8701.660-1098 HMO Blue Broch

Serving: Central, El Paso, Northeast, South, and Southeast Texas areas Enrollment in this Plan is limited; see page 9 for requirements. Dallas/ Ft. Worth/ Tyler areas

Enrollment code: 4Z1 Self Only 4Z2 Self and Family

Austin/ Beaumont/ Corpus Christi/ El Paso/ Houston/ San Antonio areas

Enrollment code: 4Y1 Self Only 4Y2 Self and Family

Visit the OPM website at http:// www. opm. gov/ insure and this Plans website at http:// www. bcbstx. com

A Health Maintenance Organization 1999

Authorized for distribution by the:

RI 73- 707

Independent Licensees of the Blue Cross and Blue Shield Association

*Rio Grande HMO, Inc.

? O2@@@@@@@@@@@@@@@@@@@6K? ? W2@@@@@@@@@@@@@@@@@@@@@@@6X? ? ?W&@@@@@@@@@@@@@@@@@@@@@@@@@)X ? ?7@@@@@@@@@@@@@@@@@@@@@@@@@@@1 ? J@@@@@@@@@@@@@@@@@@@@??@@@@@@@ ? 7@@@@@@@@@@@@@@@@@@@@??@@@@@@@@@@6K? ? @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@6X? ? ?J@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@1? ? ?7@@@@@@@@@@@(Y@@@@@@@@@@@@@@@@@@@@@@@@L ? J@@@@@@@@@@@@H?3@@@@@@@@@@@@@@@@@@@@@@@1 ? 7@@@@@@@@@@@5??N@@@@@@@@@@@@@@@@@@@@@@@@L? ? ?J@@@@@@@@@@@@H?e3@@@@@@@@@@@@@@@@@@@@@@@1? ? ?7@@@@@@@@@@@5fN@@@@@@@@@@@@@@@@@@@@@@@@? ? ?@@@@@@@@@@@@Hf?3@@@@@@@@@@@@@@@@@@@@@@@L ? J@@@@@@@@@@@5?f?N@@@@@@@@@@@@@@@@@@@@@@@1 ? 7@@@@@@@@@@@H?g3@@@@@@@@@@@@@@@@@@@@@@@L? ? ?J@@@@@@@@@@@@hV4@@@@@@@@@@@@@@@@@@@@@@1? ? ?7@@@X W@@@X?gI4@? ? J@@@@1 ?W&@@@1? ? 7@@@@@L? W&@@@@@? ? @@@@@@)X ?W&@@@@@@L ? ?J@@@@@@@)X? W&@@@@@@@1 ? ?7@@@@@@@@)X ?W&@@@@@@@@@ ? J@@@@@@@@@@1 W&@@@@@@@@@@L? ? ?O&@@@@@@@@@@@L? 7@@@@@@@@@@@)K ? ?@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@hf? ?@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@H? 3@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@hf? ?@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@5 N@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@hf? ?@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@H ?3@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@hf? ?@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@5? ?N@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@hf? ?@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@H? @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@hf? ?@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@5 3@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@hf? ?@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@H N@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@hf? ?@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@5? ?3@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@hf? ?@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@H? ?N@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@hf? ?@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@hf?

? ? ? ? ? ?@@@@@@? @@@@@? @@@@@? @@@@@@@@@@@@@@ ?@@@@@@? @@@@@@@@@@@@@@@@hf? ?@@@@@@? @@@@@? @@@@@? @@@@@@@@@@@@@@ ?@@@@@@? I4@@@@@@@@@@@@hf? ?@@@@@@? @@@@@? @@@@@? @@@@@@@@@@@@@@ ?@@@@@@? I'@@@@@@@@@@hf? ?@@@@@@? @@@@@? @@@@@? @@@@@@@@@@@@@@ ?@@@@@@? ?V'@@@@@@@@@hf? ?@@@@@@? @@@@@? @@@@@? @@@@@@@@@@@@@@ ?@@@@@@? N@@@@@@@@@hf? ?@@@@@@? @@@@@? @@@@@? @@@@@@@@@@@@@@ ?@@@@@@? ?3@@@@@@@@hf? ?@@@@@@? @@@@@? @@@@@? @@@@@@@@@@@@@@ ?@@@@@@? ?N@@@@@@@@hf? ?@@@@@@? @@@@@? @@@@@? @@@@@@@@@@@@@@ ?@@@@@@? @@@@@@@@hf? ?@@@@@@? @@@@@? @@@@@? @@@@@@@@@@@@@@ ?@@@@@@? 3@@@@@@@hf? ?@@@@@@? @@@@@? @@@@@? @@@@@@@@@@@@@@ ?@@@@@@? N@@@@@@@hf? ?@@@@@@? @@@@@? @@@@@? @@@@@@@@@@@@@@ ?@@@@@@? ?@@@@@@@hf? ?@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@@@@@@ ?@@@@@@? @@@@@@@@6X ?@@@@@@@hf? ?@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@@@@@@ ?@@@@@@? @@@@@@@@@)X?hf?@@@@@@@hf? ?@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@@@@@@ ?@@@@@@? @@@@@@@@@@1?hfJ@@@@@@@hf? ?@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@@@@@@ ?@@@@@@? @@@@@@@@@@@?hf7@@@@@@@hf? ?@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@@@@@@ ?@@@@@@? @@@@@@@@@@@?hf@@@@@@@@hf? ?@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@@@? ?@@@@@@? @@@@@@@@@@@?hf@@@@@@@@hf? ?@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@@@? ?@@@@@@? @@@@@@@@@@5?he?J@@@@@@@@hf? ?@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@? ?@@@@@@? @@@@@@@@@(Y?heW&@@@@@@@@hf? ?@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@? ?@@@@@@? @@@@@@@@0Yhe?W&@@@@@@@@@hf? ?@@@@@@? @@@@@@@@@? @@@@@@@@@? ?@@@@@@? ?7@@@@@@@@@@hf? ?@@@@@@? @@@@@@@@@? @@@@@@@@@? ?@@@@@@? J@@@@@@@@@@@hf? ?@@@@@@? @@@@@@@@@? @@@@@@@@@? ?@@@@@@? 7@@@@@@@@@@@hf? ?@@@@@@? @@@@@@@@@? @@@@@@@@@? ?@@@@@@? @@@@@@@@@@@@hf? ?@@@@@@? @@@@@@@@@? @@@@@@@@@? ?@@@@@@? ?I'@@@@@@@@@hf? ?@@@@@@? @@@@@@@@@? @@@@@@@@@? ?@@@@@@? V'@@@@@@@@hf? ?@@@@@@? @@@@@@@@@? @@@@@@@@@? ?@@@@@@? ?V'@@@@@@@hf? ?@@@@@@? @@@@@@@@@? @@@@@@@@@? ?@@@@@@? N@@@@@@@hf? ?@@@@@@? @@@@@@@@@? @@@@@@@@@? ?@@@@@@? ?3@@@@@@hf? ?@@@@@@? @@@@@@@@@? @@@@@@@@@? ?@@@@@@? @@@@@@@@@6K?hf?N@@@@@@hf? ?@@@@@@? @@@@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@@@@@@ ?@@@@@@? @@@@@@@@@@@6X?hf@@@@@@hf? ?@@@@@@? @@@@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@@@@@@ ?@@@@@@? @@@@@@@@@@@@1?hf3@@@@@hf? ?@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@@@@@@ ?@@@@@@? @@@@@@@@@@@@@?hfN@@@@@hf? ?@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@@@@@@ ?@@@@@@? @@@@@@@@@@@@@?hf?@@@@@hf? ?@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@@@@@@ ?@@@@@@? @@@@@@@@@@@@@?hf?@@@@@hf? ?@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@@@@@@ ?@@@@@@? @@@@@@@@@@@@5?hf?@@@@@hf? ?@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@@@@@@ ?@@@@@@? @@@@@@@@@@@0Y?hf?@@@@@hf? ?@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@@@? @@@@@@@@@@@@@@ ?@@@@@@? @@@@@@@@@0M? J@@@@@hf? ?@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@? ?@@@@? @@@@@@@@@@@@@@ ?@@@@@@? 7@@@@@hf? ?@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@? ?@@@@? @@@@@@@@@@@@@@ ?@@@@@@? @@@@@@hf? ?@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@? ?@@@@? @@@@@@@@@@@@@@ ?@@@@@@? @@@@@@hf? ?@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@? ?@@@@? @@@@@@@@@@@@@@ ?@@@@@@? ?J@@@@@@hf? ?@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@? ?@@@@? @@@@@@@@@@@@@@ ?@@@@@@? W&@@@@@@hf? ?@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@? ?@@@@? @@@@@@@@@@@@@@ ?@@@@@@? 7@@@@@@@hf? ?@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@? ?@@@@? @@@@@@@@@@@@@@ ?@@@@@@? ?J@@@@@@@@hf? ?@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@? ?@@@@? @@@@@@@@@@@@@@ ?@@@@@@? W&@@@@@@@@hf? ?@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@? ?@@@@? @@@@@@@@@@@@@@ ?@@@@@@? ?O&@@@@@@@@@hf? ?@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@? ?@@@@? @@@@@@@@@@@@@@ ?@@@@@@? O2@@@@@@@@@@@@hf? ?@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@? ?@@@@? @@@@@@@@@@@@@@ ?@@@@@@? O2@@@@@@@@@@@@@@hf? ?@@@@@@? @@@@@@@@@@@@@@@@@@@@@@@@@? ?@@@@? @@@@@@@@@@@@@@ ?@@@@@@? O2@@@@@@@@@@@@@@@@@@@@hf? ?@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@hf?

? ? ? ? ?@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@hf? ?@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@hf? ?@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@hf? ?@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@hf? ?@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@hf? ?@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@hf? ?@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@hf? ?@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@hf? ?@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@hf? ?@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@hf? ?@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@hf? ?@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@0M ?

? ? ? ? ? ? @@@@@@@@ @@ @@g?@@@@@@@@@ ?@@? ? @@@@@@@@ @@ @@g?@@@@@@@@@ ?@@? ? @@ @@ @@g?@@? ?@@? ? @@hW2@6X?e?W2@6X@@e?W2@6Xe?@6?2@eO2@@6Ke@@g?@@?g?@6?2@6KO2@6X?e@6?2@6X??@@?e?W2@@@6Xe@@e?@@??W2@6XfW2@6X?e?O2@@6K? ? @@g?W&@@@)XeW&@@@@@@eW&@@@)X??@@@@@?@@@@@@@@?@@g?@@?g?@@@@@@@@@@@1?e@@@@@@)X?@@?eW&@@@@@)X?@@e?@@?W&@@@)X??W&@@@)Xe@@@@@@@@ ? @@@@@@@??7@?e@1e7@(MI'@@e7@e?@1??@@(M??@0MeW@@?@@g?@@@@@@@@??@@(M?@@(M?@@?e@@(MI'@1?@@?e7@(M?I'@1?3@L?J@5?7@e?@1??7@?e@1e@@e?I4@ ? @@@@@@@??@@@@@@@e@@H??N@@e@@@@@@@??@@Hg?O&@@?@@g?@@@@@@@@??@@He@@H??@@?e@@H??N@@?@@?e@@H?eN@@?N@1?7@H?@@@@@@@??@@@@@@@e3@@6K? ? @@g?@@@@@@@e@@f@@e@@@@@@@??@@?e?W2@@0Y@@?@@g?@@?g?@@?e@@e?@@?e@@f@@?@@?e@@f?@@??@@?@@e@@@@@@@??@@@@@@@eV4@@@@6X ? @@g?@@Xg@@L??J@@e@@X?f?@@?e?7@?eJ@@?@@g?@@?g?@@?e@@e?@@?e@@L??J@@?@@?e@@L?eJ@@??@@?@@e@@X?f?@@Xh?I4@@1 ? @@g?3@)KO2(e3@)KO&@@e3@)KO2(??@@?e?@@??O&@@?@@g?@@?g?@@?e@@e?@@?e@@)KO&@5?@@?e3@)K?O&@5??3@?@5e3@)KO2(??3@)KO2(e@6K?e@@ ? @@g?V'@@@(YeV'@@@@@@eV'@@@(Y??@@?e?3@@@@@@@?@@g?@@@@@@@@@?@@?e@@e?@@?e@@@@@@(Y?@@?eV'@@@@@(Y??N@@@HeV'@@@(Y??V'@@@(Ye3@@@@@@5 ? @@hV4@0Y?e?V4@0?4@e?V4@0Ye?@@?e?V4@@0?4@?@@g?@@@@@@@@@?@@?e@@e?@@?e@@V4@0Y??@@?e?V4@@@0Yf3@@?e?V4@0YfV4@0Y?eV4@@@@0Y ?

@@ V@5? ? @@ @@@(Y? ? @@ @@0Y ?

? @@g@@ ?@@?g@@hf?@@@@@@@6X W2@??@@? @@@@@@6X ? @@g@@ ?@@??@@?e@@hf?@@@@@@@@)X? 7@5??@@??@@? @@@@@@@)X? ? @@g@@ ?@@?J@@Le@@hf?@@?f?@1? ?J@@gJ@@L @@e?I'@1? ? @@g@@eW2@6X?e?O2@@6K??@@?7@@1e@@W2@@6Xg?@@?f?@@??W2@6Xe?@6?2@@6X?eW2@6X??7@@1??@@?7@@1fO2@@6Kg@@fN@@?@6?2@?eW2@@@6X??W2@6?2@e@6?2@??O2@@6K??@6?2@6KO2@6X?hf? @@g@@?W&@@@)Xe@@@@@@@@?@@?3@@5e@@@@@@@1g?@@?f?@5?W&@@@)X??@@@@@@@1??W&@@@)X?3@@5??@@?3@@5e?@@@@@@@@?f@@fJ@@?@@@@@??W&@@@@@)KO&@@@@@@e@@@@@?@@@@@@@@?@@@@@@@@@@@1?hf? @@@@@@@@@@?7@?e@1e@0M??W@@?@@?N@@He@@(Me@@g?@@@@@@@@@H?7@e?@1??@@(M??@@??7@?e@1?N@@H??@@?N@@He?@@?eI4@?f@@e?O&@5?@@(Me?7@(M?I'@@@@(MI'@@e@@(Me@0M??W@@?@@(M?@@(M?@@?hf? @@@@@@@@@@?@@@@@@@gO&@@?@@??@@?e@@H?e@@g?@@@@@@@@@L?@@@@@@@??@@He?@@??@@@@@@@e@@e?@@??@@?e?3@@6Kh@@@@@@@(Y?@@H?e?@@He?N@@@@H??N@@e@@H?gO&@@?@@He@@H??@@?hf? @@g@@?@@@@@@@eW2@@0Y@@?@@??@@?e@@f@@g?@@?f?@1?@@@@@@@??@@?e?@@??@@@@@@@e@@e?@@??@@?e?V4@@@@6X?f@@@@@@0Ye@@f?@@?f@@@@f@@e@@fW2@@0Y@@?@@?e@@e?@@?hf? @@g@@?@@Xg7@e?J@@?@@??@@?e@@f@@g?@@?f?@@?@@X?f?@@?e?@@??@@Xg@@e?@@??@@?gI4@@1?f@@h@@f?@@Le?J@@@@L??J@@e@@f7@e?J@@?@@?e@@e?@@?hf? @@g@@?3@)KO2(e@@eO&@@?@@??@@Le@@f@@g?@@?f?@5?3@)KO2(??@@?e?@@??3@)KO2(e@@e?@@??@@Le?@6Ke?@@?f@@h@@f?3@)K?O&@@@@)KO&@@e@@f@@eO&@@?@@?e@@e?@@?hf? @@g@@?V'@@@(Ye3@@@@@@@?@@??@@1e@@f@@g?@@@@@@@@(Y?V'@@@(Y??@@?e?@@??V'@@@(Ye@@e?@@??@@1e?3@@@@@@5?f@@h@@f?V'@@@@@(MI'@@@@@@e@@f3@@@@@@@?@@?e@@e?@@?hf? @@g@@eV4@0Y?eV4@@0?4@?@@??@@@e@@f@@g?@@@@@@@0Ye?V4@0Ye?@@?e?@@?eV4@0Y?e@@e?@@??@@@e?V4@@@@0Y?f@@h@@gV4@@@0Y??S@@0Y@@e@@fV4@@0?4@?@@?e@@e?@@?hf?

@@Y?e@5 ? @@@@@@(Y ? ?I4@@0Y? ?

? ? ? ? ? ? ?

For changes in benefits

see page 22.

H H

* d/ b/ a HMO Blue, Central Texas; HMO Blue, El Paso; HMO Blue, Northeast Texas; HMO Blue, South Texas; HMO Blue, Southeast Texas

2 Rio Grande HMO, Inc., 4150 Pinnacle, Suite 203, El Paso, TX 79902 has entered into a contract (CS 2786) with the Office of Personnel

Management (OPM) as authorized by the Federal Employees Health Benefits (FEHB) law, to provide a comprehensive medical plan herein called HMO Blue, or the Plan.

This brochure is the official statement of benefits on which you can rely. A person enrolled in the Plan is entitled to the benefits stated in this brochure. If enrolled for Self and Family, each eligible family member is also entitled to these benefits.

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

Table of Contents Page Inspector General Advisory on Fraud . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3- 6

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

Facts about this Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7- 10

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

General Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10- 11

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

General Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12- 18

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

Other Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Dental care; Vision care

How to Obtain Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19- 20 How HMO Blue Changes in January 1999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Summary of Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 1999 Rate Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Inspector General Advisory: Stop Health Care Fraud!

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

Call the provider and ask for an explanation - sometimes the problem is a simple error. If the provider does not resolve the matter, or if you remain concerned, call your plan and explain the situation. The telephone numbers are as follows: HMO Blue, Central Texas (Austin/ San Antonio) - 512/ 345- 5455 or 1- 800/ 382- 6105; HMO Blue,

El Paso - 915/ 542- 1547 or 1- 800/ 831- 0576; HMO Blue, Northeast Texas (Dallas/ Ft. Worth/ Tyler) - 972/ 766- 8885 or 1- 800/ 554- 6321; HMO Blue, South Texas (Corpus Christi) - 512/ 878- 1626 or 1- 800/ 580- 2796; and HMO Blue, Southeast Texas (Beaumont/ Houston) - 713/ 663- 1268 or 1- 800/ 235- 0796. If the matter is not resolved after speaking to your plan (and you still suspect fraud has been committed), call or write:

THE HEALTH CARE FRAUD HOTLINE 202/ 418- 3300

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

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

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

General Information

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

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

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

Benefits and rates begin on the effective date of your enrollment, as set by your employing office or retirement system. As a member of this Plan, once your enrollment is effective, you will be covered only for services provided or arranged by a Plan doctor except in the case of emergency as described on page 15. If you are confined in a hospital on the effective date, you must notify the Plan so that it may arrange for the transfer of your care to Plan providers. See If you are hospitalized on page 4.

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

Confidentiality If you are a new member

General Information continued

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

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

The benefits in this brochure are effective on January 1 for those already enrolled in this Plan; if you changed plans or plan options, see If you are a new member above. In both cases, however, the Plans new rates are effective the first day of the enrollees first full pay period that begins on or after January 1 (January 1 for all annuitants). Generally, you must be continuously enrolled in the FEHB Program for the last five years before

you retire to continue your enrollment for you and any eligible family members after you retire. The FEHB Program provides Self Only coverage for the enrollee alone or Self and Family

coverage for the enrollee, his or her spouse, and unmarried dependent children under age 22. Under certain circumstances, coverage will also be provided under a family enrollment for a disabled child 22 years of age or older who is incapable of self- support. An enrollee with Self Only coverage who is expecting a baby or the addition of a child may change

to a Self and Family enrollment up to 60 days after the birth or addition. The effective date of the enrollment change is the first day of the pay period in which the child was born or became an eligible family member. The enrollee is responsible for his or her share of the Self and Family premium for that time period; both parent and child are covered only for care received from Plan providers, except for emergency benefits. You will not be informed by your employing office (or your retirement system) or your Plan when

a family member loses eligibility. You must direct questions about enrollment and eligibility, including whether a dependent age 22

or older is eligible for coverage, to your employing office or retirement system. The Plan does not determine eligibility and cannot change an enrollment status without the necessary information from the employing agency or retirement system. An employee, annuitant, or family member enrolled in one FEHB plan is not entitled to receive

benefits under any other FEHB plan. Report additions and deletions (including divorces) of covered family members to the Plan promptly. If you are an annuitant or former spouse with FEHB coverage and you are also covered by

Medicare Part B, you may drop your FEHB coverage and enroll in a Medicare prepaid plan when one is available in your area. If you later change your mind and want to reenroll in FEHB, you may do so at the next open season, or whenever you involuntarily lose coverage in the Medicare prepaid plan or move out of the area it serves. Most Federal annuitants have Medicare Part A. If you do not have Medicare Part A, you may enroll

in a Medicare prepaid plan, but you will probably have to pay for hospital coverage in addition to the Part B premium. Before you join the plan, ask whether they will provide hospital benefits and, if so, what you will have to pay. You may also remain enrolled in this Plan when you join a Medicare prepaid plan.

Your responsibility Things to keep in mind If you are

hospitalized

General Information continued

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

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

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

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

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

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

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

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

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

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

Temporary continuation of coverage (TCC) Former spouse coverage

Coverage after enrollment ends Notification and election requirements

General Information continued

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

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

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

When none of the above choices are available or chosen when coverage as an employee or family member ends, or when TCC coverage ends (except by cancellation or nonpayment of premium), you may be eligible to convert to an individual, nongroup contract. You will not be required to provide evidence of good health and the plan is not permitted to impose a waiting period or limit coverage for preexisting conditions. If you wish to convert to an individual contract, you must apply in writing to the carrier of the plan in which you are enrolled within 31 days after receiving notice of the conversion right from your employing agency. 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.

Conversion to individual coverage Certificate of Creditable Coverage

Facts about this Plan

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

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

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

All carriers in the FEHB Program must provide certain information to you. If you did not receive information about this Plan, you can obtain it by calling the Carrier at: Central Texas (Austin/ San Antonio) - 512/ 345- 5455 or 1- 800/ 382- 6105 or you may write to the Plan at HMO Blue, Central Texas, 9020- II Capital of Texas Highway North, Suite 400, Austin, Texas 78759; El Paso - 915/ 542- 1547 or 1- 800/ 831- 0576 or you may write to the Plan at HMO Blue, El Paso, 4150 Pinnacle, Suite 203, El Paso, TX 79902; Northeast Texas (Dallas/ Fort Worth/ Tyler) - 972/ 766- 8885 or 1- 800/ 554- 6321 or you may write to the Plan at HMO Blue, Northeast Texas, P. O. Box 833840, Richardson, Texas 75083- 3840; South Texas (Corpus Christi) - 512/ 878- 1626 or 1- 800/ 580- 2796 or you may write to the Plan at HMO Blue, South Texas, 4444 Corona, Suite 120, Corpus Christi, Texas 78411; and Southeast Texas (Beaumont/ Houston) - 713/ 663- 1268 or 1- 800/ 235- 0796 or you may write to the Plan at HMO Blue, Southeast Texas, 4888 Loop Central Drive, Suite 200, Houston, Texas 77081. You may also contact the carrier at its website at http:// www. bcbstx. com.

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

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

confidentiality and transfer of medical records. HMO Blue is a Mixed Model Prepayment (MMP) Plan. The Plan contracts with individual physicians, IPAs and medical groups. Each member of the family is free to choose his/ her own primary care physician (PCP) from among all Plan PCPs. The Plan has contracts with 2,367 PCPs and over 6,653 specialists. The Plan has contracts with 168 hospitals for inpatient services.

The first and most important decision each member must make is the selection of a primary care doctor. The decision is important since it is through this doctor that all other health services, particularly those of specialists, are obtained. It is the responsibility of your primary care doctor to obtain any necessary authorizations from the Plan before referring you to a specialist or making arrangements for hospitalization. Services of other providers are covered only when you have been referred by your primary care doctor, with the following exception: Awoman may choose a participating obstetrician, gynecologist to provide all obstretric and gynecological services, including the well women care, without a referral from her primary care provider.

Members with chronic, disabling, or life- threatening illnesses (a disease or condition for which the likelihood of death is probable unless the course of the disease or condition is interrupted) may apply to utilize a specialty care physician as a primary care physician, provided that the request includes a certification of medical need, along with all applicable supporting documentation, and is signed by the member and the specialty care physician interested in serving as the primary care physician, the specialty care physician meets the requirements for primary care physician participation, and the specialty care physician is willing to accept the coordination of all of the members health care needs.

Who provides care to plan members?

Role of a primary care doctor Information you

have a right to know

Facts about this Plan continued

The Plans provider directory lists primary care doctors (family practitioners, pediatricians and internists), with their locations and phone numbers, and notes whether or not the doctor is accepting new patients. Directory updates are subject to change without notice and are updated on a regular basis. They are available at the time of enrollment or upon request by calling the Member Services Department at 1- 800/ 382- 6105 or 512/ 345- 5455 for Central Texas; 1- 800/ 831- 0576 or 915/ 542- 1547 for El Paso; 1- 800/ 554- 6321 or 972/ 766- 8885 for Northeast Texas; 1- 800/ 580- 2796 or 512/ 878- 1626 for South Texas; and 1- 800/ 235- 0796 or 713/ 663- 1268 for Southeast Texas. You can also find out if your doctor participates with this Plan by calling this number. If you are interested in receiving care from a specific provider who is listed in the directory, call the provider to verify that he or she still participates with the Plan and is accepting new patients. Important note: When you enroll in this Plan, services (except for emergency benefits) are provided through the Plans delivery system; the continued availability and/ or participation of any one doctor, hospital, or other provider cannot be guaranteed.

If you enroll, you will be asked to let the Plan know which primary care doctor( s) youve selected for you and each member of your family by sending a selection form to the Plan. If you need help choosing a doctor, call the Plan. Members may change their doctor selection by notifying the Plan 30 days in advance.

If you are receiving services from a doctor who leaves the Plan, the Plan will pay for covered services, in- network, until the Plan can arrange with you for you to be seen by another participating doctor. When the services have been authorized as an out- of- Plan referral, the Plan will continue to pay for covered services, but generally, not to exceed 30 days.

Except in a medical emergency or when a primary care doctor has designated another doctor to see his or her patients, or when he or she is unavailable, you must receive a referral from your primary care doctor before seeing any other doctor or obtaining special services. Referral to a participating specialist is given at the primary care doctors discretion; if non- Plan specialists or consultants are required, the primary care doctor will arrange appropriate referrals.

When you receive a referral from your primary care doctor, you must return to the primary care doctor after the consultation unless your doctor authorizes additional visits. All follow- up care must be provided or authorized by the primary care doctor. Do not go to the specialist for a second visit unless your primary care doctor has arranged for, and the Plan has issued an authorization for, the referral in advance.

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

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

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

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

For new members Referrals for

specialty care Authorizations Choosing your

doctor

Facts about this Plan continued

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

Copayments are required for a few benefits. However, copayments will not be required for the remainder of the calendar year after your out- of- pocket expenses for services provided or arranged by the Plan reach $1,000 per Self Only enrollment or per individual member or $2,000 per Self and Family enrollment.

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

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

The Plans Medical Director determines what procedures and services are experimental/ investigational using Blue Cross and Blue Shield of Texas Medical Policy Guidelines that are developed from resources such as Optimed Managed Care System Protocols & Criteria, the Medical Advisory Committee, and physician consultants/ experts.

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

The Plan has reciprocal agreements with certain other Blue Cross and Blue Shield affiliated HMOs to provide urgent care to you or a member of your family when it is needed and you are outside of the service area. You may also obtain a guest membership with a Blue Cross and Blue Shield HMO when temporarily residing in an alternate service area. If you would like more information about receiving care away from home, please call the Member Services Department for your area. Please see How to Obtain Benefits for the phone number in your area.

The service area for this Plan, where Plan providers and facilities are located, is described below. You must live or work in the service area to enroll in this Plan. Benefits for care outside the service area are limited to emergency services, as described on page 15, or as described above under Reciprocity.

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

The service areas for this Plan include the following counties in Texas: Dallas/ Fort Worth/ Tyler areas Northeast Texas (Dallas/ Fort Worth) - Collin, Dallas, Denton, Ellis, Johnson, Rockwall, and Tarrant. Northeast Texas (Tyler) - Anderson, Cherokee, and Smith.

Hospital care Out- of- pocket maximum

Deductible carryover Submit claims promptly Other considerations Reciprocity

The Plans service areas Experimental/ investigational determinations

Facts about this Plan continued

Austin/ Beaumont/ Corpus Christi/ El Paso/ Houston/ San Antonio areas Central Texas (Austin/ San Antonio) - Bastrop, Bexar, Blanco, Burnet, Caldwell, Comal, Hays, Lee, Travis, Williamson, and Wilson.

El Paso - El Paso county. South Texas (Corpus Christi) - Aransas, Bee, Brooks, Cameron, Hidalgo, Jim Wells, Kenedy, Kleberg, Nueces, San Patricio, Starr, and Willacy.

Southeast Texas (Beaumont/ Houston) - Brazoria, Chambers, Fort Bend, Galveston, Hardin, Harris, Jefferson, Liberty, Montgomery, Orange, Waller, and Wharton.

General Limitations

Although a specific service may be listed as a benefit, it will be covered for you only if, in the judgment of your Plan doctor, it is medically necessary for the prevention, diagnosis, or treatment of your illness or condition. No oral statement of any person shall modify or otherwise affect the benefits, limitations and exclusions of this brochure, convey or void any coverage, increase or reduce any benefits under this Plan or be used in the prosecution or defense of a claim under this Plan. This brochure is the official statement of benefits on which you can rely.

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

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

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

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

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

One plan normally pays its benefits in full as the primary payer, and the other plan pays a reduced benefit as the secondary payer. When this Plan is the secondary payer, it will pay the lesser of (1) its benefits in full or (2) a reduced amount which, when added to the benefits payable by the other coverage, will not exceed reasonable charges. The determination of which health coverage is primary (pays its benefits first) is made according to guidelines provided by the National Association of

Important notice Circumstances beyond Plan control

Other sources of benefits Medicare

Group health insurance and automobile insurance

General Limitations continued

Insurance Commissioners. When benefits are payable under automobile insurance, including nofault, the automobile insurer is primary (pays its benefits first) if it is legally obligated to provide benefits for health care expenses without regard to other health benefits coverage the enrollee may have. This provision applies whether or not a claim is filed under the other coverage. When applicable, authorization must be given this Plan to obtain information about benefits or services available from the other coverage, or to recover overpayments from other coverages.

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

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

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

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

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

General Exclusions

All benefits are subject to the limitations and exclusions in this brochure. Although a specific service may be listed as a benefit, it will not be covered for you unless your Plan doctor determines it is medically necessary to prevent, diagnose or treat your illness or condition and the Plan agrees, as discussed under Authorizations on page 8. The following are excluded:

Care by non- Plan doctors or hospitals except for authorized referrals or emergencies (see Emergency Benefits); Expenses incurred while not covered by this Plan; Services furnished or billed by a provider or facility barred from the FEHB Program; Services not required according to accepted standards of medical, dental, or psychiatric practice; Procedures, treatments, drugs or devices that are experimental or investigational; Procedures, services, drugs and supplies related to sex transformations; and Procedures, services, drugs and supplies related to abortions except when the life of the mother

would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest.

Workers compensation DVA facilities, DoD facilities, and Indian Health Service Other government agencies Liability insurance and third party actions CHAMPUS

Medicaid

12 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS Medical and Surgical Benefits

A comprehensive range of preventive, diagnostic and treatment services is provided by Plan doctors and other Plan providers. This includes all necessary office visits; you pay a $10 office visit copay, but no additional copay for laboratory tests and X- rays. Within the service area, house calls will be provided if, in the judgment of the Plan doctor, such care is necessary and appropriate; you pay a $15 copay for a doctors house call. You pay nothing for home visits by nurses and health aides, but preauthorization is required.

The following services are included and are subject to the office visit copay unless stated otherwise: Preventive care, including well- baby care and periodic check- ups; copays are waived for newborn

well- baby care up to age 2 Mammograms are covered as follows: for women age 35 through age 39, one mammogram during these five years; for women age 40 through 49, one mammogram every year; for women age

50 through 64, one mammogram every year; and for women age 65 and above, one mammogram every two years. In addition to routine screening, mammograms are covered when prescribed by the doctor as medically necessary to diagnose or treat your illness. Annual physical examination for the detection of prostate cancer is covered for male members. In

addition, an annual prostate- specific antigen (PSA) test will be covered for male members who are at least fifty years of age and asymptomatic or at least forty years of age with a family history of prostate cancer or another prostate cancer risk factor. Routine immunizations and boosters; childhood immunizations required by law up to age six are

covered with no copayment. Consultations by specialists Diagnostic procedures, such as laboratory tests and X- rays Complete obstetrical (maternity) care for all covered females, including prenatal, delivery and

postnatal care by a Plan doctor. The mother, at her option, may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a caesarean delivery. Inpatient stays will be extended if medically necessary. Copays are waived for maternity care. If enrollment in the Plan is terminated during pregnancy, benefits will not be provided after coverage under the Plan has ended. Ordinary nursery care of the newborn child during the covered portion of the mothers hospital confinement for maternity will be covered under either a Self Only or Self and Family enrollment; other care of an infant who requires definitive treatment will be covered only if the infant is covered under a Self and Family enrollment. Post delivery care for mother and newborn will be provided in the mothers home, a health care providers office, or a health care facility if the member elects to be discharged before the minimum hours of inpatient coverage. If the member remains in the hospital, this may be provided in the hospital. Post delivery care means postpartum health care services provided in accordance with accepted maternal and neonatal physical assessments, and includes parent education, assistance and training in breast feeding and bottle feeding and the performance of necessary and appropriate clinical tests. Voluntary sterilization and family planning services Diagnosis and treatment of diseases of the eye Allergy testing and treatment, including testing and treatment materials; you pay 50% of charges.

Allergy serum is covered in full; you pay nothing. The insertion of internal prosthetic devices, such as pacemakers and artificial joints Cornea, heart, heart/ lung, kidney, liver and single and double lung transplants; allogeneic

(donor) bone marrow transplants; autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute lymphocytic or nonlymphocytic leukemia, advanced Hodgkins lymphoma, advanced non- Hodgkins lymphoma, advanced neuroblastoma, breast cancer; multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors. Transplants are covered only when approved by the Plans Medical Director. Related medical and hospital expenses of the donor are covered when the recipient is covered by this Plan. Women who undergo mastectomies may, at their option, have this procedure performed on an

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

on an inpatient basis and remain in the hospital up to 24 hours after the procedure.

What is covered

13 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS Medical and Surgical Benefits continued

Dialysis; copay is waived Chemotherapy and radiation therapy; copay is waived Surgical treatment of morbid obesity Home health services of nurses and health aides, including intravenous fluids and medications,

when prescribed by your Plan doctor, who will periodically review the program for continuing appropriateness and need All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and

other Plan providers, at no additional cost to you

Oral and maxillofacial surgery is provided for non- dental surgical and hospitalization procedures for congenital defects, such as cleft lip and cleft palate, and for medical or surgical procedures occurring within or adjacent to the oral cavity or sinuses including, but not limited to, treatment of fractures and excision of tumors and cysts. Diagnostic and/ or surgical treatment of conditions affecting the temporomandibular joint (including the jaw or craniomandibular joint) as a result of an accident, a trauma, a congenital defect, a developmental defect, or a pathology. All other procedures involving the teeth or intra- oral areas surrounding the teeth are not covered, including any dental care involved in the treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

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

Rehabilitation services and therapies (physical, speech, occupational, inhalation, hearing and cardiac), that in the opinion of a physician are medically necessary, will be covered with unlimited visits if they meet or exceed treatment goals for the member; for a physically- disabled person, treatment goals may include maintenance of functioning or prevention or slowing of further deterioration;

you pay a $10 copay per outpatient session. Speech therapy is limited to treatment of certain speech impairments of organic origin. Occupational therapy is limited to services that assist the member to achieve and maintain self- care and improved functioning in other activities of daily living.

Orthopedic devices, such as braces, and prosthetic devices, such as artificial limbs and lenses following cataract removal are covered; you pay 50% of charges.

Durable medical equipment, such as wheelchairs and hospital beds; you pay 50% of charges.

Chiropractic services when authorized by the primary care physician

Diagnosis and treatment of infertility is covered; you pay a $10 office visit copay. The following types of artificial insemination are covered: intravaginal insemination (IVI); intracervical insemination (ICI) and intrauterine insemination (IUI); cost of donor sperm is covered. Fertility drugs are not covered. Other assisted reproductive technology (ART) procedures, such as in vitro fertilization and embryo transfer, are not covered.

Physical examinations that are not necessary for medical reasons, such as those required for obtaining or continuing employment or insurance, attending school or camp, or travel Reversal of voluntary, surgically- induced sterility Surgery primarily for cosmetic purposes Homemaker services Hearing aids, contact or corrective lenses and eyeglass frames, unless otherwise specified Transplants not listed as covered Contraceptive devices Foot orthotics Blood and blood derivatives not replaced by the member Radial keratotomy Acupuncture

What is not covered Limited benefits

14 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS Hospital/ Extended Care Benefits

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

Semiprivate room accommodations; when a Plan doctor determines it is medically necessary, the doctor may prescribe private accommodations or private duty nursing care Specialized care units, such as intensive care or cardiac care units

The Plan provides coverage for necessary outpatient surgery services. You pay nothing. The Plan provides a comprehensive range of benefits for up to 60 days per member per calendar year when full- time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan. You pay nothing. All necessary services are covered, including:

Bed, board and general nursing care Drugs, biologicals, supplies, and equipment ordinarily provided or arranged by the skilled nursing

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

Services of a private- duty registered nurse (R. N.) or licensed vocational nurse (L. V. N.) which are medically necessary and require the skills of an R. N. or L. V. N. are covered. You pay nothing.

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

Personal comfort items, such as telephone and television Blood and blood derivatives not replaced by the member Custodial care, rest cures, domiciliary or convalescent care Private- duty nursing services for the convenience of the patient or patients family or those consisting primarily of such acts as bathing, feeding, mobilizing, exercising, homemaking, giving

medication, or acting as a companion or sitter

Extended care Hospice care Private- duty nursing care

Ambulance service Limited benefits

Inpatient dental procedures

What is not covered What is covered

Hospital care Outpatient Surgery

15 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS Emergency Benefits

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

If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (e. g., the 911 telephone system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a family member should notify the Plan within 24 hours unless it was not reasonably possible to do so. It is your responsibility to ensure that the Plan has been timely notified.

If you need to be hospitalized in a non- Plan facility, the Plan must be notified within 24 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If you are hospitalized in non- Plan facilities and a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

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

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

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

$25 per hospital emergency room visit or urgent care center visit for emergency services that are covered benefits of this Plan. If the emergency results in admission to a hospital, the copay is waived.

Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.

If you need to be hospitalized, the Plan must be notified within 24 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

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

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

Emergency care at a doctors office or an urgent care center Emergency care as an outpatient or inpatient at a hospital, including doctors services Ambulance service approved by the Plan A medical screening examination or other evaluation provided in the emergency department of a

hospital which was necessary to determine whether an emergency medical condition existed.

Plan pays . . . You pay . . . Emergencies outside the service area

Plan pays . . . You pay . . . What is covered What is a medical emergency?

Emergencies within the service area

16 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS Emergency Benefits continued

Elective care or nonemergency care Emergency care provided outside the service area if the need for care could have been foreseen

before leaving the service area Medical and hospital costs resulting from a normal full- term delivery of a baby outside the service area

With your authorization, the Plan will pay benefits directly to the providers of your emergency care upon receipt of their claims. Physician claims should be submitted on the HCFA 1500 claim form. If you are required to pay for the services, submit itemized bills and your receipts to the Plan along with an explanation of the services and the identification information from your ID card.

Payment will be sent to you (or the provider if you did not pay the bill), unless the claim is denied. If it is denied, you will receive notice of the decision, including the reasons for the denial and the provisions of the contract on which denial was based. If you disagree with the Plans decision, you may request reconsideration in accordance with the disputed claims procedure described on page 19.

What is not covered Filing claims for non- Plan providers

17 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS Mental Conditions/ Substance Abuse Benefits

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

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

Up to 20 outpatient visits to Plan doctors, consultants or other psychiatric personnel each calendar year; you pay nothing for each covered visit all charges thereafter..

Up to 30 days of hospitalization each calendar year; you pay nothing for the first 30 days all charges thereafter. Each day of hospital inpatient services may be exchanged for two days of care in a psychiatric intermediate care facility, for up to a maximum of 60 days per calendar year.

Coverage for the treatment of Serious Mental Illness for inpatient and outpatient care will be the same as for treatment of all medically necessary care for other physical illness as provided for in this brochure with no dollar or day limit. You pay a $10 office visit copay for outpatient care.

Serious Mental Illness means the following psychiatric illnesses as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual (DSM) III- R:

a) Schizophrenia; b) Paranoid and other psychotic disorders; c) Bipolar disorders (mixed, manic, and depressive); d) Major depressive disorders (single episode or recurrent); and e) Schizo affective disorders (bipolar or depressive).

The treatment of pervasive development disorders, obsessive compulsive disorders, and depression in childhood or adolescence is covered; services are limited to a maximum of 45 days of inpatient care per calendar year and 60 visits for outpatient care per calendar year. You pay a $10 office visit copay for outpatient care.

Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through relatively short- term treatment Psychiatric evaluation or therapy on court order or as a condition of parole or probation, unless

determined by a Plan doctor to be necessary and appropriate Psychological testing that is not medically necessary to determine the appropriate treatment of a

short- term psychiatric condition Any services or supplies provided for treatment of adolescent behavior disorders, including

conduct disorders and oppositional disorders. This Plan provides medical and hospital services such as acute detoxification services for the medical, non- psychiatric aspects of substance abuse, including alcoholism and drug addiction, the same as for any other illness or condition and, to the extent shown below, the services necessary for diagnosis and treatment.

Unlimited number of outpatient visits to Plan providers for treatment each calendar year; you pay a $10 copay for each covered visit.

The Plan provides inpatient hospital services for the medical, non- psychiatric aspects of substance abuse the same as for any other illness with no dollar or day limit when you are hospitalized under the care of a Plan doctor. You pay nothing.

Substance abuse rehabilitation shall be limited to a maximum of three (3) series of treatments during

Mental conditions What is covered

Outpatient care Inpatient care

What is not covered Substance abuse

What is covered Serious mental illness

Outpatient care Inpatient care

18 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS Mental Conditions/ Substance Abuse Benefits continued

the lifetime of any member. A series of treatment is a planned, structured and organized program to promote chemical free status which may include different facilities or modalities and is complete when a member is discharged on medical advice from inpatient detoxification, inpatient rehabilitation/ treatment, partial hospitalization or intensive outpatient treatment or a series of these levels of treatments without a lapse in treatment or when a member fails to materially comply with the treatment program for a period of thirty (30) days

. Treatment that is not authorized by a Plan doctor

Prescription Drug Benefits

Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 30- day supply. You pay a $5 copay per prescription or refill for generic drugs, and a $10 copay per prescription or refill for name brand drugs for up to a 30- day supply, or 90- day supply for mail order.

The Plan also covers prescription drugs obtained at non- Plan Pharmacies outside the service area. The Plan will reimburse you 50% of the cost of covered prescription drug charges.

Covered medications and accessories include: Drugs for which a prescription is required by Federal law Oral contraceptive drugs Disposable needles and syringes needed to inject covered prescribed medication Prescription orders for insulin, insulin analogs, syringes, prescriptive and non- prescriptive oral

agents for controlling blood sugar (you pay the prescription drug copay shown above or 50%, whichever is less). Diabetic equipment and supplies are covered for Members who have been diagnosed with (a)

insulin dependent or non- insulin dependent diabetes, (b) elevated blood glucose levels induced by pregnancy, or (c) another medical condition associated with elevated blood glucose levels. Diabetic equipment and supplies include blood glucose monitors, insulin pumps and necessary accessories, insulin infusion devices, podiatric appliances, test strips for blood glucose monitors, visual reading and urine test strips, lancets, injection aids, and glucagon emergency kits. You pay

50% of charges on all diabetic equipment and supplies. Intravenous fluids and medication for home use, implantable drugs, such as Norplant, and some injectable drugs, such as Depo Provera, are covered under Medical and Surgical Benefits.

Drugs to treat sexual dysfunction are limited. Contact the Plan for dose limits. See page 19 for the telephone numbers for Member Services.

Drugs available without a prescription or for which there is a nonprescription equivalent available Vitamins and nutritional substances that can be purchased without a prescription Medical supplies such as dressings and antiseptics Drugs for cosmetic purposes Drugs to enhance athletic performance Contraceptive devices Fertility drugs Smoking cessation drugs and medication including, but not limited to, nicotine gum and nicotine

patches

What is not covered What is not covered

What is covered Limited benefits

Other Benefits

Restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury occurring while the member is covered under the FEHB Program. The services must be received within 24 months from the date of the accident, unless the members medical condition indicates the dental care must be delayed.

You pay a $10 copay. Other dental services not shown as covered In addition to the medical and surgical benefits provided for the diagnosis and treatment of the diseases of the eye, an annual eye exam, including refraction (to provide a written lens prescription) may be obtained from Plan providers. You pay a $10 copay per visit.

Corrective lenses or frames Eye exercises

How to Obtain Benefits

If you have a question concerning Plan benefits or how to arrange for care, contact the Plans Member Services Office in your region as follows: Central Texas - 512/ 345- 5455 or 1- 800/ 382- 6105 or you may write to the Plan at HMO Blue, Central Texas, 9020- II Capital of Texas Highway North, Suite 400, Austin, Texas 78759; El Paso - 915/ 542- 1547 or 1- 800/ 831- 0576 or you may write to HMO Blue, El Paso, 4150 Pinnacle, Suite 203, El Paso, TX 79902; Northeast Texas - 972/ 766- 8885 or 1- 800/ 554- 6321 or you may write to the Plan at HMO Blue, Northeast Texas, P. O. Box 833840, Richardson, Texas 75083- 3840; South Texas - 512/ 878- 1626 or 1- 800/ 580- 2796 or you may write to the Plan at HMO Blue, South Texas, 4444 Corona, Suite 120, Corpus Christi, Texas 78411; and Southeast Texas - 713/ 663- 1268 or 1- 800/ 235- 0796 or you may write to the Plan at HMO Blue, Southeast Texas, P. O. Box 272169, Houston, Texas 77277- 2169.

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

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

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

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

Questions Disputed claims review

Plan reconsideration Dental care

What is covered Accidental injury benefit

What is not covered What is not covered

OPM review Vision care

What is covered

How to Obtain Benefits continued

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

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

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

date of your request to the Plan or (b) the dates the Plan requested and you provided additional information to the Plan); Copies of documents that support your claim, such as doctors letters, operative reports, bills, medical records, and explanation of benefit (EOB) forms; and Your daytime phone number.

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

Send your request for review to: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3, P. O. Box 436, Washington, DC 20044.

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

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

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

Notes

How HMO Blue Changes in January 1999

Do not rely on this page; it is not an official statement of benefits. Several changes have been made to comply with the Presidents mandate to implement the recommendations of the Patient Bill of Rights.

If you have a chronic, complex, or serious medical condition that causes you to frequently see a Plan specialist, your primary care doctor will develop a treatment plan with you and your health plan that allows an adequate number of direct access visits with that specialist, without the need to obtain further referrals (See page 8 for details). Amedical emergency is defined as the sudden and unexpected onset of a condition or an injury that

you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care (See page 15). The medical management of mental conditions will be covered under this Plans Medical and

Surgical Benefits provision. 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 20 outpatient Mental Conditions visit limit.

The office visit copay has increased to $10 per visit and the copay for house calls has increased to $15 per physician home visit (See page 12). The $10 office visit copay does not apply to routine childhood immunizations and boosters up to

age 6 (See page 12). There is no copay for home visits by nurses and health aides, but preauthorization is required. The copay for allergy testing and treatment is 50% of charges per visit. Allergy serum is covered

in full (See page 12). Benefits for transplants have increased to include double lung transplants (See page 12). The copay for rehabilitative therapy has increased to $10 per outpatient session (See page 13). The coinsurance for orthopedic and prosthetic devices has increased to 50% of charges (See page

13). The coinsurance for durable medical equipment has increased to 50% of charges (See page 17). The copay for diagnosis and treatment of infertility has increased to $10 per visit (See page 17). Hearing aids are no longer a covered benefit. Benefits for outpatient Mental Conditions visits have increased from 25 visits per calendar year

with a $25 copay per visit to 20 visits per calendar year with no copay (See page 17). The office visit copay for treatment of Serious Mental Illness is $10 (See page 17). The copay for outpatient substance abuse benefits has increased to $10 per visit (See page 17). Benefits for inpatient substance abuse rehabilitation have decreased from 60 days per calendar year

to three separate series of treatment per lifetime of the member with no copay (See page 17). Prescription Drug benefits have increased to include coverage for insulin analogs, syringes, and

prescriptive and non- prescriptive oral agents for controlling blood sugar. You pay the $5 or $10 prescription drug copay or 50% of charges, whichever is less (See page 18). Benefits for diabetic supplies have increased from coverage for medically necessary glucometer

strips with a $5 copay to coverage for blood glucose monitors and test strips, insulin pumps and necessary accessories, insulin infusion devices, podiatric appliances, visual reading and urine test strips, lancets, injection aids, and glucagon emergency kits. You pay 50% of charges (See page 18). The copay for treatment due to accidental injury to sound, natural teeth and vision care has

increased to $10 per visit (See page 19). Coverage of drugs for sexual dysfunction are shown under the Prescription Drug benefit (See page

18). The Plan has reduced its service area to delete Gonzales County and Guadalupe County, Texas. The Plan service area has expanded to include the following counties in Texas: Blanco, Burnet,

Caldwell, Lee and Wilson.

Program- wide Changes

Changes to this Plan

Summary of Benefits for HMO Blue - 1999

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

Benefits Plan pays/ provides Page

Comprehensive range of medical and surgical services without dollar or day limit. Includes inhospital doctor care, room and board, general nursing care, private room and private nursing care if medically necessary, diagnostic tests, drugs and medical supplies, use of operating room, intensive care and complete maternity care. You pay nothing for each admission . . . . . . . . . . . . 14

All necessary services for up to 60 days each calendar year. You pay nothing . . . . . . . . . . 14

Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per year. You pay nothing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Covered the same as for any other illness when under the care of a Plan doctor. You pay

nothing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Comprehensive range of services such as diagnosis and treatment of illness or injury, including specialists care; preventive care, including well- baby care, periodic check- ups and routine immunizations; laboratory tests and X- rays; complete maternity care. You pay a $10 copay per office visit; copays are waived for maternity care, well- baby care and childhood immunizations; $15 per house call by a doctor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12,13

All necessary visits by nurses and health aides. You pay nothing. . . . . . . . . . . . . . . . . . . . . 12

Up to 20 outpatient visits per year. You pay nothing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Unlimited outpatient visits per year. You pay a $10 copay per visit . . . . . . . . . . . . . . . . . . . 17

Reasonable charges for services and supplies required because of a medical emergency. You pay

a $25 copay to the hospital for each emergency room visit and any charges for services that are not covered by this Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy. You pay a $5 copay per prescription or refill for generic drugs and a $10 copay per prescription or refill for name brand drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Accidental injury benefit; you pay a $10 copay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

An annual eye exam, including refraction. You pay a $10 copay per visit . . . . . . . . . . . . . . 19

Copayments are required for a few benefits; however, copayments will not be required for the remainder of the calendar year after your out- of- pocket expenses reach $1,000 for a Self Only enrollment or individual member and $2,000 for a Self and Family enrollment. . . . . . . . . . . 9 Inpatient care

Mental conditions

Mental conditions Substance

abuse Outpatient care

Home health care Hospital

Substance abuse

Emergency care Prescription drugs Dental care Vision care Out- of- pocket maximum

Extended care

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.

1999 Rate Information for HMO Blue

Self Only 4Y1 $60.82 $20.27 $131.78 $43.92 $71.97 $9.12 Self and Family 4Y2 $160.39 $54.67 $347.51 $118.45 $183.29 $31.77

Non- Postal Premium Postal Premium Biweekly Monthly Biweekly Type of Code Govt Your Govt Your USPS Your Enrollment Share Share Share Share Share Share

8701.660- 1098 24 Self Only 4Z1 $58.24 $19.41 $126.18 $42.06 $68.91 $8.74

Self and Family 4Z2 $155.56 $51.85 $337.04 $112.35 $183.29 $24.12