill you up to the Medicare fee schedule amount even if you do not have Medicare Part B, it is generally to your financial advantage to use a physician who participates with Medicare. The Carriers explanation of benefits (EOB) will tell you how much the physician can charge you in addition to what the Plan paid. If you are billed more than the physician is allowed to charge, ask the physician to reduce the bill. If you have already paid more than you have to pay, ask for a refund. If you cannot get a reduction or refund, or are not sure how much you owe, call the Plan at 703/ 683- 5585 for assistance.

Overpayments Vested rights

Limit on your costs if youre age 65 or older and dont have Medicare

Inpatient hospital

care Physician services

General Exclusions

These exclusions apply to more than one or to all benefits categories. Exclusions that are primarily identified with a single benefit category are listed along with that benefit category, but may apply to other categories. Therefore, please refer to the specific benefit sections as well to assure that you are aware of all benefit exclusions.

Benefits are provided only for services and supplies that are medically necessary (see definition). The Carrier reserves the right to determine medical necessity. The fact that a covered provider has prescribed, recommended, or approved a service or supply does not, in itself, make it medically necessary.

Benefits will not be paid for services and supplies when:

Benefits will not be paid for:

No charge would be made if the covered individual had no health insurance coverage Furnished without charge (except as described on page 9); while in active military service; or

required for illness or injury sustained on or after the effective date of enrollment (1) as a result of an act of war within the United States, its territories, or possessions or (2) during combat

Furnished by immediate relatives or household members, such as a spouse, parent, child, brother, or sister, by blood, marriage or adoption

Furnished or billed by a provider or facility that has been barred from the FEHB Program Furnished or billed by a noncovered facility, except that medically necessary prescription drugs

are covered For or related to sex transformation, sexual dysfunction or sexual inadequacy Not specifically listed as covered Investigational or experimental Not provided in accordance with accepted professional medical standards in the United States Provided in connection with a non- covered service

Any portion of a providers fee or charge ordinarily due from the enrollee but that has been waived. If a provider routinely waives (does not require the enrollee to pay) a deductible, copay or coinsurance, the Carrier will calculate the actual provider fee or charge by reducing the fee or charge by the amount waived.

Charges the enrollee or Plan has no legal obligation to pay, such as excess charges for an annuitant age 65 or older who is not covered by Medicare Parts A and/ or B (see page 10), doctor charges exceeding the amount specified by the Department of Health and Human Services when benefits are payable under Medicare (limiting charge see page 33), or State premium taxes however applied.

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.

Routine preventive care, immunizations and all related expenses except as provided on pages 18 and 20

Treatment for weight control or reduction (except morbid obesity) Social, recreational and educational services or training Treatment of corns, calluses and foot subluxations Therapy for developmental delays, learning disabilities, stuttering, tongue thrusting or deviate

swallowing Treatment of temporomandibular joint disorder Expenses incurred while not covered under this Plan Services rendered by Christian Scientist providers (including sanitoriums) Services rendered by massage therapists, rolfers, myotherapists, and trager clinics Services rendered by hypnotherapists, neuromuscular therapists and naturopaths Hospital benefits for admissions required for surgical procedures excluded by this Plan Interest, completion of claim forms, or similar administrative charges made by providers

Benefits

Inpatient Hospital Benefits What is covered

Room and board POS benefit Precertification

Waiver PPO benefit Non- PPO benefit

Other charges POS benefit PPO benefit

Weekend admissions

Related Benefits Pre- admission testing

Take- home items

Non- PPO benefit Limited benefits

Hospitalization for dental work

Professional charges

The Plan pays for inpatient hospital services as shown below. The medical necessity of your hospital admission must be precertified for you to receive full Plan benefits. Emergency admissions not precertified must be reported within two business days following the day of admission even if you have been discharged. Otherwise, the benefits payable will be reduced by $500. See page 31 for details.

This precertification requirement does not apply to persons whose primary coverage is Medicare Part A or another health insurance policy or when the hospital admission is outside the United States and Puerto Rico. For information on when Medicare is primary, see pages 32 and 33.

The Plan pays the following for room and board (except for mental conditions or substance abuse treatment) for ward, semiprivate or intensive care. Special diets and general nursing care are included.

Standard Option only - After a $350 copay per admission, the Plan pays 100% of covered charges for services provided by a POS facility.

High Option - Plan pays full charges Standard Option - After a $350 per admission (no deductible). deductible, Plan pays full charges.

See page 7 for information on PPO hospitals.

High Option - After a $150 per admission Standard Option - After a $600 per admission deductible, Plan pays full charges. deductible, Plan pays 70% of covered charges.

If a private room is used, both options will pay the average semiprivate rate charged by the hospital. If the hospital has private rooms only, the average semiprivate rate is determined on the basis of the semiprivate charge of the most comparable hospital in the area or the billed charge, whichever is less. If the patients isolation is required to prevent contagion of others, the private room charge will be covered.

Hospital services and supplies, including, but not limited to, use of operating, treatment and recovery rooms; X- rays and lab tests; chemotherapy; drugs and medicines for use in the hospital; and blood or blood plasma not donated or replaced.

Standard Option only - After a $350 copay per admission, the Plan pays 100% of covered charges for services received from a POS facility or ordered by a provider representing the POS facility.

High Option - Plan pays 100% of covered Standard Option - Plan pays 95% of covered charges. charges.

High Option - Plan pays 85% for the first 30 Standard Option - Plan pays 70% of covered days, then 100% of covered charges. charges.

Plan pays Inpatient Hospital Benefits for covered room and board charges and covered hospital services and supplies in connection with dental procedures only when a non- dental physical impairment exists that makes hospitalization necessary to safeguard the health of the patient.

Benefits for hospital admissions on Friday or Saturday are limited to: (1) a medical emergency, (2) surgery performed within 24 hours of admission, or (3) a childbirth- related admission.

Preadmission testing is covered under Other Medical Benefits (page 18 ). Charges for professional services of a doctor or any other practitioner covered by this Plan, even though billed by a hospital as part of hospital services, are covered only under Other Medical Benefits (page 18), except for inpatient pathology and radiology charges, which are payable as described above under Other charges.

Drugs, medical supplies, appliances, medical equipment and any other covered items billed by a hospital to be used at home are covered only under Other Medical Benefits (page 18).

The Plan pays for the following services: For covered surgical procedures:

Standard Option only - The Plan pays 100% of covered charges for covered surgical services received from a POS provider. NOTE: POS benefits are available for the services of a specialist if: 1) the specialist is a POS provider and 2) a POS primary care physician has formally referred the patient to a POS specialist.

Both Options - The Plan pays 95% of the surgeons negotiated rate (after the $200 calendar year deductible has been met for Standard Option).

High Option - The Plan pays 85% of the Standard Option - After the $350 calendar year reasonable and customary allowance. deductible has been met, the Plan pays 70% of

the reasonable and customary allowance. When multiple or bilateral surgical procedures that add time or complexity to patient care are performed during the same operative session, the Plan pays as follows:

Standard Option only - The Plan pays 100% of covered charges for covered surgical services received from a POS provider.

Both Options - The Plan pays 95% of the surgeons negotiated rate (after a $200 calendar year deductible has been met for Standard Option) for the major procedure and no more than 50% of the surgeons negotiated rate for all subsequent procedures.

High Option - The Plan pays 85% of the reason- Standard Option - After the $350 calendar year able and customary allowance for the first or deductible has been met, the Plan pays 70% of major procedure and 50% of the reasonable and the reasonable and customary allowance for the customary allowance for the second or lesser first or major procedure and 50% of the reasonprocedure( s). able and customary allowance for the second

or lesser procedure( s).

Both Options - When an incidental procedure (e. g., incidental appendectomy, lysis of adhesions, excision of scar) is performed through the same incision, the reasonable and customary allowance will be that of the major procedure only.

Inpatient Hospital Benefits continued

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

Custodial care (see definition, page 38). Room and board when the medical services did not require the acute hospital inpatient setting,

but could have been provided safely on an outpatient basis; or in facilities that are primarily (1) convalescent nursing homes, hotels or homes for the aged whose primary purpose is to furnish custodial care; (2) operated as schools; or (3) places for drug addicts or alcoholics, except as provided for Substance abuse rehabilitation on page 17.

Private duty nursing care while confined in a hospital Surcharges made by hospitals

The non- PPO benefits are the standard benefits of this plan. POS benefits apply only when you use a POS provider. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non- PPO benefits apply.

What is not covered

What is covered Surgical Benefits

Hospital inpatient and outpatient

POS benefit PPO benefit Non- PPO benefit

Multiple surgical procedures

POS benefit PPO benefit

Non- PPO benefit Incidental procedures

Surgical Benefits continued

Assistant surgeon (inpatient/ outpatient)

POS benefit PPO benefit

Second opinion (voluntary) Pre- surgical testing Anesthesia

POS benefit PPO benefit Non- PPO benefit

Organ/ tissue transplants and donor expenses

What is covered Non- PPO

benefit Standard Option only - The Plan pays 100% of covered charges for covered assistant surgeon

services received from a POS provider.

High Option - The Plan pays 20% of the Standard Option - After the $200 calendar negotiated rate. year deductible has been met, the Plan pays

assistant surgeons fees up to 15% of the negotiated rate.

High Option - Assistant surgeons fees are Standard Option - After the $350 calendar payable up to 20% of the reasonable and year deductible has been met, the Plan pays customary allowance for the surgery. assistant surgeons fees up to 15% of the

reasonable and customary allowance for the surgery.

Second surgical opinions are covered under Other Medical Benefits. Laboratory tests, pathology, radiology and X- rays related to surgery are paid as Other Medical Benefits (see page 18).

Standard Option only - The Plan pays 100% of covered charges for covered anesthesia services received from a POS facility or ordered by a provider representing the POS facility.

Both Options - The Plan pays 95% of the negotiated rate (after the $200 calendar year deductible has been met for Standard Option).

High Option - The Plan pays 85% of the Standard Option - After the $350 calendar year reasonable and customary allowance. deductible has been met, the Plan pays 70% of

the reasonable and customary allowance. This benefit applies only if the recipient is covered by the Plan. A recipient is a person insured by the Plan who undergoes a surgical procedure to receive a body organ/ tissue transplant. A donor is a person who undergoes a surgical procedure for the purpose of donating a body organ( s)/ tissue for transplant surgery. All reasonable and customary inpatient hospital and medical charges incurred for a surgical transplant, whether incurred by the recipient or donor, will be considered expenses of the recipient and will be covered the same as for any other illness or injury. Plan approval is required on all related expenses prior to the surgery. The charges for procurement of cadaver organs are also based on Plan approval.

Both Options - Transplant charges will be covered up to a $100,000 maximum per transplant. Cornea, bone, heart, kidney, liver, pancreas, heart/ lung, single lung and double lung transplants. Bone marrow transplants and stem cell support as follows:

Allogeneic bone marrow for acute leukemia, advanced Hodgkins lymphoma, advanced nonHodgkins lymphoma, advanced neuroblastoma (children over age one), aplastic anemia, chronic myelogenous leukemia, infantile malignant osteopetrosis, severe combined immunodeficiency, thalassemia major, and Wiskott- Aldrich syndrome

Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute lymphocytic or non- lymphocytic leukemia; advanced Hodgkins lymphoma and advanced non- Hodgkins lymphoma; advanced neuroblastoma; testicular, mediastinal, retroperitoneal and ovarian germ cell tumors; breast cancer; multiple myeloma; and epithelial ovarian cancer.

Related medical and hospital expenses of the donor are covered when the recipient is covered by the Plan.

Surgical Benefits continued

What is not covered

Oral and maxillofacial surgery

What is not covered

The Plan provides a Managed Transplant System (MTS) Program. If the member agrees to participate in this program, then charges for most of the above procedures are covered up to a maximum of $300,000 per transplant. Included in this $300,000 maximum is a travel and lodging allowance of $8,000 for the recipient and one family member. Routine aftercare provided by the transplant center and its affiliated providers for one year after the transplant is also included. The MTS Program covers the following transplants: bone marrow, heart, kidney/ pancreas, liver, heart/ lung, single lung and double lung transplants.

Donor screening tests for organ transplants, except those performed for the actual donor when the recipient is covered by the Plan.

Services or supplies for or related to organ/ tissue transplants for any diagnosis not specifically listed as covered including chemotherapy and/ or radiation therapy when supported by allogeneic or autologous bone marrow or stem cell transplants, drugs or medications administered to stimulate or mobilize stem cells for transplant, and all other services or supplies which would not be medically necessary or appropriate but for the non- covered procedure.

Islet of Langerhans, artificial heart and other transplants not listed as covered. Allogeneic and autologous bone marrow and stem cell transplants for solid tumors except as

noted above. The following procedures are covered as shown on page 13: Reduction of fractures of the jaw or facial bones Surgical correction of cleft lip, cleft palate or severe functional malocclusion Removal of stones from salivary ducts Excision of tori, leukoplakia or malignancies Excision of cysts and incision of abscesses not involving the teeth Removal of impacted teeth When multiple or bilateral oral maxillofacial surgical procedures that add time or complexity to patient care are performed during the same operative session, the Plan pays the same benefits as indicated under Multiple surgical procedures for the above listed procedures except that removal of impactions are paid at the reasonable and customary allowance for each procedure performed. Procedures that involve teeth or their supporting structures (such as the periodontal membrane, gingiva and alveolar bone) are considered dental treatment rather than oral surgery. For covered dental treatment, see pages 23 through 26.

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

Eye surgery, such as radial keratotomy, when the primary purpose is to correct myopia, hyperopia, or astigmatism; eye exercises and orthoptics (visual training)

Cosmetic surgery and all related expenses except for the correction of congenital anomalies, repair following an accidental injury or breast reconstruction following a mastectomy

Injections of silicone, collagens and similar substances All procedures associated with treatment of temporomandibular disorders

Mastectomy surgery

Maternity Benefits What is covered

PPO benefit

Non- PPO benefit

Other charges PPO benefit Room and board

POS benefit Inpatient hospital

Precertification POS benefit

Non- PPO benefit

Outpatient care POS benefit Obstetrical care

PPO benefit

Non- PPO benefit

Related benefits Diagnosis and treatment of infertility Pregnancy risk management program Voluntary sterilization

For whom

The Plan pays the same benefits for hospital, surgery (delivery), laboratory tests and other medical expenses as for illness or injury. 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.

The medical necessity of your hospital admission must be precertified for you to receive full Plan benefits. Unscheduled or emergency admissions not precertified must be reported within two business days following the day of admission even if you have been discharged. Newborn admissions that extend beyond the mothers discharge must be precertified. If any of the above are not done, the benefits payable will be reduced by $500. See page 31 for details.

Plan pays room and board charges for ward, semiprivate or intensive care.

Standard Option only - After the $350 copay per admission, the Plan pays 100% of covered charges for services provided by a POS facility.

High Option - Plan pays full charges (no Standard Option - After a $350 per admission deductible). deductible, Plan pays full charges. See page 7 for information on PPO hospitals.

High Option - After a $150 per admission Standard Option - After a $600 per admission deductible, Plan pays full charges. deductible, Plan pays 70% of covered charges.

Standard Option only - After the $350 copay per admission, the Plan pays 100% of covered charges for services received from a POS facility or ordered by a provider representing the POS facility.

High Option - Plan pays 100% of covered Standard Option - Plan pays 95% of charges. covered charges.

High Option - The Plan pays 85% for the first Standard Option - The Plan pays 70% of 30 days, then 100% of covered charges. covered charges.

Hospital bassinet and nursery charges for days on which both mother and child would normally be confined following delivery are considered hospital expenses of the mother, not the child. When a newborn requires definitive treatment or evaluation for medical or surgical reasons, during or after the mothers stay, the newborn is considered a patient in his or her own right and a separate per admission deductible applies. Expenses of the newborn are payable only if the child is covered under a Self and Family enrollment.

Stand- by doctor charges will be covered only if medically necessary treatment is actually rendered to the child by the doctor.

Facility charges for an outpatient delivery or delivery at a birthing center are covered as outpatient surgery under Other Medical Benefits.

Standard Option only - The Plan pays 100% of covered charges for covered obstetrical services received from a POS provider.

Both Options - The Plan pays 95% of the negotiated rate (after the $200 calendar year deductible has been met for Standard Option).

High Option - The Plan pays 85% of the Standard Option - After the $350 calendar reasonable and customary allowance. year deductible has been met, the Plan pays

70% of the reasonable and customary allowance.

Covered under Other Medical Benefits subject to Plan approval. See page 18. Covered under Other Medical Benefits subject to Plan approval. See page 18. Covered under Surgical Benefits. See page 13 Benefits are payable under Self Only enrollments and for family members covered under Self and Family enrollments.

POS and PPO benefits do not apply to Mental Conditions/ Substance Abuse Benefits. The Plan pays for the following services:

High Option - After a $500 per admission Standard Option - After a $500 per admission deductible, the Plan pays 70% of covered charges deductible, the Plan pays 60% of covered charges for inpatient room and board and other hospital for inpatient room and board and other hospital charges for up to 100 days per calendar year. charges for up to 100 days per calendar year.

Two admissions in the same year separated by 30 or fewer days are considered one admission and require one deductible.

The medical necessity of your admission to a hospital or other covered facility must be precertified for you to receive full Plan benefits. Emergency admissions must be reported within two business days following the day of admission even if you have been discharged. Otherwise, the benefits payable will be reduced by $500. See page 31 for details.

High Option - After the $275 calendar year Standard Option - After the $300 per person/ deductible, doctors inpatient services are payable $600 per family mental conditions calendar at 80% of reasonable and customary charges for year deductible, doctors inpatient services are services rendered during the 100 days per payable at 50% of reasonable and customary calendar year of covered inpatient care. charges for services rendered during the 100

days per calendar year of covered inpatient care.

Both Options - The Plan provides benefits for day treatment, subject to the Plans approval, limited to the Plans inpatient benefits (See Inpatient Care above). Day treatment is also known as transitional care or partial hospitalization.

High Option - After the $275 calendar year Standard Option - After the $300 mental condeductible, the Plan pays 50% of reasonable ditions calendar year deductible, the Plan pays and customary charges, to a maximum Plan 50% of reasonable and customary charges, to a payment of $50 per visit, for up to 25 office maximum Plan payment of $50 per visit, for up visits per calendar year for the treatment of to 25 office visits per calendar year for the mental conditions. treatment of mental conditions. Visits used by the member in satisfying the deductible do not count toward the 25 visit limit.

Both Options - After satisfaction of a $500 calendar year deductible, the Plan pays 70%, up to annual maximum, of the remaining covered charges for room and board and other charges made by a hospital or rehabilitation facility for treatment of alcohol or drug abuse, including outpatient services and supplies. Benefits for the treatment of substance abuse are limited to a maximum Plan payment of $3,500 per person per calendar year.

Precertification requirements described above apply to all admissions for treatment of substance abuse.

Treatment of learning disabilities Treatment related to marital discord Personal comfort items such as telephone and television, guest meals and beds, barber and

beauty services Custodial care (see page 38)

Maternity Benefits continued

What is not covered Assisted Reproductive Technology (ART) procedures such as artificial insemination, in vitro

fertilization, embryo transfer and Gamete Intrafallopian Transfer (GIFT), as well as services and supplies related to ART procedures, are not covered. Contraceptive drugs (including oral and injectable contraceptives and implanted contraceptives,

such as Norplant) and devices Reversal of voluntary surgical sterilization and all related expenses

Mental Conditions/ Substance Abuse Benefits What is covered

Mental conditions Inpatient care

Precertification Inpatient visits

Hospital Day Treatment

Outpatient care Substance abuse

Precertification What is not covered

Other Medical Benefits What is covered

POS benefit PPO benefit Non- PPO benefit

Routine services Physical exams

What is not covered Breast cancer screening

Cervical cancer screening Colorectal cancer screening Prostate cancer screening

Standard Option only - The Plan pays 100% of covered charges for inpatient medical care services received from a POS provider. After the $50 copay applicable to outpatient facility charges and emergency room charges (non- accidental injury), the Plan pays 100% of covered charges for medical services received from a POS provider. After a $10 copay for each access to a POS providers care, the Plan pays 100% of covered charges for medical care received from a POS provider. NOTE: POS benefits are available for the services of a specialist if: 1) the specialist is a POS provider and 2) a POS primary care physician has formally referred the patient to a POS specialist.

High Option - After the $200 calendar year Standard Option - After the $200 calendar year deductible has been met, the Plan pays 95% of deductible has been met, the Plan pays 95% of negotiated rate for the services listed on this page. negotiated rate for the services listed on this page

except for home and office visits. After a $20 co- payment per visit, the Plan pays 100% for home and office visits, including medical care other than x- rays, labs and surgeries rendered by the doctor during the visit.

High Option - After the $275 calendar year Standard Option - After the $350 calendar year deductible has been met, the Plan pays 80% of deductible has been met, the Plan pays 70% of reasonable and customary charges for the reasonable and customary charges for the following: following: Home, office and hospital visits and other medical care, including office visits and tests used

to monitor pharmacotherapy for mental conditions Hospital services: outpatient services and supplies including those related to services covered

under Dental Benefits Anesthesia and its administration for non- surgical procedures (see page 14 for benefits in conjunction with surgery) Allergy treatment, serum, and injections Blood transfusions, including blood, plasma and blood plasma expanders Radiation therapy and chemotherapy Home IV therapy Diagnostic X- ray, and laboratory tests, including electrocardiogram, electroencephalogram,

radioisotope other machine testing and preadmission diagnostic testing. Diagnosis and treatment of infertility when approved by the Plan (see page 17 for exclusions) Pregnancy risk management programs when approved by the Plan Renal Dialysis Physical, occupational and speech therapy, when prescribed by a doctor and rendered by a

qualified professional therapist is payable up to a total of 40 visits under High Option and 24 visits under Standard Option per calendar year. Each type of therapy rendered is considered a separate visit. Speech therapy is payable only if services are provided to restore speech when functional loss of speech is due to disease, illness, or injury

In addition to coverage of diagnostic X- ray, laboratory and pathology services and machine diagnostic tests, the following routine (screening) services are covered as preventive care:

Routine physicals, including a complete history and workup, are covered once every two years for members age 13 through 39 and once every year for those age 40 and above.

Physical exams for school, sports, employment or travel Mammograms are covered for women age 35 and older as follows: From age 35 through 39, one mammogram screening during this five year period From age 40 through 49, one mammogram screening every one or two consecutive calendar years From age 50 through 64, one mammogram screening every calendar year At age 65 or older, one mammogram screening every two consecutive calendar years

Annual coverage of one pap smear for women age 18 and older Annual coverage of one fecal occult blood test for members age 40 and older Annual coverage of one PSA (Prostate Specific Antigen) test for men age 40 and older

POS and PPO benefits do not apply to Other services or Limited benefits.

Disposable needles and syringes Oxygen and equipment for its administration Local professional ambulance service associated with covered hospital inpatient care or when

related to, and within 72 hours after, an accidental injury or medical emergency or during covered home health care Insulin and diabetic supplies (such as needles, syringes and test materials) Orthopedic braces and prosthetic appliances such as artificial limbs and eyes when ordered by

a doctor, including replacement when required by a change in the patients condition, and expenses for repair and adjustment

Benefits are provided for private duty nursing care performed outside the hospital by a registered nurse (R. N.), licensed practical nurse (L. P. N.), or licensed vocational nurse (L. V. N.); and for parttime or intermittent nursing care furnished during home visits by an R. N., L. P. N., L. V. N. and home health aides that are part of a home health care plan that starts within 36 hours after discharge from a covered hospital confinement.

A doctor must certify in writing as to the (1) length of time such care is needed, (2) specific professional skills required by the patient and (3) medical necessity for the skilled service. In addition, for benefits to be paid for home visits, the doctor must certify that further inpatient care would be required if home health care were not given and the home health care plan must be coordinated by the hospital and the covered services billed for by a health care provider organization (such as a hospital or a home health care agency). The Plan may request nursing notes.

Benefits for nursing services and home health care are limited to a maximum Plan payment of $10,000 per person per calendar year.

Nursing care primarily for custodial care (see page 38) After satisfaction of the calendar year deductible, the Plan will pay up to $100 for enrollment in one smoking cessation program, including any related prescription drugs, per member per lifetime. Smoking cessation drugs and medications, including nicotine patches, are not available under any other Plan provisions. Benefits will be paid directly to the enrollee upon submission of a completed claim form and bill.

The following supplies are covered under specific circumstances: Hearing aids, including exams and adjustments to hearing devices, if required to correct a

hearing impairment caused by surgery or injury and obtained within 120 days thereof One pair of eyeglasses or contact lenses, including exams, if required to correct impairment

directly caused by accidental ocular injury or intraocular surgery (such as removal of cataracts) and obtained within one year of the injury or surgery Surgical bras, limited to one bra per operative session, are covered when a mastectomy has

been performed Eyeglasses, contact lenses (including their replacements and spares), special tinting, and related

examinations and tests (except as provided above) Eye exercises and orthoptics (visual training) Sun or heat lamps; heating pads; air conditioners, purifiers and humidifiers; exercise, safety,

computer, communication and convenience equipment; stair glides, ramps, liftchairs, elevators and other modifications or alterations to vehicles or households; whirlpools, saunas and similar household items Travel, transportation, convalescent care or rest cures Orthopedic and corrective shoes, arch supports, foot orthotics and other supportive foot devices;

elastic stockings and support hose Hearing aids, and related examinations and tests (except as provided above); batteries, glasses

or ocular exams if part of hearing device; repairs or replacements of hearing devices Services and supplies for cosmetic purposes such as Rogaine or wigs Chelation therapy, except for acute arsenic, gold, lead or mercury poisoning Maintenance cardiac rehabilitation and exercise programs

Other services Other Medical Benefits continued

Limited benefits Nursing services and home health care

What is not covered Smoking cessation benefit

Supplies What is not covered

Remission Bereavement benefit

Immunizations Childhood

Age 65 and over Skilled nursing facilities

Well child care Additional Benefits

Accidental injury Chiropractic services

Durable medical equipment

Emergency room PPO

Non- PPO Hospice Care

Both Options pay 100% of reasonable and customary charges for non- surgical outpatient treatment rendered within 72 hours of an accidental injury (see page 38).

Chiropractic treatment is payable for up to $15 per visit under High Option, not to exceed 25 visits per calendar year, and up to $10 per visit under Standard Option, not to exceed 12 visits per calendar year.

The Plan pays 80% under High Option and 70% under Standard Option after a $100 copayment per device for the rental, repair and purchase of durable medical equipment. A purchase of durable medical equipment in excess of $300 must be supported by a letter of medical necessity and preapproved by the Plan to be covered. (See definition on page 38)

Treatment for any reason other than an accidental injury, is covered as follows:

High Option - The Plan pays 95% of the Standard Option - The Plan pays 95% of the negotiated rate after a $50 copay per access negotiated rate after a $50 copay per access to care. to care.

High Option - The Plan pays 80% of rea- Standard Option - The Plan pays 70% of sonable and customary charges after a $50 reasonable and customary charges after a copay per access to care. $50 copay per access to care.

Both Options pay: (1) 100% of covered charges up to $2,000 for each period of care for outpatient care from a hospice care program; (2) $150 per day up to $3,000 for each period of care for inpatient care in a hospice.

These benefits will be paid if the hospice care program begins after a persons primary doctor certifies terminal illness and life expectancy of six months or less, and if any service or inpatient hospice stay that is a part of the program is: ordered by the supervising doctor, charged by the hospice care program, and provided within six months from the date the person entered (or re- entered after a period of

remission) a hospice care program. A remission is the halt or actual reduction in the progression of illness resulting in discharge from a hospice care program with no further expenses incurred. A readmission within three months of a prior discharge is considered as part of the same period of care. A new period begins three months after a prior discharge with maximum benefits available.

Both Options pay $200 for family bereavement counseling and supportive services if the covered family members receive these services from a hospice care program within three months following the death of a covered family member who received hospice care benefits under the Plan.

Both Options pay 100% of reasonable and customary charges for childhood immunizations recommended by the American Academy of Pediatrics for dependent children under age 22.

Both options pay 100% of reasonable and customary charges for one annual influenza and one annual pneumoccocal vaccine.

When Medicare Part A is primary payer (it pays first) and has made payment, Both Options provide secondary benefits for the applicable Medicare Part A copayments in full.

Well child care (including blood lead level screenings and routine office visits, lab, and X- rays) for children through age 12 is payable up to $150 per child for High Option and up to $125 per child for Standard Option per calendar year.

You may purchase the following medications and supplies prescribed by a doctor from either a pharmacy or by mail: Drugs that by Federal law of the United States require a doctors prescription for their purchase Insulin Needles and syringes for the administration of covered medications

Contraceptive drugs and devices, including Norplant Medical supplies such as dressings and antiseptics Drugs for cosmetic purposes Medication that does not require a prescription under Federal law even if your doctor prescribes it or state law requires it Nutritional supplements; vitamins and minerals Drugs to aid in smoking cessation other than those covered under the Smoking cessation benefit.

The Plan will cover up to a 30- day supply of covered drugs or supplies from participating retail pharmacies (PAID Direct) or from non- participating retail pharmacies. Call Postmasters Benefit Plan at 703/ 683- 5585 to locate a PAID Direct pharmacy in your area.

High Option - After the $100 calendar year Standard Option - After the $50 calendar year drug deductible, the Plan pays 80% of the drug deductible, you pay to the pharmacy a $10

discounted cost. copayment for generic and a $20 copayment for name brand drugs per prescription or refill. The Plan will pay the remainder of the discounted cost.

An ID card will be sent to each member along with a list of participating retail pharmacies. When you present the card you will be given a discount on your prescription. You must show your prescription drug card to receive the discount. There is no claim form to file.

High Option - After the $100 calendar year drug Standard Option - After the $100 calendar year deductible, the Plan pays 80% of the covered drug deductible, the Plan pays 70% of the charge. covered charge.

Obtain a receipt when you use a non- participating pharmacy. Receipts must include the prescription number, name of drug, prescribing doctors name, date, name and address of pharmacy or store where drug was purchased, the number of days the supply covers, patients name and charge. Canceled checks or cash register receipts are not acceptable. Use a HCFA- 1500 claim form to claim benefits for prescription drugs and supplies you purchase. You may obtain these forms by calling 703/ 683- 5585. Mail it to Postmasters Benefit Plan, 1019 North Royal Street, Alexandria, VA 22314- 1596.

High Option - When Medicare Part B is the Standard Option - When Medicare is the primary payer, the Plan waives the $100 primary payer, the Plan waives the $100 calendar year drug deductible for participating calendar year drug deductible for non- particiand non- participating pharmacies and the 20% pating pharmacies and pays 70%. The Plan also coinsurance for participating pharmacies. waives the $50 calendar year drug deductible for

participating pharmacies. The copayments of $10

and $20 for participating pharmacies are not waived.

You may purchase up to a 90- day supply of maintenance drugs through the Mail Order Drug Program. All drugs and supplies listed above are covered except for those that require constant refrigeration, are too heavy to mail, or that must be administered by doctors in a clinical setting.

Under the Mail Order Drug Program, if a generic equivalent to the prescribed drug is available, Merck- Medco Services will dispense the generic equivalent instead of the name brand unless your doctor specifies that the name brand is required.

High Option - You pay $5 for generic and $12 Standard Option - After a $50 calendar year for name brand drugs. drug deductible, you pay $10 for generic and

$20 for name brand drugs.

High Option - When Medicare Part B is the Standard Option - When Medicare Part B is primary payer, the Plan waives the $5 and the primary payer, the Plan waives the $50

$12 copayments. calendar year drug deductible and the $10 and

$20 copayments

Waiver Prescription Drug Benefits

What is covered What is not covered

From a pharmacy Participating retail pharmacy

Non- participating retail pharmacy

To claim benefits

By mail

Waiver

Prescription Drug Benefits continued

Prescribers choice program

To claim benefits

When your mail order prescription is received it will be reviewed to determine if it is a prescription that could be replaced with a more cost effective alternative medication or preferred drug. A pharmacist will contact your doctor and identify the cost effective alternative medication that is available. If your doctor agrees to change your medication to this preferred drug at the time your prescription is filled, you will be sent a check for one half the amount of your applicable mail order drug copay.

The Plan will send you information on the Mail Order Drug Program. To use the Program: (1) Complete the initial mail order form. (2) Enclose your prescription and copayment. (3) Mail your order to Merck- Medco Services. (4) Allow approximately two weeks for delivery.

Youll receive forms for refills and future prescription orders each time you receive drugs or supplies under this Program. In the meantime, if you have any questions about a particular drug or a prescription, you may call Merck- Medco Services toll- free: 1- 800- 631- 7780. To request order forms, you may call toll- free: 1- 800- 631- 7780 or the Plan at 1- 703- 683- 5585.

Dental Benefits

The Plan will pay actual charges up to the amount specified in the Schedule of dental allowances under both Standard and High Options.

The Plan pays covered charges up to the High Option Schedule of dental allowances for repair of accidental injury (see page 38) to sound natural teeth. Injury to the teeth from chewing or biting is not considered an accidental injury for purposes of this provision.

After satisfaction of a $30 dental deductible, the Plan pays covered charges for basic services up to the applicable limit shown in the Schedule of dental allowances on pages 23 and 24.

After the $30 dental deductible the Plan pays covered charges up to a percentage of the applicable limit shown in the Schedule of dental allowances on page 25. This percentage depends upon the number of calendar years the member has been continuously enrolled under the High Option of this Plan, as follows: first calendar year, 50% of scheduled limit; second calendar year, 75% of scheduled limit; thereafter, 100% of scheduled limit.

The maximum benefit payable for any calendar year is $800 per person, $2,000 per family. Only scheduled limits shown in the Schedule of dental allowances may be applied toward the dental deductible or the maximums payable.

The following Schedule of dental allowances, for basic and major services is a complete list of covered dental services available under the High Option.

Note: The Plan pays actual charges up to the scheduled limits.

What is covered Both Options

Accidental injury to teeth

High Option Basic services

Major services ADA Diagnostic Scheduled Code Limit

0120 Periodic oral evaluation (routine exams limited to two per year). ......... $ 6.50 0140 Limited oral evaluation- problem focused ........... 6.50 0150 Comprehensive oral evaluation ........................... 9.00 0160 Detailed and extensive oral evaluation- problem

focused, by report ............................................ 11.00 0210 Intraoral, complete series including bitewings

(limited to one every three years) .................... 23.00 0220 Intraoral, periapical first film .............................. 3.50 0230 Intraoral, periapical each additional film ............ 1.00 0240 Intraoral, occlusal film ........................................ 6.00 0250 Extraoral, first film .............................................. 7.00 0260 Extraoral, each additional film ............................ 7.00 0270 Bitewing, single film ........................................... 3.50 0272 Bitewings, two films ........................................... 6.50 0274 Bitewings, four films (bitewings limited to two

series per year) .................................................. 9.50 0330 Panoramic film (considered a complete

series) .............................................................. 19.00 0460 Pulp vitality tests ................................................. 7.00 0470 Diagnostic casts ................................................. 15.50

High Option basic services

ADA Preventive Scheduled Code Limit

1110 Prophylaxis, adult (age 14 or over) ............... $ 14.50 1120 Prophylaxis, child (under age 14) (prophylaxes

or cleanings are limited to two per year) ......... 10.50 1201 Topical application of fluoride, including

prophylaxis ...................................................... 17.00 1203 Topical application of fluoride, prophylaxis

not included ....................................................... 6.50 (applications of fluoride, limited to one per year and to children under age 14) 1510 Space maintainer, fixed, unilateral .................... 77.50 1515 Space maintainer, fixed, bilateral ...................... 77.50 1520 Space maintainer, removable, unilateral ......... 113.50 1525 Space maintainer, removable, bilateral ........... 113.50 1550 Recementation of space maintainer (space

maintainers are passive appliances, schedule limit includes all adjustments) ......................... 10.00

Dental Benefits continued

ADA Restorative Scheduled Code Limit

Note: Multiple restorations on one surface will be considered as a single restoration. 2110 Amalgam, one surface, primary ..................... $ 13.50 2120 Amalgam, two surfaces, primary ..................... 19.50 2130 Amalgam, three surfaces, primary ................... 25.00 2140 Amalgam, one surface, permanent ................... 14.50 2150 Amalgam, two surfaces, permanent ................. 22.00 2160 Amalgam, three surfaces, permanent ............... 29.50 2210 Silicate cement ................................................. 18.00 2330 Resin, one surface ............................................ 17.00 2331 Resin, two surfaces ........................................... 24.00 2332 Resin, three surfaces ......................................... 29.50 2951 Pin retention, per tooth in addition to

restoration ....................................................... 10.50

Endodontics

3110 Pulp cap, direct .................................................. 9.50 3120 Pulp cap, indirect ............................................... 9.50 3220 Therapeutic pulpotomy. ................................... 17.50 3310 Root canal, one ................................................ 108.00 3320 Root canal, two ................................................ 131.00 3330 Root canal, three or more ................................ 178.50 3351 Apexification /recalcification- initial visit ......... 7.00 3410 Apicoectomy/ periradicular surgery- anterior ... 113.00

Periodontics

4210 Gingivectomy or gingivoplasty, per quadrant .. 86.00 4211 Gingivectomy or gingivoplasty, per tooth ........ 22.00 4220 Gingival curettage, surgical, per quadrant,

by report ......................................................... 12.00 4240 Gingival flap procedure including root

planing, per quadrant ...................................... 33.50 4249 Clinical crown lengthening- hard tissue ............ 90.00 4260 Osseous surgery (including flap entry and closure)

per quadrant .................................................. 194.00 4263 Bone replacement graft- first site in

quadrant .......................................................... 84.00 4271 Free soft tissue, graft procedure (including

donor site surgery) ......................................... 142.00 4320 Provisional splinting, intracoronal ................... 33.50 4321 Provisional splinting, extracoronal ................... 35.50 4341 Periodontal scaling and root planing, per

quadrant .......................................................... 15.00 4910 Periodontal maintenance procedures

(following active therapy) .............................. 19.50

High Option basic services continued

ADA Prosthodontics (removable) repairs Scheduled Code Limit

5510 Repair broken complete denture base ............. $ 26.00 5520 Replace missing or broken teeth,

complete denture (each tooth) ......................... 5.00 5610 Repair resin denture base ................................. 25.00 5620 Repair cast framework ..................................... 34.00 5630 Repair or replace broken clasp ......................... 20.00 5640 Replace broken teeth, per tooth ......................... 5.00 5650 Add tooth to existing partial denture ................ 11.00 5660 Add clasp to existing partial denture ................ 24.00

Oral surgery (includes local anesthesia and routine postoperative care)

7110 Extraction, single tooth ..................................... 17.00 7120 Extraction, each additional tooth ....................... 14.50 7130 Root removal, exposed roots ............................. 18.00 7210 Surgical removal of erupted tooth requiring

elevation of mucoperiosteal flap and removal of bone and/ or section of tooth ........................ 24.00 7250 Surgical removal of residual tooth roots

(cutting procedure) .......................................... 28.50 7281 Surgical exposure of impacted or

unerupted tooth to aid eruption ........................ 46.50 7310 Alveoloplasty in conjunction with

extractions per quadrant .................................. 30.50 7320 Alveoloplasty not in conjunction with

extractions per quadrant .................................. 49.50 7450 Removal of odontogenic cyst or tumor,

lesion diameter up to 1.25 cm .......................... 42.00 7451 Removal of odontogenic cyst or tumor,

lesion diameter over 1.25 cm........................... 94.50 7510 Incision and drainage of abscess, intraoral

soft tissue ......................................................... 24.50 7520 Incision and drainage of abscess, extraoral

soft tissue ......................................................... 24.50 7970 Excision of hyperplastic tissue, per arch ........... 67.00 7971 Excision of pericoronal gingiva ........................ 28.50

Adjunctive general services

9220 General anesthesia ............................................. 45.00 9230 Analgesia ............................................................ 9.00 9240 Intravenous sedation .......................................... 43.00 9310 Consultation (diagnostic service provided

by dentist or physician other than practitioner providing treatment) ........................................ 18.00 9430 Office visit for observation (during regularly

scheduled hours) ................................................ 6.50 9440 Office visit, after regularly scheduled hours ..... 8.00 9950 Occlusion analysis, mounted case .................... 17.50 9951 Occlusal adjustment, limited ............................ 25.00 9952 Occlusal adjustment, complete ........................ 110.00

High Option major services Dental Benefits continued

ADA Restorative Scheduled Code limit

2410 Gold foil, one surface ................................... $ 24.50 2420 Gold foil, two surfaces ................................... 53.50 2430 Gold foil, three surfaces ................................. 74.50 2510 Inlay, metallic, one surface ............................. 40.00 2520 Inlay, metallic, two surfaces. .......................... 92.50 2530 Inlay, metallic, three or more surfaces .......... 117.50 2610 Inlay, porcelain/ ceramic, one surface ............. 24.50 2620 Inlay, porcelain/ ceramic, two surfaces ............ 45.00 2630 Inlay, porcelain/ ceramic, three or more

surfaces ......................................................... 69.00 2710 Crown, resin (laboratory) ................................ 73.50 2720 Crown, resin with high noble metal .............. 198.50 2721 Crown, resin with predominantly base

metal ........................................................... 167.00 2722 Crown, resin with noble metal ...................... 182.50 2740 Crown, porcelain/ ceramic substrate .............. 184.00 2750 Crown, porcelain fused to high noble

metal ........................................................... 215.50 2751 Crown, porcelain fused to predominantly

base metal ................................................... 184.00 2752 Crown, porcelain fused to noble metal ......... 199.50 2790 Crown, full cast high noble metal ................. 203.50 2791 Crown, full cast predominantly base metal ... 172.00 2792 Crown, full cast noble metal ......................... 188.00 2810 Crown, 3/ 4 cast metallic ............................... 198.50 2910 Recement inlay ............................................... 11.50 2920 Recement crown ............................................. 11.50 2930- 31 Prefabricated stainless steel crown primary

or permanent tooth ........................................ 40.00 2932 Prefabricated resin crown ............................... 40.00 2940 Sedative filling .................................................. 8.00 2950 Core buildup including any pins ..................... 22.00 2952 Cast post and core in addition to crown .......... 56.50 2954 Prefabricated post and core in addition to

crown ............................................................ 32.00 2970 Temporary crown (fractured tooth)................. 40.00

Prosthodontics (removable)

5110- 20 Complete upper or lower denture .................. 242.50 5130- 40 Immediate upper or lower denture ................ 275.00 5211 Maxillary partial denture- resin (including

any conventional clasps, rest and teeth) ...... 237.50 5212 Mandibular partial denture- resin base

(including any conventional clasps, rest and teeth) ........................................................... 237.50 5213 Maxillary partial denture- cast metal

framework with resin denture bases (including any conventional clasps and teeth) ........................................................... 271.00 5214 Mandibular partial denture- cast metal

framework with resin denture bases (including any conventional clasps, rest and teeth) ........................................................... 271.00 5281 Removable unilateral partial denture- one

piece cast metal (including clasp and teeth) ........................................................... 157.50

ADA Scheduled Code Limit

5410- 11 Adjust complete upper or lower denture ...... $ 17.00 5421- 22 Adjust partial upper or lower denture ............. 17.00 5710- 11 Rebase complete denture ............................... 94.50 5720- 21 Rebase partial denture .................................... 71.00 5730- 31 Reline complete denture (chairside) ............... 56.50 5740- 41 Reline partial denture (chairside) .................... 43.00 5750- 51 Reline complete denture (laboratory) ............. 76.00 5760- 61 Reline partial denture (laboratory) .................. 65.00 5810- 11 Interim complete denture .............................. 115.50 5820- 21 Interim partial denture ..................................... 65.00 5850 Tissue conditioning per denture unit ............... 20.00 5860 Overdenture, complete, by report ................. 350.00 5861 Overdenture, partial, by report ...................... 280.00 5862 Precision attachment, by report ....................... 98.00

Prosthodontics (fixed)

6210 Pontic, cast high noble metal ........................ 204.00 6211 Pontic, cast predominantly base metal .......... 172.00 6212 Pontic, cast noble metal ................................ 188.00 6240 Pontic, porcelain fused to high noble metal .. 215.50 6241 Pontic, porcelain fused to predominantly

base metal ................................................... 184.00 6242 Pontic, porcelain fused to noble metal .......... 199.50 6250 Pontic, resin with high noble metal ............... 222.00 6251 Pontic, resin with predominantly base

metal ........................................................... 175.00 6252 Pontic, resin with noble metal ....................... 197.00 6520 Inlay, metallic two surfaces ............................ 92.50 6530 Inlay, metallic three or more surfaces ........... 117.50 6545 Retainer- Cast metal for resin bonded fixed

prosthetics ..................................................... 34.00 6720 Crown, resin with high noble metal .............. 215.50 6721 Crown, resin with predominantly base

metal ........................................................... 184.00 6722 Crown, resin with noble metal ...................... 199.50 6750 Crown, porcelain fused to high noble

metal ........................................................... 234.00 6751 Crown, porcelain fused to predominantly

base metal ................................................... 185.00 6752 Crown, porcelain fused to noble metal ......... 205.00 6780 Crown, 3/ 4 cast high noble metal .................. 198.50 6790 Crown, full cast high noble metal ................. 209.00 6791 Crown, full cast predominantly base metal ... 187.00 6792 Crown, full cast noble metal ......................... 185.00 6930 Recement fixed partial denture ....................... 21.00 6940 Stress breaker .................................................. 56.50 6950 Precision attachment ....................................... 92.50 6970 Cast post and core in addition to

fixed partial denture retainer ......................... 66.00 6971 Cast post as part of

fixed partial denture retainer ......................... 51.00 6972 Prefabricated post and core in addition

to fixed partial denture retainer ..................... 37.00

Dental Benefits continued

Standard Option The Plan covers charges up to the applicable limit shown in the following Schedule of dental allowances. There is no calendar year maximum or deductible. This is a complete list of covered services.

ADA Scheduled Code Diagnostic limit

0120 Periodic oral evaluation (routine limited to two per year) ............................................. $ 6.50 0140 Limited oral evaluation- problem focused ........................................................................ 6.50 0150 Comprehensive oral evaluation ....................................................................................... 9.00 0210 Intraoral, complete series including bitewings

(limited to one every three years) ................................................................................. 15.00 0220 Intraoral, periapical, first film .......................................................................................... 1.00 0230 Intraoral, periapical, each additional film ........................................................................ 1.00 0240 Intraoral, occlusal film ..................................................................................................... 7.50 0270 Bitewing, single film ....................................................................................................... 3.00 0272 Bitewings, two films ........................................................................................................ 4.00 0274 Bitewings, four films (bitewings limited to two series per year) ..................................... 6.50 0330 Panoramic film (considered a complete series) .............................................................. 15.00

Preventive

1110 Prophylaxis, adult (age 14 or over) ................................................................................. 10.50 1120 Prophylaxis, child (under age 14)( prophylaxes, or cleanings, limited to two per year) .. 10.50 1201 Topical application of fluoride, including prophylaxis ................................................... 16.00 1203 Topical application of fluoride, prophylaxis not included (application

of fluoride limited to one per year and to children under age 14) .................................. 5.50

Restorative

Note: Multiple restorations in one surface will be considered as a single restoration. 2110 Amalgam, one surface, primary ...................................................................................... 11.50 2120 Amalgam, two surfaces, primary .................................................................................... 16.50 2130 Amalgam, three surfaces, primary .................................................................................. 22.00 2140 Amalgam, one surface, permanent ................................................................................. 11.50 2150 Amalgam, two surfaces, permanent ................................................................................ 18.00 2160 Amalgam, three surfaces, permanent .............................................................................. 22.00 2210 Silicate cement ................................................................................................................ 16.50 2330 Resin, one surface ........................................................................................................... 11.50 2331 Resin, two surfaces ......................................................................................................... 18.00 2332 Resin, three surfaces ....................................................................................................... 22.00

Oral surgery

7110 Extraction, single tooth ................................................................................................... 12.50 7120 Extraction, each additional tooth ..................................................................................... 7.50 7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal

flap and removal of bone and/ or section of tooth .......................................................... 19.00 For covered oral and maxillofacial surgery, see page 15.

Services and supplies furnished by other than a licensed dentist, except for a prophylaxis (cleaning) which may be performed by a licensed dental hygienist working under the supervision of a dentist or in an accredited school of dentistry Dental services and supplies for which other benefits are payable under this Plan Replacement of bridges, dentures or appliances within five years of coverage of previous

placement by this Plan Fluorides for home use Dental implants Any dental service or supply for cosmetic purposes Training in preventive care, oral hygiene or dietary practices Orthodontic treatment

Related benefit Oral and maxillofacial surgery

What is not covered

If you do not receive your identification card( s) within 60 days after the effective date of your enrollment, call the Carrier at 703/ 683- 5585 to report the delay. In the meantime, use your copy of the SF 2809 enrollment form or your annuitant confirmation letter from OPM as proof of enrollment when you obtain services. This is also the number to call for claim forms or advice on filing claims.

If you have a question concerning Plan benefits, contact the Carrier at 703/ 683- 5585 or you may write the Carrier at 1019 North Royal Street, Alexandria, VA 22314- 1596.

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 providers.

Claims filed by your doctor that include an assignment of benefits to the doctor are to be filed on the form HCFA- 1500, Health Insurance Claim Form. The claim form must be signed to authorize release of medical information and assignment of benefits. A Signature on File is acceptable. Claims submitted by enrollees may be submitted on the HCFA 1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show: Name of patient and relationship to enrollee Plan identification number of enrollee Name and address of person or firm providing the service or supply Providers tax identification number (needed for assigned claims and PPO providers) Dates that services or supplies were furnished Type of each service or supply and the charge Diagnosis

In addition: All requests for additional information needed by the Plan should be responded to promptly. For claims under Other Medical Benefits, the attending doctor must complete a doctors statement. A copy of the explanation of benefits (EOB) from any primary payer (such as Medicare) must

be sent with your claim. Bills for private duty nurses must show that the nurse is a registered or licensed practical nurse

and should include nursing notes. Claims for rental or purchase of durable medical equipment in excess of $300, private duty

nursing, and physical, occupational and speech therapy require a written statement from the doctor specifying the medical necessity for the service or supply and the length of time needed. Claims for overseas (foreign) services should include an English translation. Charges should be

converted to U. S. dollars using the exchange rate applicable at the time the expense was incurred. For dental claims, complete the members section of the claim form and give it to the dentist to

complete the remainder. For prescription drug claims, see page 21.

Canceled checks, cash register receipts or balance due statements are not acceptable. After completing and signing a claim form and attaching proper documentation, send claims to:

Postmasters Benefit Plan 1019 North Royal Street Alexandria, VA 22314- 1596

Telephone 703/ 683- 5585

Keep a separate record of the medical expenses of each covered family member as deductibles and maximum allowances apply separately to each person. Save copies of all medical bills, including those you accumulate to satisfy a deductible. In most instances, they will serve as evidence of your claim. The Carrier will not provide duplicate or year end statements.

When covered expenses exceed the deductible, complete a claim form, attach itemized bills, and send them to the Plan. Claims for out- of- hospital benefits should not be submitted more often than quarterly. To avoid denial, all claims must be submitted no later than December 31 of the calendar year after the year in which the covered service was provided, unless timely filing was prevented by administrative operations of Government or legal incapacitation, provided the claim was submitted as soon as reasonably possible. If the Plan returns a claim or part of a claim for additional information, it must be resubmitted within 90 days, or before the timely filing period expires, whichever is later. Once benefits have been paid, there is a three year limitation on the reissuance of uncashed checks.

Claim forms and identification cards How to Claim Benefits

How to file claims

Records Submit claims promptly

How to Claim Benefits continued

Claims with no procedure codes or experimental procedure codes are reviewed by PBPs Technical Advisory Dept., to determine whether the procedure is or is not experimental or investigational. Claims requiring a review by a physician or specialist are sent to First Health Group Corp., for review by appropriate physicians and specialists who recommend whether the services should or should not be considered experimental or investigational.

To authorize direct payment to a hospital, doctor, or dentist, complete the authorization on the claim form or on the assignment form furnished by the hospital, doctor, or dentist.

Reply promptly when the Carrier requests information in connection with a claim. If you do not respond, the Carrier may delay processing or limit the benefits available.

Medical and other information provided to the Carrier, including claim files is kept confidential and will be used only: 1) by the Carrier 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 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. As part of its administration of the prescription drug benefits, the Plan may disclose information about a members prescription drug utilization, including the names of prescribing physicians, to any treating physicians or dispensing pharmacies.

If a claim for payment is denied by the Carrier, you must ask the Carrier, in writing, within six months of the date of the denial, to reconsider its decision 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 Carrier an opportunity to reconsider your claim. Before you ask the Carrier to reconsider, you should first check with your provider or facility to be sure that the claim was filed correctly. For instance, did they use the correct procedure code for the service( s) performed (surgery, laboratory test, X- ray, office visit, etc.)? Indicate any complications of any surgical procedure( s) performed. Include copies of an operative or procedure report, or other documentation that supports your claim. Your written request to the Carrier must state why, based on specific benefit provisions in this brochure, you believe the denied claim for payment should have been paid.

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

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

You may also ask OPM for a review if the Carrier fails to respond within 30 days of your written request for reconsideration or 30 days after you have supplied additional information to the Carrier. In this case, OPM must receive a request for review within 120 days of your request to the Carrier for reconsideration or of the date you were notified that the Carrier 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 Carrier should have paid the denied claim. If the Carrier has reconsidered and denied more than one unrelated claim, clearly identify the documents for each claim.

Disputed claims review

Reconsideration OPM review

Experimental/ investigational determinations

When more information is needed Confidentiality Direct payment

to hospital or provider of care

Your request must include the following information or it will be returned by OPM: A copy of your letter to the Carrier requesting reconsideration; A copy of the Carriers reconsideration decision (if the Carrier failed to respond, provide

instead (a) the date of your request to the Carrier, or (b) the dates the Carrier requested and you provided additional information to the Carrier); Copies of documents that support your claim (such as doctors letters, operative reports, bills,

medical records, explanation of benefit (EOB) forms; and Your daytime phone number.

Medical documentation received from you or the Carrier 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 2, 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 Carriers decision on your claim, and you decide to bring a lawsuit based on the denial, the lawsuit must be brought no later than December 31 of the third year after the year in which the services or supplies upon which the claim is predicated were provided. Pursuant to section 890.107, title 5, CFR, such a lawsuit must be brought against the Office of Personnel Management in Federal court.

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

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 Carrier to determine if the Carrier has acted properly in denying you the payment or service, and the information so collected may be disclosed to you and/ or the Carrier in support of OPMs decision on the disputed claim.

Standard Option enrollees can limit their out- of- pocket expenses using the Plans POS program. For a brief explanation of the program, see the POS sections on pages xx and xx. For a description of POS benefits, see the benefit sections of the brochure.

To use the POS program, each member must 1) register his/ her intent to do so by selecting a POS Primary Care Physician, 2) obtain pre- approval for specialty referrals and 3) obtain care from a POS provider. Although a referral is not required for lab and x- ray services, enrollees must use POS network providers to receive POS benefits. The Plan provides the mechanisms noted below to help the patient comply with these provisions. If for any reason the member does not comply, the Plan cannot provide POS benefits.

The member can call 1- 800- 654- 6530 at any time to speak with a Referral Management Coordinator (RMC) to identify the POS providers located in the area where the enrollee intends to obtain care.

The member must speak with an RMC at 1- 800- 654- 6530 to select both their POS Primary Care Physician and a POS Primary Care Physician for each covered family member prior to receiving care applicable to the POS program. After this selection is made, the Plan provides POS benefits for POS covered services provided by a POS Primary Care Physician. If currently there is no POS Primary Care Physician in the area where the member intends to obtain care, the RMC will help the member to select a qualified physician in that area to act as the members POS Primary Care Physician. The Plan will not provide POS benefits for care rendered prior to selecting a POS Primary Care Physician.

If a POS Primary Care Physician indicates the need for a referral to a specialist or either a CAT Scan or an MRI, the member must speak with an RMC at 1- 800- 654- 6530 to receive a written specialty referral. A referral is not necessary to see a network gynecologist. If care begins within 90 days of the date of the written specialty referral, you can visit your specialist for up to 180 days from the referral date without the need to obtain further referrals. If care is not begun within 90 days or exceeds 180 days, the member must speak with an RMC at 1- 800- 654- 6530 to receive a written renewal of the specialty referral. If the specialist or the Primary Care Physician indicates the need for additional referrals, the member must speak with an RMC at 1- 800- 654- 6530 to receive additional written specialty referrals.

Privacy Act statement

How to Obtain POS Benefits (Standard Option) How to Claim Benefits continued

Protection Against Catastrophic Costs

For those services with coinsurance, the Plan pays 100% of reasonable and customary charges for the remainder of the calendar year after out- of- pocket expenses for the coinsurances and deductible shown below for that calendar year exceed $2,500 under High Option and $6,700 ($ 3,000 if using PPO providers) under Standard Option for you and any covered family members.

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

High Option Standard Option

The 20% you pay for Other Medical Benefits The 30% you pay for Other Medical Benefits or 5% if using a PPO; or 5% if using a PPO; The 20% you pay for Emergency Room The 30% you pay for Emergency Room

Treatment or 5% if using a PPO; Treatment or 5% if using a PPO; The 15% you pay for Inpatient Hospital The 30% you pay for Inpatient Hospital

Benefits; Benefits; or 5% if using a PPO; The 15% you pay for Surgical benefits or The 30% you pay for Surgical benefits or

5% if using a PPO; 5% if using a PPO; The $200 (PPO) and $275 (Non- PPO) The $200 (PPO) and $350 (Non- PPO)

calendar year deductible; and calendar year deductible; and The $100 calendar year prescription drug The $100 calendar year prescription drug

deductible and the 20% you pay for deductible and the 30% you pay for prescriptions filled by a retail pharmacy. non- participating pharmacies.

The following cannot be counted toward out- of- pocket expenses: Copayments The $50 calendar year prescription drug deductible for participating pharmacies and the Mail

Order Drug Program. Expenses in excess of reasonable and customary allowances or maximum benefit limitations; Expenses for mental conditions, substance abuse or dental care and the inpatient hospital

deductible; and Any amounts you pay because benefits have been reduced for non- compliance with this Plans

cost containment requirements (see page 31). If you changed to this Plan during open season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plans catastrophic protection benefit during the prior year 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 already met the covered out- of- pocket maximum expense level in full, your old plans catastrophic protection benefit will continue to apply until the effective date. If you have not met this expense level in full, your old plan will first apply your covered out- of- pocket expenses until the prior years catastrophic level is reached and then apply the catastrophic protection benefit to covered out- of- pocket expenses incurred from that point until the effective date. The old plan will pay these covered expenses according to this years benefits; benefit changes are effective on January 1.

Catastrophic protection

Carryover

Precertify before admission

Other Information

Precertification

Precertification is not a guarantee of benefit payments. Precertification of an inpatient admission is a predetermination that, based on the information given, the admission meets the medical necessity requirements of the Plan. It is your responsibility to ensure that precertification is obtained. If Precertification is not obtained and benefits are otherwise payable, benefits for the admission will be reduced by $500.

To precertify a scheduled admission: You, your representative, your doctor or your hospital must call, First Health Group Corp.,

prior to admission. The toll- free number is 1- 800- 654- 6530. Provide the following information: enrollees name and Plan identification number; patients

name, birth date and phone number; reason for hospitalization; proposed treatment or surgery; name of hospital or facility; name and phone number of admitting doctor; and number of planned days of confinement.

First Health Group Corp., will then tell the doctor and hospital the number of approved days of confinement for the care of the patients condition. Written confirmation of the Carriers precertification decision will be sent to you, your doctor, and the hospital. If the length of stay needs to be extended, follow the procedures below.

If any additional days are required, your doctor or the hospital must call the above number and request certification of additional days. If the admission is precertified but you remain confined beyond the number of days certified as medically necessary, the Plan will not pay for charges incurred on any extra days that are determined to not be medically necessary by the Carrier during the claim review.

You dont need to certify an admission when: Medicare Part A, or another group health insurance policy, is the primary payer for the hospital

stay (see pages 32- 34). Precertification is required, however, when Medicare hospital benefits are exhausted prior to using lifetime reserve days. You are confined in a hospital outside the United States and Puerto Rico.

When there is an unscheduled maternity admission or an emergency admission due to a condition that puts the patients life in danger or could cause serious damage to bodily function, you, your representative, the doctor, or the hospital must telephone 1- 800- 654- 6530 within two business days following the day of admission, even if the patient has been discharged from the hospital. Otherwise, inpatient benefits otherwise payable for the admission will be reduced by $500.

Newborn admissions that extend beyond the mothers discharge date must also be certified. You, your representative, the doctor or hospital must request certification for the newborns continued stay within two business days following the day of the mothers discharge.

An early determination of need for admission (precertification of the medical necessity of inpatient admission) is binding on the Carrier unless the Carrier is misled by the information given to it. After the claim is received, the Carrier will first determine whether the admission was precertified and then provide benefits according to all of the terms of this brochure.

If precertification is not obtained before admission to the hospital (or within two business days following the day of a maternity or emergency admission or, in the case of a newborn, the mothers discharge), a medical necessity determination will be made at the time the claim is filed. If the Carrier determines that the hospitalization was not medically necessary the inpatient hospital benefits will not be paid. However, medical supplies and services otherwise payable on an outpatient basis will be paid.

If the claim review determines that the admission was medically necessary, any benefits payable according to all of the terms of this brochure will be reduced by $500 for failing to have the admission precertified.

If the admission is determined to be medically necessary, but part of the length of stay was found not to be medically necessary, inpatient hospital benefits will not be paid for the portion of the stay that was not medically necessary. However, medical services and supplies otherwise payable on an outpatient basis will be paid.

Need additional days?

Maternity or emergency admissions

Other considerations

If you do not precertify

Precertification continued

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 703/ 683- 5585 or you may write the Carrier at 1019 North Royal Street, Alexandria, VA 22314- 5585.

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.

Information you have a right to know

Information that must be made available to you includes:

This Plan and Medicare

The following information applies only to enrollees and covered family members who are entitled to benefits from both this Plan and Medicare. You must disclose information about Medicare coverage, including your enrollment in a Medicare prepaid plan, to this Carrier; this applies whether or not you file a claim under Medicare. You must also give this Carrier authorization to obtain information about benefits or services denied or paid by Medicare when they request it. It is also important that you inform the Carrier about other coverage you may have as this coverage may affect primary/ secondary status of this Plan and Medicare (see pages 9- 10).

This Plan covers most of the same kinds of expenses as Medicare Part A, hospital insurance, and Part B, medical insurance, except that Medicare does not cover prescription drugs.

The following rules apply to enrollees and their family members who are entitled to benefits from both a FEHB plan and Medicare.

1) You are age 65 or over, have Medicare Part A (or Parts A and B), and are employed by the Federal Government; 2) Your covered spouse is age 65 or over and has Medicare Part A (or Parts A and B) and you are

employed by the Federal Government; 3) The patient (you or a covered family member) is within the first 30 months of eligibility to

receive Medicare Part A benefits due to End Stage Renal Disease (ESRD) except when Medicare (based on age or disability) was the patients primary payer on the day before he or she became eligible for Medicare Part A due to ESRD; or 4) The patient (you or a covered family member) is under age 65 and eligible for Medicare solely

on the basis of disability, and you are employed by the Federal Government. For purposes of this section, employed by the Federal Government means that you are eligible for FEHB coverage based on your current employment and you do not hold an appointment described under Rule 6 of the following Medicare is primary section.

1) You are an annuitant age 65 or over, covered by Medicare Part A (or Parts A and B) and are not employed by the Federal Government; 2) Your covered spouse is age 65 or over and has Medicare Part A (or Parts A and B) and you are

not employed by the Federal Government; 3) You are age 65 or over and ( a ) you are a Federal judge who retired under title 28, U. S. C., ( b )

you are a Tax Court judge who retired under Section 7447 of title 26, U. S. C., or ( c ) you are the covered spouse of a retired judge described in ( a ) or ( b ); 4) You are an annuitant not employed by the Federal Government, and either you or a covered

family member (who may or may not be employed by the Federal Government) is under age 65 and eligible for Medicare on the basis of disability; 5) You are enrolled in Part B only, regardless of your employment status; 6) You are age 65 or over and employed by the Federal Government in an appointment that

excludes similarly appointed nonretired employees from FEHB coverage, and have Medicare Part A (or Part A and B); or

Coordinating benefits

This Plan is primary if:

Medicare is primary if:

This Plan and Medicare continued

7) You are a former Federal employee receiving workers compensation and the Office of Workers Compensation has determined that you are unable to return to duty; 8) The patient (you or a covered family member) has completed the 30- month ESRD coordination

period and is still eligible for Medicare due to ESRD; or 9) The patient (you or a covered family member) becomes eligible for Medicare due to ESRD after

Medicare assumed primary payer status for the patient under rules 1) through 7) above. When Medicare is primary, all or part of your Plan deductibles and coinsurance will be waived as follows:

Inpatient Hospital Benefits: If you are enrolled in Medicare Part A, the Plan will waive the deductible and coinsurance.

Surgical Benefits: If you are enrolled in Medicare Part B, the Plan will waive the deductible and coinsurance applicable to surgical and medical care.

Mental Conditions/ Substance Abuse Benefits: If you are enrolled in Medicare Part A, the Plan waives the inpatient deductible and coinsurance for hospital charges. If you are enrolled in Medicare Part B, the Plan waives the deductible and coinsurance for doctors inpatient services and outpatient care.

Other Medical Benefits: If you are enrolled in Medicare Part B, the Plan waives the calendar year deductible and coinsurance.

Prescription Drug Benefits: If you are enrolled in Medicare Part B, the Plan waives the High Option Prescription Drug deductible for non- participating pharmacies and the deductible and coinsurance for participating pharmacies. Under the Standard Option, for non- participating pharmacies, the Plan waives the Prescription Drug deductible and pays 70%. The coinsurance for non- participating pharmacies is not waived. The copayments for participating pharmacies ($ 10 or $20) are not waived. The Plan also waives the prescription drug deductible for participating pharmacies. The Mail Order Drug Program copayments are waived for both options.

Dental Benefits: The deductible is not waived. When Medicare is the primary payer, this Plan will limit its payment to an amount that supplements the benefits that would be payable by Medicare, regardless of whether or not Medicare benefits are paid. However, the Plan will pay its regular benefits for emergency services to an institutional provider, such as a hospital, that does not participate with Medicare and is not reimbursed by Medicare.

If you are enrolled in Medicare, you may be asked by a physician to sign a private contract agreeing that you can be billed for services that would ordinarily be covered by Medicare. Should you sign such an agreement, Medicare will not pay any portion of the charges, and you may receive less or no payment for those services under this Plan.

When you are enrolled in a Medicare prepaid plan while you are a member of this Plan, you may continue to obtain benefits from this Plan. If you submit claims for services covered by this Plan that you receive from providers that are not in the Medicare plans network, the Plan will not waive any deductibles or coinsurance when paying these claims.

If you are covered by Medicare Part B and it is primary, you should be aware that your out- ofpocket costs for services covered by both this Plan and Medicare Part B will depend on whether your doctor accepts Medicare assignment for the claim.

Doctors who participate with Medicare accept assignment; that is, they have agreed not to bill you for more than the Medicare- approved amount for covered services. Some doctors who do not participate with Medicare accept assignment on certain claims. If you use a doctor who accepts Medicare assignment for the claim, the doctor is permitted to bill you after the Plan has paid, only when the Medicare and Plan payments combined do not total the Medicare- approved amount.

Doctors who do not participate with Medicare are not required to accept direct payment, or assignment, from Medicare. Although they can bill you for more than the amount Medicare would pay, Medicare law (the Social Security Act, 42 U. S. C.) sets a limit on how much you are obligated to pay. This amount, called the limiting charge, is 115 percent of the Medicare- approved amount. Under this law, if you use a doctor who does not accept assignment for the claim, the doctor is permitted to bill you after the Plan has paid only if the Medicare and Plan payments combined do not total

When Medicare is primary

When you also enroll in a Medicare prepaid plan Medicares payment and this Plan

This Plan and Medicare continued

the limiting charge. Neither you nor your FEHB Plan is liable for any amount in excess of the Medicare limiting charge for charges of a doctor who does not participate with Medicare. The Medicare Summary Notice (MSN) form will have more information about this limit.

If your doctor does not participate with Medicare, asks you to pay more than the limiting charge and he or she is under contract with this Plan, call the Plan. If your doctor is not a Plan doctor, ask the doctor to reduce the charge or report him or her to the Medicare carrier that sent you the Medicare MSN form. In any case, a doctor who does not participate with Medicare is not entitled to payment of more than 115 percent of the Medicare- approved amount.

If you are enrolled in a Medicare HMO and obtain care from a non- HMO provider and the HMO will not pay for the care, the Plan will base allowable charges on the Medicare limiting charge and apply the appropriate deductibles and pay regular benefits.

In most cases, when services are covered by both Medicare and this Plan, Medicare is the primary payer if you are an annuitant and this Plan is primary if you are an employee. When Medicare is the primary payer, your claims should first be submitted to Medicare. After Medicare has paid its benefits, the Carrier will consider the balance of any covered expenses. To be sure your claims are processed by this Carrier, you must submit the MSN form from Medicare and duplicates of all bills along with a completed claim form. The Carrier will not process your claim without knowing whether you have Medicare and, if you do, without receiving the Medicare MSN.

Medicare HMOs

How to claim benefits

Enrollment Information If you are a new member

If you are hospitalized

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 Carrier. 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 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 Carrier. See How to claim benefits on page 27.

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 (see Effective date on page 38). Coverage under your new plan for a hospitalized member may be delayed if you are currently enrolled in another FEHB plan and you or a covered family member are hospitalized on the effective date of your enrollment; see If you are hospitalized below.

No FEHB plan may 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.

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.

Enrollment Information continued

Your responsibility

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 a 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. You will not be informed by your employing office (or your retirement system) or your

Carrier 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 Carrier 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 Program. Report additions and deletions (including divorces) of covered family members to the

Carrier 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. See page 34 for how this Plans benefits are affected when you are enrolled in a Medicare prepaid plan.

Contact your local Social Security Administration (SSA) office for information on local Medicare plans (also known as Coordinated Care Plans or Medicare HMOs) or request it from SSA at 1- 800/ 638- 6833. Contact your retirement system for information on dropping your FEHB enrollment and changing to a Medicare prepaid plan. Federal annuitants are not required to enroll in Medicare Part B (or Part A) in order to be

covered under the FEHB Program nor are their FEHB benefits reduced if they do not have Medicare Part B (or Part A).

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

Things to keep in mind

Coverage after enrollment ends

Enrollment Information continued

Former spouse coverage

Temporary continuation of coverage

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 pay for only 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.

Notification and election requirements: 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.

Enrollment Information continued

Conversion to individual coverage

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.

Certificate of Creditable Coverage

Definitions

An injury caused by an external force or element such as a blow or fall that requires immediate medical attention. Also included are animal bites, poisonings, and dental care required to repair injuries to sound natural teeth as a result of an accidental injury, not from biting or chewing.

The period from entry (admission) into a hospital or other covered facility until discharge. In counting days of inpatient care, the date of entry and the date of discharge are counted as the same day.

An authorization by an enrollee or spouse for the Carrier to issue payment of benefits directly to the provider. The Carrier reserves the right to pay the member directly for all covered services.

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

A condition existing at or from birth which is a significant deviation from the common form or norm. For purposes of this Plan, congenital anomalies include protruding ear deformities, cleft lips, cleft palates, birthmarks, webbed fingers or toes and other conditions that the Carrier may determine to be congenital anomalies. In no event will the term congenital anomaly include conditions relating to teeth or intra- oral structures supporting the teeth.

Any operative procedure or any portion of a procedure performed primarily to improve physical appearance and/ or treat a mental condition through change in bodily form.

Treatment or services, regardless of who recommends them or where they are provided, that could be rendered safely and reasonably by a person not medically skilled, or that are designed mainly to help the patient with daily living activities. These activities include but are not limited to:

(1) personal care such as help in: walking; getting in and out of bed; bathing; eating by spoon, tube or gastrostomy; exercising; dressing;

(2) homemaking, such as preparing meals or special diets; (3) moving the patient; (4) acting as companion or sitter; (5) supervising medication that can usually be self administered; or (6) treatment or services that any person may be able to perform with minimal instruction, including

but not limited to recording temperature, pulse, and respirations, or administration and monitoring of feeding systems.

The Carrier determines which services are custodial care. Equipment and supplies that: (1) are prescribed by your attending doctor; (2) are medically necessary; (3) are primarily and customarily used only for a medical purpose; (4) are generally useful only to a person with an illness or injury; (5) are designed for prolonged use; and (6) serve a specific therapeutic purpose in the treatment of an illness or injury.

The date the benefits described in this brochure are effective: (1) January 1 for continuing enrollments and for all annuitant enrollments; (2) the first day of the first full pay period of the new year for enrollees who change plans or options

or elect FEHB coverage during the open season for the first time; or (3) for new enrollees during the calendar year, but not during the open season, the effective date of

enrollment as determined by the employing office or retirement system.

Accidental injury Admission Assignment Calendar year Congenital anomaly

Cosmetic surgery Custodial care

Durable medical equipment

Effective date

Definitions continued

Experimental or investigational

Group health coverage

Home health care agency

Hospice care program

Incurred date

Medical emergency

Medically necessary

A drug, device or biological product is experimental or investigational if the drug, device, or biological product cannot be lawfully marketed without approval of the U. S. Food and Drug Administration (FDA) and approval for marketing has not been given at the time it is furnished. Approval means all forms of acceptance by the FDA.

A medical treatment or procedure, or a drug, device, or biological product is experimental or investigational if 1) reliable evidence shows that it is the subject of ongoing phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or 2) reliable evidence show that the consensus of opinion among experts regarding the drug, device, or biological product or medical treatment or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis.

Reliable evidence shall mean only published reports and articles in the authoritative medical and scientific literature; the written protocol or protocols used by the treating facility or the protocol( s) of another facility studying substantially the same drug, device, or medical treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device, or medical treatment or procedure.

Health care coverage that a member is eligible for because of employment by, membership in, or connection with, a particular organization or group that provides payment for hospital, medical, or other health care services or supplies, or that pays a specific amount for each day or period of hospitalization if the specified amount exceeds $200 per day, including extension of any of these benefits through COBRA.

An agency or organization that provides a program of home health care that meets all the following requirements: (1) it is certified by the patients doctor as an appropriate provider of home health services; (2) it has a full- time administrator; (3) it maintains written records of services provided to the patient; and (4) its staff includes at least one registered nurse (R. N.).

A formal program directed by a doctor to help care for the terminally ill through either: (1) a centrally administered, medically directed and nurse coordinated program that provides a coherent system of home care; uses a hospice team; and is available 24 hours a day; or (2) confinement of the terminally ill person in a hospice. The hospice team must include a doctor and registered nurse (R. N.) and may include social workers, clergymen/ counselors, volunteers, clinical psychologists and physical or occupational therapists.

The date services and supplies are received. The applicable benefits are those in effect on this date. The incurred date for major dental care expenses that involve preparatory services is the date the inlay, crown, bridge or denture is seated, placed or installed in the patients mouth.

The sudden and unexpected onset of a condition requiring immediate medical care, which the covered person secures within 72 hours after the onset. The severity of the condition, as revealed by the doctors diagnosis, must be such as would normally require emergency care. Medical emergencies include heart attacks, strokes, loss of consciousness or respiration, convulsions, and such other acute conditions as may be determined by the Plan to be medical emergencies.

Services, drugs, supplies or equipment provided by a hospital or covered provider of the health care services that the Carrier determines:

(1) are appropriate to diagnose or treat the patients condition, illness or injury; (2) are consistent with standards of good medical practice in the United States; (3) are not primarily for the personal comfort or convenience of the patient, the family, or the

provider; (4) are not a part of or associated with the scholastic education or vocational training of the

patient; and (5) in the case of inpatient care, cannot be provided safely on an outpatient basis. The fact that a covered provider has prescribed, recommended, or approved a service, supply, drug or equipment does not, in itself, make it medically or dentally necessary.

Definitions continued

Mental conditions/ substance abuse Conditions and diseases listed in the most recent edition of the International Classification of

Diseases (ICD) as psychoses, neurotic disorders, or personality disorders; other nonpsychotic mental disorders listed in the ICD, to be determined by the Carrier; or disorders listed in the ICD requiring treatment for abuse of or dependence upon substances such as alcohol, narcotics, or hallucinogens.

A condition in which an individual weighs the greater of 100 pounds or 100% over his or her normal weight.

Internists, obstetricians, gynecologists, general practitioners, family practitioners or pediatricians who participate in the point- of- service network used by this Plan.

Any licensed physician who participates in the point- of- service network used by this Plan but who is not a POS primary care physician.

The prevailing charge in a geographic area made by other providers for the treatment of an illness or injury of comparable severity and nature. Benefits are based on, and limited to, expenses that are reasonable and customary as determined by statistical profiles developed by Medicode Inc. These profiles are updated once per year. The 80th percentile of the Medicode Inc. is used in determining the benefits available for all surgical, anesthesia, medical and mental health care. Any amount above the Plans allowance is the patients responsibility.

A natural tooth that is whole or properly restored, without impairing periodontal or other conditions and not in need of the treatment rendered or proposed for any reason other than accidental injury.

A surgical procedure means cutting, suturing, treating burns, correcting a fracture, reducing a dislocation, manipulating a joint under anesthesia, electrocauterizing, tapping (paracentesis), applying plaster casts, administering pneumothorax, endoscopy or injecting sclerosing solution.

Morbid obesity POS primary care physician

POS specialist

Reasonable and customary

Sound natural tooth

Surgery

Index A

Abortion 11 Accidental injury 3, 15, 19, 20, 23,

38, 40 Additional benefits 2, 3, 20 Allergy treatment 3,18 Ambulance 3, 19 Anesthesia 7, 14, 18, 24, 25, 40 Assignment 9, 10, 27, 28, 33, 38 Assistant surgeon 14 Assisted reproductive technology 17

Bassinet and nursery charges 16 Birthing center 16 Blood or blood plasma 12 Bone marrow transplant 14 Breast cancer screening 18 Burns 40

Calendar year deductible 2, 7, 8, 13, 14, 16, 17, 18, 19, 30, 33 Carryover 8, 30 Catastrophic protection 30 Cervical cancer screening 18 Chemotherapy 3, 12, 15, 18 Childbirth 3, 12 Claim benefits 3, 21, 22, 27, 34 Coinsurance 3, 8, 10, 11, 21, 30, 33 Colorectal cancer screening 18 Congenital anomalies 15 Contact lenses 19 Contraceptive drugs and devices 21 Convalescent care 19 Coordinating benefits 32 Cosmetic surgery 15, 38 Covered charges 8, 12, 13, 14, 16, 17,

18, 20, 23 Covered facility 5, 17, 34, 38 Covered provider 6, 11, 38, 39 Custodial care 13, 16, 19, 38

Days certified 31 Deductible 2, 3, 7, 8, 10, 11, 12, 13,

14, 16, 17, 18, 19, 21, 23, 26, 27, 30, 33, 34 Dental benefits/ care 3, 8, 18, 23, 30,

33, 38, 39 Diabetic supplies 19 Disputed claims 5, 28 Donor expenses 14 Durable medical equipment 3, 20,

27, 38

Effective date 8, 10, 27, 30, 34, 35, 36, 38 Embryo transfer 17

Emergency admission 12, 16, 17, 18, 31 Emergency care 39 Exclusions 2, 9, 11 Experimental 11, 28, 39 Explanation of benefits 10, 27 Extractions 24 Eyeglasses 19

Family limit 8 Fecal occult blood test 18 Flexible benefits option 5 Free- standing ambulatory facilities 5

Gamete intrafallopian transfer (GIFT) 17

Home health care 19, 39 Home, office and hospital visits 18 Hospice care 3, 20, 39 Hospital admission 6, 12, 16 Hospital visits 7, 18

Immunizations 3, 11, 20 Incidental procedures 13 Infertility 3, 16, 18 Inpatient care 12, 13, 17, 19, 20, 38, 39 Insulin 19, 21 In vitro fertilization 17

Laboratory 5, 14, 16, 18, 25, 28 Lifetime maximum 8 Licensed practical nurse 19, 27

Mail order drug program 7, 21, 22, 30, 33 Mammograms 18 Maternity benefits 3, 6, 16 Medicaid 9 Medical emergency 12, 19, 39 Medically necessary

9, 11, 15, 16, 31, 38, 39 Medicare 2, 3, 4, 8, 9, 10, 11, 12, 20,

21, 27, 31, 32, 33, 34, 35 Mental conditions 3, 7, 8, 12, 17, 18,

30, 33, 38, 40 Multiple surgical procedures 13, 15

Negotiated rate 7, 13, 14, 16, 18, 20 Non- FEHB benefits 42 Nursing services 3, 5, 6, 19

Obstetrical care 16 Occupational therapy 3, 5, 6, 18, 27, 39 Ocular injury 19 Oral and maxillofacial surgery 15, 26 Oral contraceptives 17 Organ/ tissue transplant 14, 15 Other medical benefits 2, 3, 6, 7, 12,

14, 16, 18, 27, 30, 33 Out- of- pocket expenses 5, 29, 30 Outpatient services 7, 17, 18 Outpatient surgery 3, 16 Overseas claims 27

Pap smear 18 Physical exams 18 Physical therapy 3, 5, 6, 18, 27, 39 POS 5, 6, 12, 13, 14, 15, 16, 17, 18, 29,

40, 42, PPO 5, 6, 7, 8, 10, 12, 13, 14, 15, 16,

17, 18, 19, 27, 30 Precertification 2, 4, 5, 12, 16, 17, 31 Preferred providers 7, 8 Prescription drugs 3, 7, 11, 19, 21, 27,

28, 30, 32, 33 Prostate cancer screening 18

Radiation therapy 3, 15, 18 Reasonable and customary allowance

8, 9, 13, 14, 16, 17, 18, 20, 30 Registered nurse 5, 6, 19, 39 Renal dialysis 3, 18

Skilled nursing facility 6 Smoking cessation 8, 19, 21 Speech therapy 3, 5, 6, 18, 27, 39, 40 Sterilization 16, 17 Subrogation provision 9, 10, 28 Substance abuse 3, 5, 8, 12, 13, 17, 30,

33, 40 Surgical benefits 3, 6, 7, 13, 16, 30, 33

Vision care 42

What is not covered 3, 13, 15, 17, 18, 19, 21, 26 Workers compensation 9, 33

X- ray 18, 28, 29

Benefits on this page are not part of the FEHB contract

Non- FEHB Benefits Available to Plan Members

The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program, but are made available to all enrollees and family members of this Plan. The cost of the benefits described on this page is not included in the FEHB premium and any charges for these services do not count toward any FEHB deductibles, out- of- pocket maximum, copayment charges, etc. These benefits are not subject to the FEHB disputed claims review procedure.

Long term care What would happen if you suddenly required nursing home care? The League offers

immediate care without the red tape. Benefits are paid in addition to what you may qualify for through Medicares skilled nursing home benefits. Premiums remain the same regardless of your age. For current information, please call 1- 800- 321- 0102.

All members of the League may enroll in the League Dental Program. The League does not require enrollment in the FEHB Plan for enrollment in the League Dental Program. The League Dental Program provides up to $1,000 of benefits per year. With the League Dental Program, you do not have to change from your current dentist. This program pays benefits directly to you, or to your dentist. Members may enroll in one of the three levels of coverage: individual, self and spouse, or family. Enrollees pay premiums quarterly. Coverage becomes effective the first of the month following receipt of your completed application and quarterly premium. For more information about benefits, limitations and premiums, and to request an application, write to: League Insurance Services, 4800 Montgomery Lane, M25, Bethesda, MD 20814. To get information by telephone, call toll free 1- 800- 522- 1857.

Outlook Vision Services Program offers you and your entire family all the saving advantages available only to Outlook Vision Services members. Outlook Vision Services offers a choice of over 6000 Professional Vision Care Providers in all 50 States and Puerto Rico. The Network is comprised of well- known national and regional vision care centers, independent optometrists or opticians such as most:

JC Penney Optical, Montgomery Ward, Royal Optical, Sears, Pearl Vision, For Eyes Only, Sterling Optical, Eye Masters and many more.

Best of all, as a member, you can save up to 50% off the retail price of::

Prescription Glasses and Sunglasses Choose from all frames in stock!

Contact Lenses (even Mail Order!) Nonprescription Sunglasses Accessories

Members will be able to purchase what they want, where they want, and at a very reasonable price. For more information, contact Outlook Vision Services at:

Guardian Eagle Corporation P. O. Box 84415 Sioux Falls, SD 57118

Customer Service: 1- 800- 342- 7188 Eyewear

program Supplemental

Dental

How Postmasters Benefit Plan Changes January 1999

Several changes have been made in compliance with the Presidents mandate to implement the recommendations of the Patient Bill of Rights. If you are enrolled in this Plans Point of Service product and have a chronic, complex, or

serious medical condition that causes you to see a Plan specialist frequently, the normal referral provides for you to see your specialist for up to 180 days, without the need to obtain further referrals (See page 29 for details). The medical management of certain mental conditions will be covered under this Plans Other

Medical 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 Benefits. Office visits for the medical aspects of treatment do not count toward the 25 outpatient Mental Conditions visit limit. If you are enrolled in Medicare, you may be asked by a physician to sign a private contract

agreeing that you can be billed for services that would ordinarily be covered by Medicare. Should you sign such an agreement, Medicare will not pay any portion of the charges, and you may receive less or no payment for those services under this Plan. If you receive care from a non- network provider for services subject to reasonable and

customary (R& C) levels, PBP determines benefits based on the 80th percentile of Medicore, Inc. cost data. Previously, PBP determined benefits based on the 90th percentile. As a result of this change, the portion of billed charges for which you are responsible will increase if: 1) you receive care from a non- network provider, 2) the service you receive is subject to R& C levels AND 3) your providers charge is in the top 20 percent of provider charges, as measured by Medicode, Inc. The definition of experimental or investigational (see page 39) has been clarified to include

biological products. The states designated as medically underserved have changed for 1999. Idaho and North

Dakota have been added, and West Virginia is no longer underserved. See page 6 for information on medically underserved areas.

Office visits and tests used to monitor pharmacotherapy used to treat mental conditions are now covered under Other Medical Benefits. Reasonable and customary profiles now apply to charges for all medical and mental services. Services rendered at a hospital emergency room for any reason other than an accidental injury

are now subject to a $50 copay per access to care from a PPO or Non- PPO facility. Durable medical equipment is now covered under Additional Benefits, payable at 80% under

High Option and 70% under Standard Option after a $100 copayment per device. Prescription drugs received from a retail pharmacy are subject to a $100 per year drug

deductible rather than a $275 calendar year deductible. The calendar year deductible for PPO benefits is reduced from $275 to $200. The High Option Schedule of dental allowances is now considered a complete list of covered

services and ADA code 6980 has been removed from the schedule. Prescriptions received from a participating retail pharmacy or the Mail Order Drug Program

are now subject to a $50 per year drug deductible or a $100 per year drug deductible if the prescription is received from a non- participating pharmacy. The PPO calendar year deductible is now $200. The Non- PPO calendar year deductible is now $350. The POS per admission copayment is now $350. The POS per access to care copayment is now $10.

Program- wide Changes

Do not rely on this page. It is not an official statement of benefits.

Changes to this Plan

Both Options High Option Standard Option

NOTES

Summary of Benefits for Postmasters Benefit Plan - High Option - 1999

Do not rely on this chart alone. All benefits are subject to the definitions, 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 items below with an asterisk (*) are subject to the $200 (PPO) or $275 (Non- PPO) calendar year deductible. This Plan has two options; a summary of benefits for the Standard Option is located on page 47 of this brochure.

Benefits Plan pays/ provides Page Hospital PPO benefit: 100% of hospital room and board, no deductible applies; 100% of

other covered hospital charges

Non- PPO benefit: After a $150 per admission deductible, 100% of hospital room and board; 85% of other covered hospital charges for first 30 days, then 100%. ....... 12- 13

Surgical PPO benefit: 95% of the surgeons negotiated rate

Non- PPO benefit: 85% of reasonable and customary allowance .............................. 13- 15

Medical PPO benefit: 95%* of negotiated rate

Non- PPO benefit: 80%* of reasonable and customary charges ................................ 18- 19

Maternity Same benefits as for illness or injury ........................................................................... 16- 17

Mental conditions After a $500 per admission deductible, 70% of hospital room and board and other hospital expenses for up to 100 days per calendar year; day treatment benefit available ................................................................................................................ 17

Substance abuse After a $500 annual deductible, 70% of covered inpatient and outpatient charges to a calendar year maximum of $3,500 ............................................................................ 17

Hospital PPO benefit: 95%* of covered charges

Non- PPO benefit: 80%* of covered charges ............................................................. 18- 19

Surgical PPO benefit: 95% of the surgeons negotiated rate

Non- PPO benefit: 85% of reasonable and customary allowance .............................. 13- 15

Medical PPO benefit: 95%* of negotiated rate

Non- PPO benefit: 80%* of reasonable and customary charges ................................ 18- 19

Maternity Same benefits as for illness or injury ........................................................................... 16- 17

Home health care 80%* of covered charges by nurses and health care agencies to a calendar year maximum of $10,000 ........................................................................................................ 19

Mental conditions 50%* of reasonable and customary charges up to $50 per visit for 25 visits per calendar year ..................................................................................................................... 17

Up to 100% of covered charges per accident for non- surgical outpatient treatment rendered within 72 hours of an accident ........................................................................... 20

Under the Mail order drug program: member pays $5 for generic and $12 for name brand drugs per prescription or refill for a 90- day supply ........................................... 21- 22

For prescriptions filled at retail pharmacies: After a $100 drug deductible, the Plan pays, for up to a 30- day supply, 80% of covered charges for drugs and medicines; at participating pharmacies, charges are discounted and no claim forms are needed. .... 21- 22

After a $30 calendar year deductible, basic and major services up to $800 per person, $2,000 per family per calendar year; based on Schedule of dental allowances .......... 23- 25

Chiropractic services; Hospice care; Immunizations; Skilled nursing facility; Well child care; durable medical equipment; and emergency room ......................................... 20

100% of reasonable and customary charges after the $200 (PPO) $275 (Non- PPO) calendar year deductible and eligible out- of- pocket expenses exceed $2,500 per person or family in a calendar year ................................................................ 30

Outpatient care

Emergency care (accidental injury)

Prescription drugs Protection against catastrophic costs Inpatient

care Dental care Additional benefits

Summary of Benefits for Postmasters Benefit Plan - Standard Option - 1999

Do not rely on this chart alone. All benefits are subject to the definitions, 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 items below with an asterisk (*) are subject to the $200 (PPO) or $350 (Non- PPO) calendar year deductible. This Plan has two options; a summary of benefits for the High Option is located on page 46 of this brochure.

Benefits Plan pays/ provides Page Hospital POS benefit: After a $350 copay per admission, 100% of covered charges

PPO benefit: After a $350 per admission deductible, 100% of hospital room and board; 95% of other covered hospital expenses

Non- PPO benefit: After a $600 per admission deductible, 70% of hospital room and board; 70% of other covered hospital charges ..................................................... 12- 13

Surgical POS benefit: 100% of covered charges

PPO benefit: 95%* of the surgeons negotiated rate

Non- PPO benefit: 70%* of reasonable and customary allowance ............................ 13- 15

Medical POS benefit: 100% of covered charges

PPO benefit: 95%* of negotiated rate

Non- PPO benefit: 70%* of reasonable and customary charges ................................ 18- 19

Maternity Same benefits as for illness or injury ........................................................................... 16- 17

Mental conditions After a $500 per admission deductible, 60% of hospital room and board and other hospital expenses for up to 100 days per calendar year; day treatment benefit available ............................................................................................................................ 17

Hospital POS benefit: After a $50 copay, 100% of covered charges

PPO benefit: 95%* of covered charges

Non- PPO benefit: 70%* of covered charges ............................................................. 18- 19

Surgical POS benefit: After a $50 facility copay or $10 office copay, 100% PPO benefit: 95%* of the surgeons negotiated rate

Non- PPO benefit: 70%* of reasonable and customary allowance ............................ 13- 15

Medical POS benefit: After a $10 copayment per office visit, 100% of covered charges

PPO benefit: 95%* of negotiated rate, $20 copayment per office visit

Non- PPO benefit: 70%* of reasonable and customary charges ................................ 18- 19

Maternity Same benefits as for illness or injury ........................................................................... 16- 17

Home health care 70%* of covered charges by nurses and health care agencies to a calendar year maximum of $10,000 ........................................................................................................ 19

Mental conditions After a $300 annual deductible, 50% of reasonable and customary charges up to $50 per visit for 25 visits per calendar year ...................................................................... 17

Under the Mail order drug program: After a $50 drug deductible, member pays $10 for generic and $20 for name brand drugs per prescription or refill for a 90- day supply.. 21- 22

For prescriptions filled at retail pharmacies: After a $100 drug deductible, the Plan pays, for up to a 30- day supply, 70% of the covered charges of non- participating pharmacies, or after a $50 drug deductible for participating pharmacies discounted charges subject to a $10 or $20 copayment. ................................................................ 21- 22

Benefits based on Schedule of dental allowances; no annual maximums ........................ 26 Chiropractic services; Hospice care; Immunizations; Skilled nursing facility; Well child care; durable medical equipment; and emergency room ................................ 20

100% of reasonable and customary charges after the $200 (PPO) $350 (Non- PPO) calendar year deductible and eligible out- of- pocket expenses exceed $6,700 ($ 3,000 if using PPO providers) per person or family in a calendar year ...................................... 30

Emergency care (accidental injury)

Prescription drugs Protection against catastrophic costs Inpatient

care Outpatient care

Dental care Additional benefits

1999 Rate Information for Postmasters

Authorized for Distribution by the:

United States Office of Personnel Management

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 Code Gov't Your Govt Your USPS Your Enrollment Share Share Share Share Share Share

High Option Self Only 361 72.06 115.75 156.13 250.84 84.98 102.85

High Option Self and Family 362 160.39 244.88 347.51 530.58 183.29 221.98

Standard Option Self Only 364 72.06 41.84 156.13 90.65 84.98 28.92

Standard Option Self and Family 365 160.39 85.99 347.51 186.31 183.29 63.09