State Health Benefit Plan, July 1, 2004 - 2005, new employee health plan decision guide

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STATE HEALTH BENEFIT PLAN JULY 1, 2004 - JUNE 30, 2005

o NEW EMPLOYEE HEALTH PLAN DECISION GUIDE

o GEORGIA DEPARTMENT OF COMMUNITY HEALTH
PHONE NUMBERS AND CONTACTS FOR BENEFIT AND PROVIDER INFORMATION

PPO, PPO CUOICE OPTIONS
(BASIC, PREMIER), INDEMNITY OPTIONS (BASIC, PREMIER)
~ For rate information, cont:tct your personnellpayroll representative
~ For benefit COVCr'dgC information, call Member Services at: (BOO) 483-6983 (outside Atlanta), or (404) 233-4479 (in Atlanta)
TOO Line for the hearing impaired: (800) 269-4719 (outside Atlama), (404) 842-8073 (in Atlanta)
You can get both National and Georgia PPO prO\ri.der information online at: www.healthygeorgia.com
BEHAVIORAL HEALTH SERVICES
All Options except HMOs
Contact Magellan for prOVider and referral information. 24 hours per day,
7 days per week. (BOO) 631-9943
www.magellanhcalth.com
TOO line for hearing impaired: (678) 319-3860 or (BOO) 201-8316

PRESCRIPTION DRUG PROGRAM INFORMATION
All Options except HMOs Contact the Pharmacy Benefits Manager, Express Scripts, at (877) 650-9342
TOO line for the hearing impaired: (BOO) 842-5754
TIle Basic and Premier dnlg lists are online at www.dch.st;J.tc.ga.us
HMOs BlueChoice HeaJlbcare Plan (BOO) 464-1367 Online provider information: www.hcbsga.com
or QGNA HealthCare Georgia
(800) 564-7642 Online provider information: www.cigna.com
KaIser Permanente (404) 261-2590 (800) 6]]-18]]
Omine provider information: www.kaiserpermaneIJte,org
UnitedHealthcare of Georgia (866) 527-9599 Online prm'ider information: www.provider.uhc.com/gdch

If you enroll for health insurance co\'en.ge under me Sute Hcalm Benefit Plan (SHBP), )'Ou should receive a Swnmary Plan DeSCription (SPD) from your Human Resourus Depanment.This SPD reflects Plan benefits as of April 1,2003. Eolch yC'J.r, any Plan changes are printed in an Upf/ater, which is your official nOlice of Plan changes. You may request a copy of the July 2003 and 2004 Updaters from your personnel office or you may print a copy from the OCH Web Site, www.dch.statc.ga.lIs.Please keep your Summary Plan Description (SPD) and Updaters for fut\ltC reference. If you arc disabled and need this information in an alternative format, call the TOO Relay Service at (800) 255-0056 (text telephone) or (800) 2550135 (voice) or write the SHBP at P.O. Box 38342, Atlanta. GA 30334.

PHONE NUMBERS AND CONTACTS FOR BENEFIT AND PROVIDER INFORMATION THE STATE HEALTH BENEFIT PLAN GENERAL INFORMATION

INSIDE FRONT COVER
.. 2 .. 4

OVERVIEW OF PLAN OPTIONS



9

~ INDEMNITY OPTIONS - BASIC AND PREMIER 9

~ PPO AND PPO CHOICE OPTIONS - BASIC AND PREMIER 10-11

~ HMO OPTIONS. .

12

~ HMO CHOICE OPTIONS . 13

BENEFITS COMPARISON: PPO, PPO CHOICE, INDEMNITY AND HMO OPTIONS. PHARMACY BENEFIT OPTIONS
SEIlVICE AREAS FOR YOUR HEALTH PLAN OPTIONS

........

....... 14



26

........ 30

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) ANNUAL NOTICE
DEPARTMENT OF COMMUNITY HEALTH PIlIVACY NOTICE

................ 35 . 36

How OCH USES AND DISCLOSES HEALTHCAIlE INFOIlMATION 37

WOMEN'S HEALTH AND CANCER RIGHTS ACT 39

PENALTIES FOil: MISIlEPRESENTATlON 39

o

THE STATE HEALTH BE EFIT PLAN (SHBP)

The Georgia Department of Community Health, which administers the State Health Benefit Plan (SHBP), continuaUy seeks to offer high-quatiry, affordable health coverage. Keep in mind, however, that you are the manager of your healthcare needs, and in turn, must take the time (0 understand your Plan benefit choices in order (Q make the; beSt decisions for yOli and your family.
You may wonder how much your heahhcare benefits will COSt this year. Monthly premiums continue to increase and benefits arc modified. This is true for State Health Iknefit Plan (SHBP) members as well as employees and retirees nationally. Why docs this happen and how C:1O we better manage hcailhcare Costs? Actually, )IOU IlIll)1 be pari oftbe ~OllltiQIl.

Peopk who do not understand thrir health eO\'er age pay more,according (0 theArnerican Medical Association.To help you beuer understand your plan and save your healthcare dollars, we have prepared a few points for you to consider.
let's start by ralkjng about how the SHBP works. It is a seif-ftmtlet[ piau, which means Ih:u all expenses arc paid by employee premiums and employer funds. Approximately 95% of the premium goes dirt:ctly to pay hc;tlthcare claims and 5% goes toward adminisu:ring the Plan.
The g...a. phs below provide you with an idea of how the cost of your healthcarc is allocated between employees and employers.

- $400


0

$350

v

: $300
"z
0 $250
.-.~
0 $200

> $150
0
" $100
~ $50
.-0 $0

--- Monthl)' Employee Contribution

Montbl)' Employer Contribution
.e

Monthl)' Total Cost
-+-

STATE HEALTH BF.:\f.F1T PLA:'Ii - PPO SI:"OGLE

5345.68

$303.45

$304.65 __ - - - - - .

52'Z3.04

5289.00 _ __ _ .........."'-- - - - - - -.- _....

$286.62

~----------.... -----

5255.27

$255.27

............... $2

27.

9

"
'I

5243.90

.

...545.10
FISCAL YEAR 2000

...$45.10
FISCAL YEAR 2001

..$48.18
FISCAL YEAR 2002

$49....38
FISCAL YEAR 2003

...$59,.06
FISCAL YEAR 2004

5505.06

-S535.00

.+ ... -----~-~-

$373:34

.54032B

..$1'31.72

-$S61.-=7?

. - - -.- - ~~6.~~-

$641.58

5461.30 5414.65 _$414.65

... SI47.10~

... $150.78

..$180.28

So wbat Call you do to belp manage your beaUbcare cos's and keep down 'be increase in premiums?
UNDERSTAND YOUR OPTIONS
Compare all your plan options, considering both the premium and out-of-pocket costs that you may incur. Web sites and phone numbers are listed on the inside front cover of the Decision Guide if you need more information.
CONSIDER ENROLLING IN A HEALTHCARE SPENDING ACCOUNT (HCSA)
A HCSA helps you save tax dollars, approximately 26-45%, depending on your tax situation. By electing to use a HCSA, you may set aside up to $5,040 aJUllIally to cover healthrdated treatment for yourself and your dependents. Eligible expenses include deductiblcs, co-paymems, over-the-counter items for medical purposes and costs for certain procedures not covered under your health plan. The benefit of this account is that you're able to pay for these out-of-pocket costs with taxfn:e dollars! Contact your HR represemative for more information.
BECOME A MORE PROACTIVE CONSUMER Of HEAlTHCARE
Most people do not realize how much their treatments, medicines and tests cost. The illustration below is one example of the savings from choosing a generic drug instead of a bmnd-name drug.

Steps You Can Take Include: ~ Keep a list of all medications you take. ~ Shop in-network providers and pharmacies.
End out what your drugstore charges for a drug, not just the co-payment.
.. Use generic medicines whenever possible. .. Make sure all procedures are preccrtified,
if required. .. Make sure you get the results of any test or
procedure. .. Talk to your prOVider. For example, ask your
doctor if tests are necessary or if there are other forms of treatment.
~ Understand what will happen if you need surgery.
~ Check your Explanation of Benefits (if provided under your plan oplion) and if something does not make sense or seems to cost too much, ask your provider about it.
These and other steps you take will help manage healthcare expenses, reduce your out-of-pocket costs and those of the Plan. In addition, these steps will help in keeping premium costs down. As an informed consumer of healthcare, you can have an impact on what you have to pay for premiums and be part of the solution.
If after reading this Guide you want more information before making a coverage decision, you can request a Summary Plan Description (SPD) booklet and Updaters from your personneVpayroll office.

PRF.SCRIPTION BRAND NAME GENERIC SAVINGS

-

-

. .

.

'Mi;'IBER'-



~O-PAYME~T ,

$25

-" ~ii-~- .TO-TAL~~...t."-l8~.(COSTl~

. PRESCJ!..I~.T_IO!,,!_. COST

\To I.!H~!lB

$90

565

$10

542

532

toyou-Sl5

-

to SHBP - $33

o GENERAL
INFORMATION

ELIGIBLE DEPENDENTS
A dependent is defined as:
~ Your spouse, if you are legally married as defined by the state of Georgia;
~ Your never-married dependcnt dtildren who are:
o Natural or 1cgalJy adopted children and
under age 19;
e Stepchildren under age 19 who live with
you al least 180 days per year;
o Olher children under age 19 if they live
wilh you permanently and legall~' depend on you for financial supporl;
Your natural children. legally adopred children or stl:pchilth'en who were covered under the SHBr before age 19 and who are physically or menrally disabled and dcpendelll all you f<lr primary support (they may continue their exisring Plan coverage past age 19): and
o Your childn::n from caregories 1,2 01':3
above who arc registered hill-time students at fully accredited schools, arc not cmployed full-Lime and arc benveen rhe agl:S of 19
and 2;.

DOCUMENTATION UPON REQUEST
In order to cover a SpOUSl: or dependent under the Plan, yOLl lllust provide dOClll1ll:ntation UpOIJ request frOlll tJle Plan. The Plan n:qui],l:s:
~ A copy of your certified maniage license to cover spouses;
~ A copy of:l certified birth certifiCate to COVCl" a natural child:
~ A copy of a stepdlUd's certified birth certificate,
showing your legal spouse as the natural parent
of thc child, ;llld a llotarizt:d Jette]' documenting
that YOllr stepchild lives in your home on a pcrmanelll basis in a parentchild relationship Jor ar k;lst 180 days per year;
~ Adopt ion papers. gu;mlian Or COurt orck]'s for other children who live with YOll perm;lllcntly and legally depend on rOll for financial support. (The SJmp wiU recognize and honor a Qualitkd Medical Child Support O]'der (QMCSO) for digiblt: ckpcndcnb. Sl:e yuu]' SPD for more inrormat ion);
~ Disahility paperwork fix disabled dependents 19 and over; this documentation must he received by the Phn before thl: child's 19th birthday: or
~ A c(.'nifiC:l\ion leue]' for full-time studelll dependents from Ihe registfa],'s office of your child's school.
SHUP conducts random audits of Plan members eligibility. Failure to provide the requested dOCurnelH'atioll within sixty days of the request, will result in the termination of the depemkllfs coverage n::r.roactively to his or her coverJ.ge effeclive date. The rccove]'y process to recover any and :111 paymenls made by thl: Plan on behalf of any ineligible dependents will begin 30 days afLer notification of cancellation.

How TO ENROll
If rou're eligible to participate: in the SHUp, rou become a member by enrolling cith<::r:
~ As a new hire, within 31 dars of your hire date. If yOll join rhe SHBP during that first 31day enrollment opportunity, roul' coveragt: will go into efftct on the first day of the month after you completc one: full calendar month of employment. See your personnel/payroll office for instructions on how to enroll.
~ As a result of a qualifying event. See \Vbel1 Are
C!Jallges Allowed? on page 6 of this Guide for
more demils.
If you elect to decline SHIW con:=rage, YOli must
complete a Declination Form. available from your personnel/payroll office, and file it within 31 days of your hire date.
If you decide to become an SHUP member, you will have two major choiccs to make:
~ YOUf coverage option-I'PO Basic, PPO Premier, PPO Choice Basic, PPO Choke: Premier, lmkmnily lbsic, lndemniry Pn.;mitr, HMO Option or HMO Choice Option (if you live or work in an HMO servin; an:a); and
~ Your coverage type-Single 01' Family coverage. For dewils on Single and Family cover-lge, see your SPD and Upda/crs.

WHAT HAPPENS IF I HAVE OTHER INSURANCE?
YOli or YOLlr covered dependents may have medical coverage under morc than one plan. In this case, the Plan's coordination of benefits (COB) provisions apply.
When SHUP benefits are coordinated, the Plan does not pay morc than [00% of the Plan's allowed amount. Non-covcrcd serviceS or items, penalties and amountS balance billed arc not pan of the allowed amount and are the subscrihc(s responsibility.
11 is important that you notify us if you have mher group coverage to prevent incorrect pnxessing of :my claims. I'or further information about COB rules, n:fer to the SPO.
COBRA RIGHTS
TIle Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986 requires that the Plan offer you, your spouse or an eligible dependent the opponunity to continue he<llthollt covemge if Plan coverage: is lost due to a qualifying event.l1H: length of time yOll may continue the coverage is based on the qualifying event. For fl.1fther information, please refe:r to your SPD.

Keep in mind that once you do enroll or decline, you cannot change your coverage voluntarily until the next Open Enrollment Period, unless you c--xperieoce a qualifying event thai would permit a corresponding change.



WHfN ARf CHA GfS AUOWfO?
TIle henefit choices you make as a new hire will Sla)' in effect for the duration of the 2004 - 2005 Plan year - Jul}' 1,2004 - June 30,2005, unless rou experience certain changes in status as defined by feder.tl law, Section 12; of the internal Revenue Code, which governs the ST-mp, does not permit canceling or othc.rwise changing your coverage during the Plan Yl.-ar unless you have a qualifying evenl.
Qualifying events include, but arc not limited to:
.. Marriage or divorce;
.. Ilirth or adoption of a child or placement for adoption;
.. Death of a spouse or child, if only dependent enrolled;
.. Your spouse's or dependent's e1igibilit}' for or loss of eligibility for other group health coverage;
.. A change in residence by you, your spouse or dependents that makes you or a covered dependent ineligible for coverage in your selected option; and
.. A change in employmelll status lhat leads to a loss or gain of digibility under the Plan.

If you declined enrollment for yourself or your dependents (including your spouse) bec-.msc of other health insurance covc.r.tge, you may, in the future, be able to enroll yourself or your dependents in the Plan. provided that you request enroUmem within 31 days of whcn your other co\'erJ.ge ends, In addition, if you have a m'. W dependent as a l"l.'Sult of marriage, binh, adoption or placement for adoption, you may be able to enroll yourself and your dependents, provided that you request enrollment within 31 days of the marriage, birth, adoption or placement for adoption, and pro\'ide the required documentation.
For additional information about qLmlifying events, see your SPD available from your pcrSOilllc! officc or online at www.dch.state.ga.lL..t

OVERVIEW or How EACH HEALTH PLAN OPTION WOKKS
On lhe following pages, yOll will find a brief descriplion of each option and importanl consider:llions 10 help yOlI select the best option for you.
Cont3ct the Member Services unit for each option if you need more detail. Telephone numbers :Lre on the inside front cover. You
also may access an SPD and Updatel's
online 3t www.dch.state.ga.us.
To help you understand the information in this
section, a few key terms are defined below:
IMPORTANT TERMS TO UNDERSTAND
Allowed Amount-A dollar amount lhe Plan uses lO calcul:ne benefits payable. The Plan uses the following allowed amounts:
o Network Rate-for in-network PPO services; o Out-ofNetwork Rate-for out-ofnetwork
PPO services; and
o Indemnity Rate-for Indemnity Option
services,
Balance BUling-A dollar amOllJ1( charged by a provider that is over the Plan's allowed amount for the care received, YOli arc subject lO balancc billing when YOll receive services from non-partil.ipating providers, including emergeol.1' services.
Co-lnsurnnce Amount-The percentage of the Plan's allowed amount paid b)' a 1)lan member in lhe PPO or Indemnity Option. Depending on the option selected, the SHOP generAlly pays 90% to
60%. so )'OUr co-insur.mce is between 10% and 40%.

Co-paymeol-A set doUar amount that rOll pay al lhe time yOU receive :crvices or ilems. For eX;llllple, rOll pay a 530 co-p:l)'melll for :Ill in-network I)PO phrsicians office visit while rOll arc at the physician's office. Co-paymcnts do not apply to Plan )'C:lf deducribles or Out-of-pocket limils unless otherwise noted.
Covered Services-Services for mcdically necessary care that are eligible for reimbursemenl under the Plan,
Deductible-A specified dollar amOlllll, which varies by Plan option, for specified cmcred services that rou must pay OUI-orpockel each Pl:m rear before the PPO Option or Indemnity Option pays a benefit. Depending on rour COVCr.lb'C option, the deductible may nm :lpply to some services. For example, the dl.-Quctible docs nOt appl)' to innetwork physician office visits under the PPO Option. R\10 Options do not have deductibles.
Emergency Care-Care.: provided when a sudden, se....ere and uncxjx:ctcd illness or injury h,lppcns that could be Iife-rhrc:ltcning or result in pcrmaneJlt impairment of hndily functions if not lrealed immediately.
Lifetime Maximum-The maxillllllll dollar amounl thal each Plan member may n,:cdve in benefits from the SHill' during his or her lifetime.
Medical Certification Program (MCP)-A feamre of the I)PO and Indemnity Options that helps you and the 1)lan save money by preventing unnecessary c:trc. To receive full benefits, you must comply with the MCP requlremems outlincd in the 51)0 and U/Xla/ers.



Out-of-Pocket Limlt-A maximum amount you would have to payout of your pocket each Plan year for covered services. Once you meet your out-of-pocket limit for the Plan year, the Plan pays 100% of the allowed amounts for most covered services for the rest of the Plan year. Your out-of-pocket costs for premiums, co-payments and non-covered charges are not applied to the limit.The deductible is applied to your annual out-of-pocket limit.
Participating Provider-Any physician, hospital or other health-service professional or bcility that ofkrs covered services and that has joined the PPO network, the Indemnity network or HMO network for the Plan option. Providers nominated and accepted under a Choice Option also are considered participating providers for the person making the nomination. PartiCipating providers may not balance bill Plan members for covered services.
PRE-EXISTING CONDITIONS AND COVERAGE LIMITS
A Pre-existing Condition (PEC) is any sickness, injury or other condition (except as noted below) for which medical advice, diagnosis, care or treatment, induding prescription medication, was recommended or received within SLX months immediately preceding a member's coverage effective date under the Plan.
New SI-IBP members who enroll in the PPO or Indenmity Option and have a PEC have a 12-momh coverage limitation period for their PECs. Coverage for each PEC is limited to $I,O<XJ during the first 12 months of Plan eovemge.
For new employees, the l2-month coverage limitation period begins the first day of the month in which the new employee was hired.

The PEe limitation period does 110t apply to coverage for pregnancy, for a newborn, or for a ne\vly adopted child or a child placed for adoption under the age of 18, if the child becomes covered within 31 days of birth or adoption.
Enrollees are treated as new members, subject to the PEC limitation period, if they are enrolling in the PPO or Indemnity Option after a coverage break of four or more months.
CREDITABLE COVERAGE
SHBP members and dependents can reduce or eliminate the l2-mOlllh PEe limitation period by documenting "creditable coverage."' Cn.:ditablc coverage generally includes the health coverage you or a family member had immediately before joining the SHBP Coverage under most group health plans, individual health policies and some governmental health progm1lls qualifies as creditable coverage.
To reduce or eliminate the PEC limitation period for your own coverage:
... You must provide the SHBP with a certificate of creditable coverage from one or more former health plans or insurers that states when your prior coverage staned and ended.

o OVERVIEW OF PLAN OPTIONS

The State Heahh Benefit Plan has conll':lClcd with heallhcare organiZ:ltions that have been carefully reviewed and selected to provide the highest Ieyel of provider accessibiliry and quality of care. When selecting your health plan option, it is t.'\:t'remely critiGl1 that you fully understand how the provider network functions for the ,'acious health plan options.

INDEMNITY OPTIONS -
BASIC AND PREMIER
Tilt: Indemnity Options arc traditional fccforscovicc plans that generally provide the same benefit coverage k"e1 no maner which qualified medical provider yOll use. These Plans reimburse up 10 the Plan's allowed amounts for con:red services,'I11c Indcnmiry Options also lise contr:lcted healthcarc providc::rs who have agreed to discounted rates without balance billing for c:..:harges over the allowed amount. As long as you lise a participating provider, you may not be balance billed for covered sen'ices. Howcwr, nOI all Georgia proViders panicip:lle in these special arr:mgemems and there are no participating Indemnity Network providers outside of Georgia. In mosl instances, non-panicipating providers' billed charges :Ire considerably higher th:1tl the Plan's allowed amounts. Hospital stays (even for emcrgcm:ies) outside of Georgia em result in signifkant balan<.:e billing amounts. In some cases, this can be wdJ in excess of 510,000.

I'oints to Consider
~ You mar access an~' provider.
~ YOli may par most heallhClre bills up 10 the deductible amount before the Plan stans paring benefits.
~ YOli continue to pay co-insurdnce for covered sen'ices after meeting the deductible (up to lhe OUH)fpockct maximum).
~ When using a non-participating provider, including aU out-of~slate providers, you are subject to bal:lIlce bilJing for charges ovcr the aUowed amowns.1l1csc :lmounk'> do nO( apply to the ollt-of-pocket maximum.
~ Compare lhe Basic and Premier Phamlaq- Options.
.. You must call the I\!'edical Cenific:nion Progr:ml 0'lCP) to prtcenify inp:uient stays at non-participating hospitals, and members must prcc:..:ertify certain outpatienl tests and procedures. Financial penalties apply if precerlific:uion rules are nOI followed.

There arc two pharmacy options under the Indemnity Plan Options.-111ese options :Ire the IJldcmnit)' "asic and [ndemnity Premier. The medical benefits are the same under the Basic and Premier options. For additional informalion refer to page 26 of this Guide.
NOt(: Somt contract groups thtU participau ill tilt SHE? au not tligib/~ to partieipau /11 tht IndrmnilJ Optioll.

NOtE: The State Health Benefit Plan does not have the legal authority to intervene when non-participating providers balance bill; therefore, the State Health Benefit Plan cannot ..educe 0 .. elltninate amounts balance billed. In addition, the Health Plan cannot make additional payments above the allowed amounts when you are balance billed by non-participating providers.

o

PPO AND PPO CHOICE OPTIONS BASIC AND PREMIER
The PPO Options offer you a network of over 14,000 Georgia participating physicians and 166 Georgia hospitals managed by 1st l\'ledical Network in the Georgia service area. You also have the added benefit of access to a national network of panicipating providers and hospitals across Ihe United States, which is managed by the Beech Stccet Corporation.The PPO Options offer you the choice and flexibility of using in-network or out-of-network providers. In order to receive the highest level of benefit coverage and avoid filing claims and balance billing, yOll will need to use an in-network provider. If YOli choose to use an om-of-network providc:r, the reimbursement will be at a lower level of benefit coverage. NOfe:The Transplant and Bch:lvioral Health Services (B1'IS) networks arc separate from the Ist Medical Network and the Ueech Street Network.
'10 view the list of 1'1'0 providers onhne, visit www,hcalth)'georgi'l COlD. If you do not have Internet :lccess, call Member Services for provider information.
.It is ultimatcly your responsibility to verify if a provider participates in the PPO network prior to receiving services. Providers may entcr or leave thc network at any time.
There arc two pharmacy options under the PPO and PPO Choice Options - PP{) B::lsic and PPO Premier. TIle medical benefits arc the same under the PPO :ll1d PPO Choice Options. Please refer to page 26 for additional information .

Points to Consider
.. You do not need [Q select a primary GIn: physician (I'CP) or obtain referrals to see specialists.
.. No balance billing when using participating PPO providers.
.. You pay a minimal co-payment for in-network PPO physician visits. Other covered services are subject to dc::ducribles and co-insurance.
.. YOli may access any licensed out--of-network physician, specialist or hospital at any time. However. you will genernUy pay more for out-of-nerwork services and dlarges are subject to b:llance billing.
.. You must <..,111 the Medical Certification IJrogram (MCP) to precertify inpaticm stays and specified olllpatient procedufCs when you arc using olll-of-network providers or Beech Street providers (National PPO network).
.. Some physicians affiliated with our PPO networks may not accept new patients at certain times during the year or may drop out during the year. Please check with the physician of your choice before you enroll in one of the PPO Options.
.. Compare the pharmacy programs .
.. In-nctwork hospitals may contract with ollt-of nctwork physicians or labs. You may be subject to balance billing by these providers.
.. YOll have access to a mltional network of Beech Street providers. Your level of benefit coverage is gener-lIly different and you are subject LO Separate deductiblcs and out--of-pockct maximums.
.. Physicians or hospitals leaving the network are not considered a qualifying event and do not allow you to dl,lIlge coverage.

The C('Orgia Sf!rt'lce tln'ti i"di/tI('S the slate of Georgia ClIlti the border comll1lll/ilit'S of tbe Clxl1tcmoogtl, Telllu!SS(.'t' an'CI, illClut/iIl,C: 8rt/(l/e)1 C(lIIII~"; and pwnL, Cit); Alabama. TlJe zip axle area III which yOi/ receille a senl;ee is IISl'tI to tletermille Il'IJf!tber or nol JUll are ;1/ tbe Georgia serillee area.!iee j}(lge 30 for fllrtbe-r b/fonlultiQ1J.

ADDITIONAL INFORMATION ABOUT
PPO CHOICE - 8ASIC AND PREMIER
lknefits under the PPO Choice Options arc the same in the PPO Et'lsic lmd PPO Premier Options. However, PPO Choice Option premiums arc higher. In return for a higher premium, rou can request that an out-of-network Georgia provider be reimbursed as an in-network provider. TIlis request is kno\vn as a Mnomination.... lf the out-of-network provider accepts your nomination, agrees to the PPO kes, and is approved by the PPO, you will receive in-network benefits for that provider. The in-network relationship between you and the provider remains in effect until you or the provider terminales Ihe llgreemenl. You may nominate as many eligible providers as you wish al lmy time during the Plan year.

Points to Consider
... TIle PPO muSI approve YOllr provider nomination before you receive sen'ices_
... If your provider docs not accept rour nomination, docs nOt accept the network fees, or is not approved by the PPO Network Administrator, then services from that provider are coyen:d at the lower, out-of-network benefit le\'el. SHBP rules do not aUow a member to change options when a nominated provider or the PPO rejects a nomination.
... Only proViders loc:ned and licensed in Georgia can be nominated, even if you live oul of state. After the PPO receives your nomination, the PPO has three business days to either reject or approve the nomination.
For further details reWlrding the nomination process and to ohl'ain the necessary paperwork, please cantllel Member Services.
Note:Tbe lJebavloral Healtb Services (BHS) amI transpltml proVider nelworks (/I'e
separate from tbe PPO provider /letwo/'k in
all PPO alld PPO Cboice 0pliollS. To nominate a JJHS provider, contact the HHS Pro,r;ram at
(800) 63/-9943. I'o/, /'IO/lli!Ulliolis of transplant
providers, C(/ll (800) 828-6518 (ullt~'ide Allanla).

HMO OPTIONS
HMO Options are available only [0 SHHP-eligibk t:mployces who livt: or work in an approved HMO service area in Georgia. -(See footnote.) Ple:ISC review the approved HMO service area list on pages 31- 34 of this Guide 10 determine if rou are eligible for an HMO. If your residence circumstanccs change during the Plan rear and yOli no longer live or work in an ::lpproved HMO service area, you will be required to changt: to another Plan option.
HMOs provide prepaid benefits for most healthcare needs, with no bills or claim torms.Yol\ are responsible for selecting a primary care physician (PCP) from a list of participating providers. M(See footnote.) YOLI must n:ccive care from your PCP or from a physiLian or f.ICi!it}' referred by rour pcp for your expenses to tx: co\'ered. except in C"'dSCS of emergenc), and in other limilt:d cases. If you receive care from a physician other than your PCI~ or without your PCP rcferral, there is no covcrage even if the physician or f.lcility is in the HMO nct work.
Points to Consider
.. You must ;u.:ccss physicians, specialists and hOSpitalS offered through the HMO's network to receive henefits, except for emergencies as defined b}' the HMO.
.. You choose a pcp to serve as your first point of conmct for most he;l1th<.:are seniccs. "(See footnotc.) Your covered family members mUSt also select a pcp. TIle PCP is responsible for coordinating rour healthc:ue services (speci:llislS, ancillary providers, hospitals).
,. Providers may drop Out of the network al any time during lhe year and this is 11m a qualifying event to change coverage.

.. See the Pharmacy lkndlt Options on page 26 to compare the pharmacy programs.
.. YOLI pay only a minimal co-paymem for liMO innetwork ph~'Sician visits. prescriptiOn drugs and somc other covered services.
.. You pay the full cost for non-referred sen'ices and for services received out.<;ide tht: H)tOs panicip:uing netWork, except for t:IJlergencies
as defined by the HMO.
.. YOli ha\'e coordinatc...-d care through a network of HMO participating pro\'iders.
,. In most cases, HMOs do nOl have: a deductible to meet, so your outol~pocketcost may he lower.
.. There are no pre-cxisting condition limitations.
.. You may be required to follow the HMO's standardized treatmcnt plan for your condition. For example, you mar be required to recei\T treatment frOI11 your primaq' care physician for a specified period befort: being referred to a specialist.
.. All services received outside the State of Gcorgia must be: coordinated through the HMO.
C-) Some contract groups that participate in
the SHBP are not eligible to participate in the HMO Options. C--) Note: UnitedHealthcare HMO does not require you to select a pcp or obtain referrals to see specialists.

HMO CHOICE OPTIONS
If yOlL are eligible for an HMO Option, YOll also :m: eligible for th:u HMO's Choice Option.
11110 Choice Option benefits are the samc as the 11.::tjX'cti\e regular HMO Option bendirs. HOWe\TC the Choice Option premiums are higher. In return for a higher premium, the HMO Choice Option gin:s llll"mbers the opportunity to reque:tl an OUI-of-nenvork Georgia provider to be trc;ttcd as an in-network provider. This requesl is known as a "nomination.~ You may nominatc providers if Ihey arc located ant! licensed in Georgia and offer services covt:l1::d by the HMO. In ;Iddition, you may nominate.: as many eligible providers as YOLI wish at any time during the Plan YC:lr.

PoinlS 10 Consider
~ 111e HMO !TIllSt approve your OLlt-of-nctwork provider before YOli receive medical scn'ices.
~ If the ollt-of-lletwork provider accepts YOllr nomination. accc.:pls the 1-I.\IOs fees and is appro\"t:d by the H.\10, you may receive in-llt:twork bcnefits from that proVider.
~ If your prm'ider does not aCCt:pt your nomination. docs not accept the.: HMO's fees, or is not approved by till' HMO, sen'ices from that providt:r are not covered.
~ Ikferral rules apply when the nominated doctor is a specialist for the B1ueChoice, elGNA and Kaiser HMOs.
~ SHllP rules do nOI pcrm..it a member to change options \.."hen a nominatcd provider or HMO rejects a nomination.
Plcase contact thc Mcmber Services Departmcnt of the respectivc HMO directly to find out more ::lbout the rcquired procedures and paperwork necessary to nominate a provider. Telephone numbers are listed on Ihe inside front cover,

You ARE PART OF THE SOLUTION!

.~U'N'DERSTA~DING Yo.u~' HEALTH

TlJis secti011 complres specific bellefllS witlJill IlJe PPO, Il1dertmily alld HMO OpUOIIS.

FOI' more speciJlc itifm'matioll Oil covered services, call the Member Services IllImbers

listed Oil the illside from cover,

00 o

o BENEFITS COMPARISON: PPO, INDEMNITY AND HMO OPTIONS
SCIIIWULE 01' B.:NEFITS FOR You AND YOUR DEPENDENTS - JULY 1, 2004

Ma.'timum Lifetime Benefit (combined for all SHBP Options)
Pre-Existing Conditions (l51 year in Plan only, subject 10 HlPAA)
Lifetime Benefit Liotit for Treatment of: (combined for PPQ Option and Indemnity) .. Temporomandibular joint
dysfunction (fMJ) .. Substance abuse .. Organ and tissue tr:msplants ... Home hypcr:llimcnt:ttion
DeductibleslCo-Payments: ... Deductible-individual to Deduclible-f.lmily m:lximum
.. Hospital deductiblc/admissionexcluding B1"IS and trJ.llsplants
... Hospital deductible/admissionBHS and transplants
.. Hospital co-payment
Annual Out-of-Pocket Limits: .. Individual (you or one of your
dcpendents) .. Family (you and yOllr dependents)
.. BHS program (per patient); BHS authorized care only

5400
$1,200 $250 $100 Nonc
S 1, 0 0 0
SV)(}()

52 million 51,000

51,100

3 episodes 5500,000 $;00,000

lo-Nctwork/OUI-of-SI:1te & OUI-QfNctwork amounts <.'()mbint:d $500 51,500

5250

5250

S100

$100

None

None

Ln-NetwOl'k/Ollt-of..State & Oul-of..Network amounts combined 52,000

52,500

S4,OOO

Primary Care Physician and/or Referral Required
Primary Care Physician or Specialist Office or Clinic Visits: .. Treafment of illness or injury

No

No

100% NR- :lfrt:r a per visit co-payment of $30;
not subject [0 dcductible

100% NR- after :I per \'isit co-payment of 530:
not subject to deductible

No
60% of DONn-; subject to deductible

- See legend on page 24 for definitions of NR, OONR and IR.

$2 mmion $1,000

BWF.CtJOICf
Tbe Plan Pays $2 million None

HMO OPTIOSS

OGNA

KAl."ER PERMANEI'I,'TE

The Plan Pays: $2 million
None

The Plan Pays.
No lifetime benefit maximums
None

UNITEOHEALnlC.o\RE
The P/(m Pays. 52 million None

$1,100
3 episodes
$,00.000 S,OO,OOO
'400
$1.200
'400 Sloo
None
S2,O<Xl 54,000 52500

No separ:uc lifetime benefit limit

No separate lifetime benefit limit

No separate lifetime benefit limit

No separate lifetime benefit limit

Not applicable

Not applicable

Not applicable

Not applicable

_..-..................... ......_.._..... _.......... ... _............ __ ... _.. _- . __ ._.............. _... _-

Not applicable

Not applicable

Not applicable

Not applicable

Not :tpplicable

Not applicable

Not applicable

Not applicable

$200

$200

5200

$200

Not :lpplicable

Not applicable

Not applicable

Not applicable

Not applicable

Not applicable

Not appliC'dblc

Not applicable

No

Yes

Yes

Yes

No

9O'XJ of JR'; subject to deductible

100% after a per visit co-payment of 5 I; for primary c:lre :md 520
for specialt)' care

100% after a per visit co-paYlllent of 5 15 for primary care and 520
for specialty care

100% after a per visit' co-paymem of $15 for prim:lf)' care and 520
for specialty cart:

100% after a per visit co-payment of 5 15 for primary care and 520
for specialty care

a ( Chari co"U,oucd PRIf>

COVERED SERVICES

----'-'-"'-



- - >......

Primary Care Physician or Specialist Office or Clinic Visits for the Following: .. Wellness care/prcvt:ntivc
hcalthcarc .. Well-newborn exam .. Well-child exam$ and
immunizations .. Annual physicals .. Annual gynecological exams

100% of NR aCler

100% of NK after

$.30 co-payment per office SjO co-paymelll per offiCI:

visit.IOO%ofNI~ with

\'isit. 100% of NK with

no co-payment for a$sodatctl no co-payment for associated

tests and immunLwtions.

tests and immunizations.

Maximum of S500 payable ~bximurn of $500 payable

per person per Plan year

pef persoll I)(:r Plan year

for aU prcn:nth'e services. fOf all preventive services.

M:lximulTI combined with M:tximlllll combined with

In-Network/Oul-Qf-5tate benefit. IJl.-Nt.""twork/Gcorgia benefit.

Not cove~d" Charges do not :lpply to deductible or annual out-ol:pocket limits.

NOltS: Lab and ICSI charges include such services as m:unmograms. proSI':l.IC scrcenings/PSAs, and pap tesrs. Gwered according to prc"cnrh"e ,--a~ age schedules.
Con:red care schedliles are online al www.hcJ.hh\geol\:ill.com or call ,\Iember
SCrvief.-'S at (ROO) 483-6983 (olllside Allama) or (404) 2334479 (insillc: Allama).

Maternity Care (prenatal, delivery and postpartum)

90% of Nil; not subject 10 deductible after initial 530 co-payment

sow' of NR;
not subject 10 deductible
after initial 530 co-payment

60% ofOONR; subject to deduetihle and
to balance billing

Physician Services Furnished in a Hospital .. Surgery in general, including charges
by :surgeon, anesthesiologist, pathologist and radiologist

90% of NIt; SUbject to deduCliblc

sow, of NR:
subjeci to dl--"ductible

60% of 001\l1t; subject to deductible

.. Lnpaticnt well-newbonl exams

100% of NR: not subject to dcductible

100% of NR; llot subjeCl 10 deductible

Not covered

Physician Services for Emergency Care

90% of NR: subject 10 deductible

90% (If NR: subject to In-Network/Georgia
tleductible

9O'Xo of NR: subjeci to In-Network/Geargia deductible
and la balance billing

Outpatient Surgery .. When billed as office visit

90% of NR: SUbjCLt to deductible

80% of NR: subject to uedllctible

60% arOONI{: subject 10 deductible

.. When billed as outpatient surgery at a facility
IIOSPtTAL SER\ ICF.S
Inpatient Services .. Inpmienr care. delivery and
inp:tticnr short-tt:rrn acutc rehabilitation services
.. Outpatient scrvicc$ .. Nan-emergency USe of Ibe emergency room .. Other

90% of NK: subject to (Jeduclible
90% of 1\'R: subject ta a per :ldmis."ion
detluctible of 5250
90% of Nit; subject to deductible; subject 10 S 100/Visit
co-payment

80'}6 of Nit: subject to deductible
8Q%ofNIt: subject to a per admission
deductible of 5250
8(jJ(, of NR; sLlbjcl.:t to deullctible; subject to SIOO/visit
l.:o-paymem

6O'J(, of OONR: subject 10 ueductible
6O%0fOONR; ~ubjeci to a per admission
dcductible of $250
(i)'X, of OO~lt sllhject to deductible; sllbjecr 10 $1 OONis!!
co-p:trlllent

.. WeU-newbom care

100% of ;'\TR: not subjcci to deductible

I()()'h, of :\'K: not sllbjeL"t 10 deductible

Not cO\'ercd

INDf.:\tNITY OPTIONS
BAStC A."lD PRF.toIIER
-
Tile e../~'!. ~aJ's.~..(;.~
9O'J' of lR per office visit after deductible.
1~ of IR with no deductible for associated
lab and test charges, up to a maximum of 5200 per person per 1'1:In year; additi01l:11 $125 benefit for screening mammogram.

BLUECIIOICE

HMO OPTIo:\,s CIGNA

UNITEDHEAL111CARE

17Je Plait Pa)'s'

TlJe Pfti,~ P!i)'S.'

n.Jp PI,,;' p(l)'~j.Jfi ~ n.Je Plan Pays

100% after a per visil co-payment of S15
for primary GIre amI 520 for specialty care.
No co-pa}'ment for immunizations and
mammograms.

100% after a per \'Isit co-payment of S 15 for primary care and 520 for specialty care. No co-payment for inulluniz.,1lions and
mammograms.

100% aft~r a per visit co-paymenl of 5 I; for primary care and 520
for specialty care. No co-parme.-"1lt for immul1i7~1.tions and
m:m1mogrnIllS.

100% after a per \'isil co-parment of 5 I; for primary care and 520
for specialty care. No l.'O-parment for inmlUl1i7.ations and
m:unmogrJ.IllS.

Note: PPO nOles to the lett also apply hen:.

90% of lit; subjeci 10 dcductible

100% after initial 520 co-payment

100% after inilial 520 co-payment

100% after initial 20 co-payment

100% after initial $20 co-payment

90'.\ of IR: subject to dctluctihle

100%

100%

100%

100';

Not cO\Trcd

100%

100%

100%

100%

90% oflR:subrcct to deductible anu to b:llance billing from lloll1,anicipating providers

100% after applicable 100% after applicable 100% after applicable 100% after applicable

eo-pa}'l1lcnt

co-payment

co-payment

co-paym~nt

90% of In: subjecl lO dnluLtibk
90'X, of Ill; subject to dcductible

100% after $20 co-payment if billed as office visit
$100 co-payment for outpatient surgery

100% after $20 eOpayment if billed as office visit
$ I 00 co-payment for outpatient surgery

100% aftcr $20 co-payment if billed as ofJke visit
$ 100 co-payment for outpatient surgery

100% aftcr $20 co-payment if billed as office visit
S100 copaymcllt for outpatient surgery

90% ofIR; subjecl 10 :t l>er admission
dcducliblt: of 5400
90% of II{; subje.--x.1 lO deductible. If SCf\;ces are in conjunction with non-emcrgency lise of the emergency room, benefit also subject to
$IOO/\'isit co-payment
90% of lit: subject to ptT admission deduCtible of $1 00

100% after

100% after

5200 per confmement 5200 per confinement

co-payment

co-payment

100% after

100% after

200 per confinemem 5200 per confinemelll

co-payment

co-paymenl

PCP prior

PCP prior

pcp prior

authoriZ3lion required allthori7..arion reqUired authori7.ation required

for coverage

for covcrnge

for eo\'cr:lge

Requires prior authori7.at'ion
from 1'1"10

100%

100%

100%
a ( Cb",., """""",'<11'1;.1101

100%

Outpatient Surgery .. Hospital/Facilit}'
Emergenf.1' Care ... Treatment of :In emergency
medicaJ condition or injury

90% of NR; subject to deductihle

80% of NR; suhject to dcduclible

60% ofOONR; subject to deductible

90W. NI{ after a per \'isit co-payment of $100;
co-insurance and hospital deductible appl}'. if admitted

9()'.l(, NR after a rx:r \'isit co-payment of $100;
co-insurance and hospital deductible apply, if admitted

90% OONR after a per visit co-payment of S 100;
co-insurance :md hospital deductible apply. if admitted.
Subject to balance billing.

Note: S 100 co-payments arc reduced ro $SO if referred by NurscCall 24 before receiving emtrgency roOm services. The ER co-payment is waived, if admitted within 24 hours.

OUTPi\TlE:'lIT TF.STING. tAn, ETC.

L1boratory; X-Rays; Diagnostic Tests; Injections, including Medications Covered Under Medical Benefits - for the Treatment of an Illness or Injury

90% of NR; subjcct to deductible

SO%of NR; subject to deductible

Allergy Shots and Serum

I(X)"Al of NR; not subjf.'Ct to the 100.16 of NR; not subject to the

deductible. If physician is seen. deductible. If physician is seen.

visit is treated as an orfice visit visit is treateJ as :Ul offic~ visit

subject to the per visit

subtect to the per visit

copayment of S30

copaymem of S30

AUergy Testing

90% ofNR: subject to deductible

80% ofNR; subject to deductible

60%ofOONR; subject to deductible
60% ofOONR; subject to deductible
60% ofOONR; subject to deductible

BEHA\IORAL HEALTH
Mental Health and Substance Abuse Inpatient Facility

90% of Nit; sllbjecl to deductible and separate hospital deductible,
if admitted when authorized by 13115

90% of NIt; subjecl to deJlIetible and separate hospital deductible,
if admitted when authorized by 13115

60% of NR; subject to deductible and separate hospilal deductible,
if admitted when authorized br nHS

Note: 1oA11 services require prior :lllthori7.:nion. 2. Inpatient facility charges (limited to 60 combined mental health
and substance abuse days per person per Plan year). 5. Subst:lOceAbuse eO\'erage limite<.lto three episodes per lifetime.

Partial Day Hospitalization and Intensive Outpatient

9O'Xi of NI{;

90'% of NI{;

subject to deductible and subject to deduclible and

separate hospital deductible, separate hospital deductible.

if admined when

if admitted when

au(horizcd b~' BUS

authorized b~' B1-IS

No benefit

Note: I. Ma.ximum Ix:nefit of 30 combined PHP/IOP \'isits/days pl'r person per P!:In rear. 2.l3encfit co\'cragc is only available when using an in-network i\bgelbt1 provider for partial/day hospitalization :tnJ intensive olltp:llient charges.

INDEMNITY OPTIONS BASIC AND PREl'tUER
The Plan Pays_ 90% of IR;
subject 10 deductible

100% after $100 per 100% after $100 per 100% after $100 per 100% after S 100 per confinement co-paymelU confinement co-payment confinement co-payment eonlinemelll co-p:lymclll

90% U{ after a per visit co-payment of 5 100; co-insurance an<.l hospital deductible, if admitlcd, apply_ Subject to balance billing from non-participating providers.
Note: PPO note 10 the left also applies here.

100% after a per visit co-payment of SSO (co-payment waived
ifadmined)

100% aftcr a per visit co-paymcnt of $SO (co-payment waived
if admitted)

100% after a per visit co-payment of SSO (co-payment waived
if admiued)

100% after a peT visit co-payment of 550 (co-pa)'lllem waived
if admitted)

90% of IR; subjecl to deductiblc

100%

100%

100%

100%

90% of IR; subject to deductible
90% ofIR; subject to deductible

100% for shots and serum after a $20 co-payment
per visit

100% for shots and serum aftcr a $20 co-payment
per visit

$; for shots and 5;0 for :l six-month
supply of serum

100% for shots and scnllTI after a 520 co-payment
per visit

100% after a 520 per 100% after a 520 per 100% after a 520 per 100% after a 520 per

visit co-payment

visit co-payment

visit co-payment

visit co-payment

90% of II{; subject to deductible
if admitted when authorized by BHS
Note: PPO notes to tile left also apply heTe.
90% of IR; subject to deductible and separat<.' hospital deductiblc,
if admitted

100% after 5S0 co-payment per confinemcnt; limited to 30 days
pC:f PI;m year

100% after S50 co-payment per confinement; limited to 30 days
pte Plan year

100% after 5;0 cO-pa)'lllent per confinement; unlimited days for 1llent.al health;
3()-<.lay limit for subst:ll1ce abuse

100% after 5;0 co-payment peT confinement; limited to 30 days
per Plan ycar

Outpatient Care:

Outpatient Care:

Outpatient Care:

Outpatient Care:

100% after S20 per visit 100% after 520 per visit 100% after $20 pef visit 100% after $20 per visit

co-paymel1l; limited to co-payment; limited to co-payment; unlimited co-payment; limited to

2S visits peT Plan )'car 25 visits per Plan year days for mental health; 25 visits peT Plan year

limited to 25 viSits for

substance abuse pCT

Plan )'car

S50 co-p:l)'mellt per confinement; contact
HI\'IO for specifics

$50 co-payment per confinement; contact
HI\'IO for specifics

$50 co-paymcnt per confinemcnt.: contaCt
HMO for specifics

S50 Co-pa)'IllCllI per confincmem; contact
HMO for specifics

Note: PPO notes to the left also apply hCTe.

23 Hour Observation Room (requires prior authorization to receive coverage.)

90% of Nit;

90",.{, of NR;

subject to $100 deductible subjl:l't to $100 dcductiblt'

No benefit

Professional Charges Inpatient (combined total for substance abuse lind mental health)

80% (If NR: subject to
deductible. MaxilUUJll 1 visit
per alithoriz-.:lIliay when
:I\uhorized by 11II5.

RO% of Nit subj-.:ct to

;0% of NR; subject to

(ledw.:tible.l\Jlaximlim I visil deduclible and balance billing.

pCI' :llItllorizcd day when Maximulll of 25 professional

:ltlthorizcd by B1-IS.

visits per person p<:r Plan year.

Outpatient (Precertification required to receive coverage,)

80% of NH: subject to tkductiblc when authorized by BIIS, limited to 50 visits
per Plan year.

80% of Nn; subject 10

50% of NR: subject to

dedllc('ibk when aUlhoriZt.:d deductible (without authori-

by 13I-1S, limited \(l 50 visits zation) and balancc billin~.

per Plan )'c:lr.

Maximum 25 combincd

mcntal he:llth, substance

abuse and brief therapy visits

per person per Plan rear.

Limited 10 scrvices rendered

by a Psychiatrist (M.D.) or

a Psychologist (ph.D.)

Nou:: In-network maximum covcrage of 50-<:ombined mental hcalth, SUbSI:lllcc.: ahuse, :llld brief Iher-Ipy visits per pl:rsun per Plan ~car.
Limil indudc.:s 25 out-of-nl~twork cUlUlsding sessions amJ 3 brief visils.

Brief-Visit Therapy (limit - 3 visits per Plan year; requires BHS prior authorization.)

100%; not subjeci to deductibk

90%: not subject to dc.:dllctible

No benefit

Note: Visits are includcd in Ihe 50-visit limit of outpatiCIH care.

DEN1'AL

I

v . ;- ' ,l i.-,.........,l.~ . _ ),>. -:-,-T-2-:

.. ~ '''''1

Dental and Oral Care
Coverage for mOSt procedures for the
prompt rcp:Lir of sound naturaJ teeth
or tissue for the cOn'eclion of damage
caused by trnumatic injury

90% of NR; subjeCl to deductible
and, if admitted,
to hospilal deductible. Nctwork proViders
may nOI be :lv;lilablc
till' all covE-re(1 services:
charges are paid at 90% NIt
subject to balance billing

80% of NIt; subject to dcuuctible
:1l1d, if admitted, to hospital deductible,
Network pl'()vidt:rs
may nOI be available for all covered services:
charges are paid at 80% NIt suhject to b:llance billing

6o'J{, of OONn;
subject to deductible
and, if admitted. to hospital deductiblc

Coverage of specific osseous surgeries for the treatment of pcricxlorltal disease

Not covcrcd

Not <:overed

Not covered

Temporomandibular joint syndrome (TMJ)

90% of NIt; subject to dcductible

80% of Nit subject 10 dedUCtible

60% of OONlt suhject to deductible

Note: Coverage for diagnostic testing and nonsurgicallreatmcm ofT:\'1J,
up 10 S1,100 pcr person lifetime
maximum bcncfit.This docs not apply
10 the HMOs.

INDEMNITY OPTIONS BASIC At~D PREMIER

90'X, of IR: subject to $100 deductible
HO% of IR; subjt:ct to deduccih1e ant..! balance billing.
PPO benefits apply when authorized by BHS.
SO'X, of He subject to dedllcribJc when authorized br lUIS, limited to 50 visils
per Plan year.

100% after $50 co-payment
[00%
100% after $20 co-payment

100% after $50 co-payment
100%
I(Xl% after S20 co-payment

100% after $50 co-payment
100%
100% after $20 co-payment

100% after $50 co-payment
100%
100% after $20 co-payment

Narc: !'PO notcs 10 the left also apply here.
[00%: not subject to deductible
Note: PPO note to the left also applies here.

Contact HMO for specifics

Contact HMO for specifics

Contact HI\Jl0 for specifics

Contact HMO for specifics

90% of lH; subject to deductible
and, if admillcd, to hospital deductible.

100% after applicable oral surgery co-payment and dental services for accidental injury to sound teeth

100% after

Services/appliances

100% after

applicable oral surgery for accidental injury to applicable oral surgery

co-payment and llental sound and natural teeth: cn-payment and dental

services for accidental

50% coverage

services for accidental

injury to sound teeth

on first SI ,000,

injury to sound tet:th

100% thereafter

Not covered
90% of [H; subject to deductible

Not covered

Not covered

Not covered

Not covered

100% after applicable co-payment fnr related surgery and diagnostic
services. Excludes appliances and
orthodontic treatment.

100% after applicable co-payment for related surgery and diagnostic
services. Excludes appliances and
orthodontic treatment.

50% for non-surgical treatment: 100% after applicahle co-payment
for related surgery and diagnostic
services. Excludes appliances and
orthodontic treatment.

IOO'){, ;Iner applicable co-payment [or related surgery and diagnostic
services. Excludes appliances and
orthodontic tre<llment.

1:1 ( c/)(,,, cOIlIi"",," jJg.22

Note: PPO Oplions include :1 diS<.'ount progralTl for \'ision screenings and eyewear. Coll[aCI BllIL>(:hoice Vision Progr...m:1I (800) 377-6436 or visit u'ww.hchsg;u:om for lTlore infonnatioll. Vision prngr:lm avail:lbilir), is subject [0 change during the Plan rear.

OTHER COVERAGE
Ambulance Services for Emergency Care
Notc:-L:J.nd or air ambulancc~to nearest fadlily to treat the condition.

9O%ofNR: subject to deductible

90% of NR; subject [0 In-NetWork/Georgia
deductible

90% of OONR; subject to In-Network/Georgia deductible

Note: limited [0 transportation for emergencies and benefits subject to balance billing for non-participating providers of ambulance scn'ices.
Urgent Care Services in an Approved Urgent c."lre Center

90% of l'\R after :1 per visil co-payment of $45:
subject to deductible

90% of i\R al'lt:r a per \'isit co,p:lyment of 4;;
subject In deductible

l'\ot applicable

Home Healthcarc Services Approved in Advance by the MCP

90% of 1\'R
subject In deductible

80''' of NR; subject to deductible

6O%0fOONR: subject to deductible

-...... --- --- --- --- .-- ......... ............................... ...........-.._--- .._......_...
NOles: I lome nursing cart': not rev1c:wed by the i'l'ICP C-Ovcrs two hours of medically necesS:lry skilled home care per day by RN or LPN if ordered by a physician: $7500 per Plan ye:lr limit is a combined total in Pro Options. Members share of cOSt is not applied to Plan year out-of-pocket limits.

Skilled Nursing FacWty Services

l\ot covered

Not covt:red

Not covered

Hospice Care
Note: Indemnity - Mer m:!y approve
additional benefits in lieLl of Acute Care hospitalization.
Durable Medical Equipment COME) - Rental or Purchase
Outpatient Acute ShortTerm Rehabilitation Services

100% of Nit; suhject to deductible

100% of Nit; slIbjcct to deductible

60% ofOONR: sllbjecr 10 deductible

9O'Yn of NI{; subjcci 10 dcductible

80% of NR; subject to deductible

I
60% of OONR; subject to {kductib1e

90% of NR:

80% of NR;

60% of OO:"lR;

subject to deductible and subject to dedllL1ihle and

subject [Q deductible

520 pcr visit co-paymenl 520 per vi!'>it co-p:tymem

. ... . ... ... ... ... .. . ... ... ... .. + +. --- --_. _.-

_ +

Note: Coyemge for up to 40 visits per Plan fC'oIr whell conditions are met for

phrskal.spccch, occllp.1tionalthcr:ll)ics and for Clrdiac rehabilitation.

INDE.'\.I:'<lIfY OPTIONS BASIC AND PR:E.\lIER
Tbe Pltm Pays:
Note: PPO note to the left also applies heft:_

BWECHOlCE
Tbe Plan PtIJ's:

liMO OPTIONS
CIGNA

The Piau Pays:

The Plan Pays, .

UNrrEDHEALUlCARE
nJe Plall Pays,

Each HMO Option m:lY offer vision care discounts or benefits. Contact the HMO directly foe more information.

90% of lit suhje<.:t 10 deductible

100%

100%

100% after:1 $;0 pee trip co-pllyment when
medically ne<.:essary

100%

90% of IR: suhject to deductible
90% of IR: subject to deductible
Note: PPO notes to Ihe left also apply heft:.

100% aIler 52; co-payment, referral required
100%; up to 120 visits
per Plan year

100% :Lftcr $25 <.:o-payment
100%; tIp to 120 visits
pCI' Plan year

100% after $30 co-payment
100%;
up to 120 visits per Plan rear

100% after 525 co-pa)'men!
100%;
up to 120 visits per Plan year

Not co\'(:rcd
100% of lit liP to l\'kdit:are's appron:d lifclime maximum;
subject to deductible

100%;
prior approval required, up to 4; days
per Plan year

100%:
prior approval required, up to 45 days
per Plan year

100%; prior approval
required, IIp to 45 days per Plan year

100%;
prior approval required,lIp to 120 days
per Plan year

100%; prior approval
required

100%; prior approv:11
required

100%;
prior approval required

100%;
prior approval required

90% of IR: subje<.'t to <.kductible
90% of IR; subject to deductible
Note: PPO note to Ihe left also applies here_

100% when medically necessary
100% after 20 per visit co-payment; lip to 40 visits per
Plan yc..-..r

100% when medically necessary

100% when medically necessary

100% when medically ncc<."SSaf)

100% after $20 per visit co-payment; up 10 40 visits per
Plan rear

100% after $20 per \'isit co-pa}'rnent; up to 40 visits per Plan year or up to two consecutive months per condition,
whiche\'cr is more

100% after $20 per visit co-paymcnt; up to 40 visits per
Plan year

a ( Ch<l"/ com/nlle,/ pl/.,:l4

PPO AND PPO CHOICE OPTIONS - BASIC AND PREMIER
PPO OI'TION InNetwork/Olit-of-Statc

Chiropractic Care
Note: Cover:tge for lip to a maximum of 40 visits per Plan year.

90% of NR;
subjt:ct ro d<.-Oucrible ami
$20 per \'isil co-payment

80% of NR; subject to deductible and $20 per visil co-payment

60%ofOONR; subject to deductible

Transplant Services

90% of Nit; subjecl to deductible al lJnicare contracted
network facilit y

90% of NR; subject to deductible at Unican: contracted
nctwork f.tcilit)'

60% of NR; subject to deductible
and balance billing

Note: Services provid(~d through Unic.trc Centers of Excellence for PPO and Imkmnity.

IMPORTANT PPO AND INDEMNITY CONSIDERATIONS

See the Summary Plan Description and Updalels for coverage details, including limitations and exclusions.
~ Ch;trges [rom non-participating provi(krs are subject to balance billing.Thesc charges arc the member's responsibility and do not ("Olllll toward deductiblcs or omof-pocket spending limits.

~ Serviccs cov(OrC{IUlldcr the PPO fmlll;1I1 In-Network/Georgia provider will apply only to the In-Network/Georgia de<.\uclihle :1ll{1 out-or-pockct limit.
~ Scrviccs covcrc<.\ under the PPO from In;\knvork/Om-of-Sratc and Out-of-Network providers apply 10 tbe same deductihle.
~ I.lfctil11e henefit maximums :trc combined totals among the PPO Options_ Indemnity Option :l1ld HMO Options (except KaisLT Pcrl11:tnente).

~ Some PPO annual maximums and limitations are combined totals_

~ Annual dollar and visit Iimilations, dcdm:lihles and ollt-ol:pocket spending limits are based on a July I to June 30 Plan year.
~ Some sen'iees may require Mep prcccrtiticatioll, prior approval or lcuers of medical necessity before such services arc covered.

~ Co-payments do not apply toward deductibles or Ollt-ot~pocket limits ullkss otherwise noted,
~ Exclusions and limitations vary :11ll0ng Plan options. Contact specitic Plan option Cor more information.

* Nn "" N<:twork Hate for in-network PPO Serviu:s DONn = OUI..()f~Netw()rk Hate for ollt-ol:nctwork PPO services IR "" lndcmnity I{ate for Indcmnity services

BI.UECHOICE

HMO OPTIONS
CIGNA

UNITEDHEALn ICARE

90'X, of IR: subject to (kuuctiblc
90% of Nit at comractl.."d facility:
60% NI{ subject to 5100 hospital deductible
Note: PPO notc to the left also applies hen:.

100% after

100% after

1000Xi after

100')(, aftn

$20 co-payment per $20 eo-paylllc..:nt pc..:r $20 co-payment per S20 co-payment per

visit; limited to 20 visits \'isit: limitc..:d to 20 visits visit; limited to 20 visits visit: limited to 20 \'isits

per Plan ~'ear

per Plan year

per Pbn year

per Plan year

100%

100%

100%

100%

IMPORTA:'<rlT HMO CO:\SIDERATIONS
... Annual dollar anu \'isit limitations arc based on a July 1 to June 30 Plan )'1."3r.
... Some services may require prior atHhori....1IiOn by the 1-[\10 before such services arc cO\"Crcd.AJso. some services may have limil:llions not cOlllainl."d in this summary.
... Most HMOs require the selection of:l primary ("Ire physician (PCP) to manage your Glre. Failure to specify a pcp could delay receipt of your ID card. HO\\'c\Ter. in somc instances the 1iJ.\'0 assigns YOll a PCP 10000dtC'd ncar your residcnce if a PCP is not specified. Note: UnitedHealthcarc docs not rc..:quire the selection of a PCP.
... Most HMOs require you to obtain refcrr:lls to sec most specialists. Failure to ohtain a referral could resuh in denial of)'uur claim. Note: Unitedl-lealthcarc dues not require a referntl for cover.lge of specialist scn'ices.
... ComaCI the HMO directly for more dct:lils reg;lf(.Iing covered sen'ices, exclusions and limimtions.

D PHARMACY
BENEFIT OPTIONS

... PPO Basic ... PPO Premier ... PPO Choice Basic

... PPO Choice Premier ... Indemnity Basic ... Indemnity Premier

WHAT A~E THE DIFFEIHNCES BETWEEN THE BASIC AND PREMIER PHARMACY OPTIONS?
Thne are three differences between the Basic and Premier prescription benefits:
... The 13asic Preferred Drug List (POL) is not as cxtr.:nsive as the Premier Preferred Drug List;
... The co-payments are different (see the Pharmacy Benefit Comparison chart on the next page); and
.. There are no Maximum Out-or-Pocket (MOP) limits for the Basic Pharmacy Options. (see the Pharmacy Benefit Comparison chart)

Before making your choice, review the 1'1'0, PPO Choice, Indemnity Plan Overviews and the Pharmacy Benefit Comparison chart.

PLAN PROvISIONS FOR THE BASIC
AND PREMIER OniONS
Progressive Drug Mallagemellt Program (PDMP) This progro.lill has been designed to assist your doctor in finuing the most appropriate drug treatment for you and your f:l1nily.The first step in the program is usually a proven less expensive treatment known to be safe and effeclive for most people. If the drug does not work for you, your doctor may progress to another drug.A Prior Authorization may be requireu as the next step in the program to obtain the drug that is best suited for you. Progressive Drug i\Ianagement helps to ensure that you are receiving the most appropriate and COSt effective drug for your condition. The POMP is in effect for the following therapeutic caregories:ACE Inhibitors, Brand NSAII), EliddlProtopic and Glucophage XR. Notr: This list is 5lIbjec! 10 c!Jlmge during ,he Pltln )'fllr.

Note: If you should go to the pharmacy and are told that your prescription cannot be ftIled because a prior authorization is required, please have your doctor call with your clinical information to Express Scripts, lnc.'s (ES['s) prior authorization unit.The prior authorization process is a telephonic process where your doctor can give your clinical information over the phone for review. If the information provided by your uoctor does not meet the criteria for the drug requested, yOll are entitled to appeal. Your physician will nced to fax a written request to 1:.5l's appeals unit that shoulu include your medical history and all previollsly llsed drugs to treat yOllr particular condition.
HEALTH MAINTENANCE ORGANIZATIONS (HMOs)
'" Generic co-payments are different from the PPO and IJl(lemllity Plan Oplions
'" No Maximum OLlt-ot~Pocket (MOP) limit tcature
'" Maintenance Drugs may be obtained for lip to a 90-day slIpply of your prescription(s) for two (2) co-payments. Note: Kaiser: one co-payment per 30day supply.
'" ContaCl respective HMO tor hlrther Plan provisions. See the inside cover lor telephone numbers and Web site addresses.
ALL PLAN OPTIONS
'" No co-payments for drugs that are covered by the SHBP will be changed or overridden on an individual basis.
111 addition, many dmgs listed as non-prctl.:rrcd have a generic or preferred brand-name drug alternative. Preferred drug alternatives arc therapeutically equivalent while being more cost effective.
'" If the drug cost is less than the co-payment, you do not pay the co-payment but the lesser of, which is the actual cost of the drug. For example, if the preferred drLl~ cost is $18.23, and the preferred drug copayment is 525.00, you will only pay SItU:').

PPO Basic PPO Choke Basic
Indemnity Basic
PPO Premier PPO Choice Premier
Indemnity Premier
HMO's - BlueChoice CIGNA UniledHealthcare Kaiser Pennanente

n:LSic (Sl."e

510

page 28 for

abbreviatcd POL

Uasic (see

SIO

page 28 for

abbrc\'iated PDL

Premier (see

51')

page 29 for

abbre\'iated POL

Premier (see

515

page 29 for

abbreviated I>OL

HMO Onlg List

510

S-'-,

S40

Does not apply

S-'-,

540

J::k>es not apply

5-'-,

-2()'\, of l:ost:

S450 per member,

minimum 540.

S 1.300 family

maximum 5100

S,--,

-200(, of cost:

5i50 per membt-r.

minimum 540.

5 LjOO r.1mily

maximum S100

S,--,

540

Does 110t apply

Kaiser Drug Ust

,
Kaiser: Eckerd r.1.cility: Drugs
510 : 516

Kail>Cr f:lcility
525

Eckert! Dntgs
Sjl

Does not apply

Does not apply

-Note: Tbe NOli-Preferred n,.,md Cu-PaJ'",eut does 110/ apply 10 IlJe QI/l".,erfy MaximulIl OUI-of-Pocket. Please COIl fact C?acb HMO regarding pharmacy lists - BlueCboice (800) 464-1367: ClGNA (ROO) 564-7642; KlIisel' Pemulllellle (800) 6/ /-/8/ I; Ullitedl/eallbcare (866) 527-9599

BASIC AND PREMIER PREFERRED DRUG LISTS
~ Tht: pharmacy drug lists ;lre created, reviewed and COl1\illually updated by a team of healthc;\re professionals including physicians and pharmacists.
~ A medication becomes a prdnrcd drug based first on dficaq', then safcty and last on cost-tlfectivcncss.
~ Your doctor c:ln usc the list associated with your chosen option to select medications for your he;lhhcarc needs, while helping you maximize your prescription drug bendit.The choice of medications is strictly between you and your doctor.

~ Preferred Drug LislS for the SHBP members are subjeel to change. Prior co purchasing your medkation(s) y011 may view the drug lists at www.dch.st:Lle.ga.usorcontact Express Scripts by phone:1( (Rn) 65()-9j42 orTDD (800) 842-5754 to gel the most current st;ltUS on any covered drug. On the following pages is an abbre\'iau:d v(. rsion of the two drug lists for comparison. Use these lists to help rou determine what yOllr co-payments will he and to evaluate which drug benefit will beSt meet rour needs.

GEORGIA BASIC PREFERRED DRUG LIST (ABBREVIATED)
EFFECTIVE JULY 1, 2004
FOR STATE HEALTH BENEFIT PLAN - PPO AND INDEMNITY HEALTH PLANS All generics are considered preferred drugs (cxampks listed in each category). If at any time during the Plan year a
brand has a generic equivalent become available, that brand \vill automatically be moved to the non-prd't:rrnl status.

KH
PA _ prior authorization re~uired QLl - quantity or therapy limits exist

ALLERGY!RESPIRATQRY ADVAIR DI$KUS, Qtt albuterol generic, Qtt
f\LLEGRA, -0, Qtt COMBIVENT, Qtt
FlOVENT ROTADISK, QI.L FORArJIL, QLl INTAL, Qtt
ipratrolJium gerleric, Qtt PROV NTIL HFA, Qtt
QVAR, QU. SEREVENT DISKUS, Qtt SINGULAIR
ANTIINFECTIVES Jcyclovir gClwric ,tnlOxicillin generic C1moxicillinldavulanic generic ,unpicillin generic AUGMENl'IN ($ AUG.'v\NTlN XI{, QLL AV[lOX, ABC PACK cefllroxime generic cephJJcxin generic C1PRO LJnUCAN, PA doxvcycline generic erylhrofllycirl generic keloconJ7.01c gcneric nilroiurrl,llain generic penicillin generic SrORANOX, QLl. lOA TEQUIN tetracycline genl'ric lilllelhoprim generic tmp/smx gerlCric ZITHROMAX
AUTONOMIC & CNS AMIlIEN, QLl Jmitriptyline generic CELEXA CONCERTA rlexlroamphelamine generic
f'AJge> 11 EfHXOR, -XR f1uoxeline generic IMITREX. ()LL
LUAI-'RO MET/\D/\TE CD lJlelhylphenicbte generic rllirtnJpine generic pJfQxetlnc generic I-',\XIL CR
REMERON soltJb SONATA. QU. STRATTERA Il'mazepam generic tr<lzoJone generic WHLBUTRIN 5R lOMIG, -ZJ\H. QLL

GASTROINTESTINAL ASACOL cilllelidine generic faillolirline generic nizJtidine generic omepra7.0le generic QlL. PA rENtASA f'REVACID. QLL PA PREVPAC QLL r,mitidine generic suhasalazine generic
CARDIOVASCULAR ADVICOR Jlenolol.seneric AVALlO[ AVAPRO bi,oprolol generic bisoprololw/hc1Z generic. chlorthalidone generic c!onidine generic COREG CRESTOR diltiJlem, er generic DIOVAN, HCT en,llapril generic enal~lpril w/helz generic gerllllbrOLri generiC hydrochlorothiazide generic INNOI-'Rf\N XL LlPITOR lisinopril generic lisinopril w/hclz generic l.OTE~"SIN IICT LOTR[L lov;151alil1 "elleric metoprolof tJrlrJle generic mocxiprrl generiC NIASPAN niiedipine er generic NORVASC propranolol generic lerzosin generic verapJmfl generic verapJrnil. xr generic lAROXOLYN ZETlA, PA
ENDOCRINE I\CTONEL QLL ACTOS, Ql.l AVANOAMET AVANDIA, QLl DIDRONEL EVIST/\ FORTEO, PA F05AMAX, QLL glipizide generic

glyburirle generic IIUMALOG HUMUllN LANTUS metformin generic NOVOLl,,,, NOVOlOG PR/\NDIN pRECOSE 5TARLIX tolazJmide generic lolblilamide generic
OBSTETRICAL/ GYNECOLOGICAL ESCLlM, QLL eSlradiol generic FEMI-IRT mearoxyprogesterone generic ORTHO EVRA. QLL ORTHO TRI-CYCI.EN LO PREMARIN PREMPIIASE PREMPRO YASMIN

EAR_NOSE_THROAT ASHLIN, Ql.L FlONASE, QLL NASON EX, QlL
UROLOGICAl. DETROl., -I.A oxybUlynin generic AVODART EDEX, QLL PA FLOMAX VIAGRA, QLL, f'A
MUSCULOSKELETAl, diclofenac sodium generic ibuprofen generic: indomethacin generic nabumelone generic rlapmxen generic VIOXX, QLL choline mag lrisJlicylale
generic dillllnisal generic satsalatc gerlCric

AUEWr<.',\lIVE PRODUCT lISTI~G row NON_PUf,WUO RWM,llS

NOr<.'-PWlfERRED BRAND

Sf.lECTW AlHRNATlvr B~A"os

Accolate

_. Singulair

Accupril,

__ lisinopril

I\ciphex

. , omerrazole, Prevacid

AClivelb

, .. , .. , FemHRl Prempro. Pre.n:ph;l5~

Altace

" .. , .. , ... , ... , .. , .. , ... I,slIlopfil

AtacanJ,

__ .. _. , . _.. Avapro, DiovJrl

Biaxin, -XL,

__ erylhromycin, Zilhrom,lX

C1arinex

.,

, Allergra

COl,lar., ... , .. , , .. , .. , , .. , ,Avapm, DiO\'an

l-IyzaJr .. , , .. , .. , , .. , , . AV;llide. Diovan I-ICT

Mi\xJlt, -MLT, _. , .. , .. , , .. , , Imilrcx, Zornig. -lMT

Mobic _

. generic NSAIOs

Nexium

..

. om~lxazole, P~evi\ciJ

I-'Iendil,

. , .. , , . JlI eOlplne, ~orV;lSC

Pmtol1ix. " .. "." .. " .. , onHo'prMole, PrevJcid

Pulmicort _

_____ __. Flovenl, QVAR

SlIlJ( . Zocor _.

. , __ . __ nifedipine l'.'orV,lSC
. .. lovaslalin, Cresl~r, lipilor

Zalait, .. , .. filioxetine, paroxetine, Lexdpro, r,lxi! CR

Zyrtec.

_. Allegra

For I'rlor Authorizat;ons (PA), Quamity l.e,-e1LJm;{s (QLL) or any questions regarding spedtle eover..ge rules or co_payment information for dn,gs 110t listed on (his document, please eontae' F_"pn"'s s<::rlpts, Inc. at 1877(;509342.

Iln'i'cd April 7. 100..J I 'lJJi.~ IW i.~ SIII?/"'-1 10 clJtIII6C 1/1 Ilw disC/rtfaJi o/I/.><, n't'" rill/('Ill of CrJIIlI!ll1!! II)' }-Jc"IIIJ.

GEORGIA PREMIER PREFERRED DRUG LIST (ABBREVIATED)
EFI'IOCTIVE JULY 1, 2004 FOR STATE HEALTH BENEFIT PLANS - PPO AND INDEMNITY HEALTH PLANS AU j.:cncrics arc considcrt:d prdcrn:d drugs (examples listed in !.-'lell cau:gory).lf:1( any lime during the Plan year a br.uuf h:L<; a generic equiv';.l!clll be...-come :n';liJahle, that brand will autOm:uically be movnl to the non-preferred status.

KfY
PA - prior authorization reljuired Qtl - quantity or therapy limits exist

ALJ.ERGY/RF.SPIRATORY ADVAIR OISKUS, QLI dlbulCl'ol generic, Qt.l AllEGRA, -il, Qt.l COMHtVEI\.T, Qtl cromolyn sodium generic FLOVENT, -ROTADISK. Qll FORADll. QU. ipr~tropillm generic. QLl MAXAIR AUTO' IAI.ER, QLt mCI;Jprorcrcoolllcncric. QtL PROVENTIL HFA, Qtl PUL\t\ICORT RESPUL(S, QLl SINGULAIR TlLADE, Qll ZVRTEC, Qll
ANTI-INFECl'IVES 'llyclovir generic amlJxicillirl generic amoxkillin/c1,l\Iul.lnic generic ampicillin gcncril
AUGMENT" ER AUG.'.IE1\'TIN X~, Qll AVELOX
ccfuroxime gCI'IC.>fic CEFZll cephalexin generic CIPRO CIPRO XR, QlL DIFlUC,\N 150...tG, QLl DIFtUCAr-., PA
doxycyclirw; generk. erythromyCIn genC'f1C GANTRISIN PEDIATlUC grb;cofulvin gcnl>fic I{eloconilzole gelll..>fic LAMISI1, P/\ MACROlllD penicillin generil: SPECTRACEF SPQRANOX Qll, P,\ lelrilcycline generiC Ifl1JYsm)( generic VALTR[)(, Qtl lITHROMAX
AUTONOMIC & eNS ADDERALI XR, PA age >2 I Jlprawlilnl generic AMIlIEN, QLL amitripTyline gCrlC'fk bupropion generic buspirooe generic CONCERTA desiPfamine generic de)(lro.lmphe!amme generic,
PAage>21 dial.('pilm generil EfFEXQR, .. XR
fluoxclinc generic imipramine generic lMITREX, Qtt LEXAPRO IOfazcpam generic MIGRANAl, Qtt nortriplrlinc generic oxal.qJam generic paroxCline generic Irazodonc generic lriazul.lm generic

WHlBUTRIN..Xl lOtOH lOMIG, -ZMT, Qtt
GASTROINTESTINAL ASACOt AZUlFID1NE EN,TAB cimctidine generic far'lotiuine generic omeprazule generic QLL, PA PANCREASE pancrelipase generic PEr-.'iASA PREVACID QlL PA PREVPAC, Qtl PIl:QCTOFOAM-HC ranitirlinc generic ROWASA ,ucralf.lle generic UI<:SO VIOKASE ZANTAC SYRUP
CARDIOVASCULAR ADVICOR AtTACE alcnolol generic henazepnl generic ben.ll.eprililictz ger'lcric (,lploprd generic CARDIZEM lA CATAPRES-rrs, QLl chol('Slyraminc generic COREG COZAAR dil!iilzem, sa generic OIOVAN. -ITCT en,11.1pril generic furosemide generic gem/ibro?il gwerir. Fiydrochlorothaizide generic 11YZAAR LEVATOl tEXXEl lIPITOR liSlnopril generic Iislflopril wihdz generic lOTREL IOVilst,ltin generic mClOl.lzonc gerleric meloprulol generic NIASPAN nicarrlipine generic lli(edipmc. cr, xl generic NIMOTOt> r-.ORVASC PI<:AVACHOt prazosin generic propr,lnorol generic spironolactone generic lcrawsin gem'ric TOI'ROL Xl IOfscmirle gCrlt'lic TRrCOR vcr<lpamil, xr generic ZOCO!<
F.NDOCRINF. ACTOS, QLL AMARYL AVANDIA, QLt

DDAVP NASAL [VISTA FOSA,\1AX, QlL glipizirlc cr ~ic
glybundc micronized generic
GlYSET t-lUMAtOG HUMULIN IN,nUS
mclformin MIACAlCIN NOVOLIN NOVOlOG PRANDIN
PRECOSE STARLIX 10J,1Zamide generic
tolbutamide generic
08STETRICAL!
GYNECOI.OGICAI. COMBlPATCH ESTRADERM PATCH, Qtl ESTRATEST, HS eslradiol patch genefic, Qtt estropipate generic ESTROSTEP FE FEMHRT
1nc<lroxvprogCSlcrone gencri( MEN ESt NUVARING ORTHO EVRA. QLl ORTHO TRI-CYCLN LO PREMARIN PREMPH!\S

PI<:EMPRO VIVEllE. -DOT. QLl
EAR-:"l'OSETHRo..n ASHLIN, Qll FtOr-.'ASE AQ, Qtt NASONEX, Qll
UROLOGICAl. DHROt, -LA OITROPAN Xt EDEX QtL, PA FlOMAX oxybut'l'nin gcoeril:
""OSCAR VIACRA QLL, PA
MUSCULOSKELETAL ARTHROTEC CEI.EBREX, Ql.l didolenal: generic f~rofcn generic i1urbiproicn generic indomethacin generil:
ketoproien generic
medofcnamale generic nilbumelonc generic nal)roxen generic piroxicam generic sul;ndac gentric lolmeTin gcneric VIOXX, QLl

ALTUINAllVI PRODUCT ll>TING tOR NON-PREHRR(() BRANDS

NON-PREfERRED BRAN!)

SHlCTEO ALTERNATII/E BRANDS

Aceon.

ben,n(,'pril. lisinopril, Ahace

Aciphex . . .

.

olneprazole, Pr('Vacid

Accolate . .

.

, .. Singulair

Accupri! , , .

bcnazeprit lisinopril, AllilCl'

Adillclla ....... , . _ .. f'rempro, ~<ISC

Adone! . . . .

. Mam<lx, MiKillein

Alacanrl. .

. ... Cozaar, Diovan

Kiaxin, -Xl

~1hrolnycin, Zilhromax

Celexa . .

, nuoxeline, paroxetine, Lcxapro. Zolo!l

Clarinex, .

. .. . ..... " . . Alle-rwa, Zyrtec

LescoJ, -XL.

. IOl/astalin, lipilor. Pral/Olchol, Zocor

Mal/ik. .

. ..... bcnazcpril, lisinopril, Ahace

Maxalt, -MLT.

. .. , lmilrex, ZomiF,. -Z,\.1T

MoIlic. , , . .

. , , ., generic NSAIDs

Nexium . . .

omq>razolc, PreYa<:id

J Plendil. . . . .

.

nilf"dipine, Norvasc

Prolonix . . .

.

omeprazole, Prevacid

PulmiOOI1., - ... " . - . , ,. .. -". Flovent

Screvenl , .

.

Faradil

Sular .

. nife'<.1ipine. Norvasc

Tcvelen

, .. , _Cozaar, Diol/i1n

for Prior AUlhorizalions (PA), Quantity ~cl1lmi1S (Qtl.) or .11)' queslions rq;arding spL"Cifk CO"Cr:>gc:: ruk:-!; or ro--p")'In~m inform:,,;on for dnll!lS nOI Lisle<! on tJili; document. pkase CQnl:K:t F.xpress Scrlpt-s, Inc. at 1-8776509342.

Rc\iSl"ll "prj! -. 11111-1 I This list I,: slIlJjt'a If} ('millS<' (I/ 11)<' diS('Tf'II'oll of rhe IJ<tH/rlll/ellt 0/ CfJllJlm/llit), Ht'{,frb.

o SERVICE AREAS
FOR YOUR HI"\I.TH PLAN OPTIONS

SERVICE AREAS
Service areas are Sratc-:lppmvcd geographic areas, such as counties or zip codes, where providers participate in Ihe network offered by the Plan option in which yOll han: enrolled.
PPO AND PPO CHOICE OPTIONS -
BASIC AND PREMIER
GeOlogia Service A"ell The Georgia service arc;. includes the state of
Georgia and the border communities of the Chattanooga, Tennessee area, including Bradle}' County; and Phenix Citr.Alahama.The zip code area in which yOll receive a service is llsed 10 (klermin<.~ whether or not rOll arc.: in the Georgia service area. If rOll receive con:rcd sen-ices from a lSI: Medical Nc:twork provider kx.-aled in onc of Ihe 7ip codes to the righl. yuu receive the highest level of con~r.tge .",ailable in the PPO Options.
OUI-o/-SllIle/NalioulI/ Service Area The out-of-state service area includes all national locations oursidc Of the Georgia service art.:a described to the right. By \lsin~ Beech Street pro\'iders outside of the Georgia servicl.: area, you are protected against bal:ll1ce biJling (being charged more than what tht' Plan allows). Howc'-cr, use of Beech Street pro'klers inside the Georgia service area is considered OUl-of-nelwork care with lower k\"e1s of coverage and separate deductibles, unlc..-ss the provider also is a 1:;1 Medical Network participant.

GEORGIA:
All counties; all zip codes
AtABAMA:
Russell County (Phenix City area): 36851, 36856, 36858, 36859, 36860, 36867, 36868, 36869, 36870, 36871 and 36875.
TENNESSEE:
Bradley County (Cleveland area): 37310, 3731 1,37312,37320,37323,37353 and 37364.
Hamilton County (Chattanooga area):
37302,37304,37308,37315,37341, 37343,37350,37351,37363,37373,
37377,37379,37384,37401,37402, 37403,37404,37405,37406,37407, 37408,37409,37410,37411,37412, 37414,37415,37416,37419,37421, 37422,37424 and 37450.

HMO OPTIONS
You must live or work in the HMO's approved sen:i.cc area (Q be eligible for co\'(~rage under th:u option. (klow are the HMO Option sc:n'ice an:;IS b)' county If you live or work in a count)' marked ~Ycs' under any of the HMOs listed, you rna)' enroll in that I-IMO. If the count)' where rOll live or work is not listed bdow, YOll are not eligible for HMO covemgc.

COUNTY OF RESlDENCE
Appling Atkinson Bacon Ibnks Barrow Bartow Ben Hill .Berrien Bibb BIeckJe)' Brooks Bryan Bulloch Burke Buus Candle.:r Carroll Catoosa Chatham Chattahoochee Chauooga Cherokee Clarke Clayton Clinch

BltlECHOICE
Not Available Not Available Not Available
Ye,
Yes
Ye,
Not Available Not AV'dilable
yO' Yes Not Available Ye, Yes Ye, Yes Not Available yO' Not Available yO' Yes Yes Ye> Yes Y", Not Available

CIG~A
yO' Not Available
Yes Not Available
Yes Yes Not Available Not Amilablc
Ye,
Yes Not Available
Y",
Yes Yes
Ye,
Yes Not Available
Yes
Yes Not Availahle
Yes Yes
Yes
Yes Not Available

KAISER PER\tA:"iE:"1TE
Not Available Not Available Not Available Not Avail:lble
Ye, Ye,
Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available
Yes
Not Available NOI Available Not Available Not Available Not Available Not Available.:
Yes
Not Avail::tble
Ye,
NOt A\':tilable

UStTED H E,\lTHC.4.RE
Yes
'1'<':5
Yes Yes Yes Yes Yes Yes yO'
Y",
Yes Yes Yes Yes Yes Yes
Y",
Yes Yes Yes Yes Yes Yes Yes Yes

COUN1Y OF RESIDENCE
Cohh Colquitt Columbia Cook Cowcta Cmwford O:lde Dawson Dee:llur OeKalb Douglas Early Echols Effingham Bbert Emanuel Evans Fayette floyd Forsyth Franklin Fulton Gilmer Glascock Gordon Grady Greene GwinnClt Habersham Hall Harris Hart Hc...-ard Hcnf)'

BI.Uf.CnQICE
Yes Not Available
Yes Not Available
Yes
Yes Not Available
Yes Not Available
Yes
Yes Not Available NOI Av'.tilablc
Yes
Yes
Yes
Not Available Yes Yes Yes Yes Yes Yes
Yes
Yc...os NOI Available
Yes
Yes NOI Availabk
Yes Yes
Yes
Yes
Yes

CIGNA Yes
Not Avail:tble Yes
Not t\\>ailable Yes
Not Available Yes
NOI Av".tilable NOt Available
Yes Yes Not Available Not A\'":tilablc
Y~
Yes Yes Yes Ycs Yes Yes Ycs
Ye~
1"101 Avail.1bk Not Avail:lbk
Yes 1"101 Available
Yes
Yes
Not Available Yes Yes
Not A\'ail:lble Not A\-ailable
Yes

K,\ISER PERMANENTF.
Ycs Not Available Not Available NOI A\-ailable
Yes Not A\'ailable NOI A\'ailable NOl Available NOI Available
Yes
Yes
Not Available Not Available Not A\':tilable Not Available NOI Availablt: Not Available
Yes
Not Available Yes
Not Available Yes
Not A\-ailable Not Available Not Available 1"101 A\rtilablc 1"101 Available
Yc..."S Not Available
Yes Not Available Not Available Not Available
Yes

UNlTEDHF.ALTlICARE
Yes Yes
Yes
Yes y""
Yes Yes
Yes Yes Yes Yes
Yes
Yes
Yes
Yes Yc...os Ycs Ycs Yes Yes Not Available Yes Nm Available Yes
y~
Yes
Yes
Yes
Ycs Yes Yes Not Available 1"101 A\-ailabJc Yes

COUNTY OF RESIDENCE
HOUSlOn
jackson jasper jefferson jenkins johnson jones L1mar lmlier I..:lllrellS Libelly lincoln Long Lowmk-s Lumpkin Madison Marion McDuffie Meriwcther Mitchell Monroe Morgan l\'luscogtt Newton Oconee Oglethorpe Paulding hadl Pickens Pierce Pike Polk Pulaski Putnam

8LUECnOlCl'
Yes Yes Not A\'ailable Yes Yes Yes Yes Not Available Not Availabk Not Available Yes Yes NOI Available Not Available Yes Yes
Y<~
Yes Yes Not Available Yes Yes Yes Yes Yes Yes Yes Yes Yes Not Available Not Available Ycs Yes NmAvailablc

CIGNA Not AV'::lilablc
Yes Not A\':lilable
Yes Not A\-ailabk Not Available
Yes Yes Not Available Yes Yes Yes Yes Not A\<lilablc Not A\'3i1abh: Y", Yes Yes Not Available Not Available Yes Not Available Yes Yes Yes Yes y", Not A\~di1:lblc NO! Available Not Available Yes Yes NO( Available NO! Available

KAISF.R PEKi\lANF.Nl'f.
Not Available Not Available Not A\"dilable Not A\'ailablc Not Available Not Available Not A\'ailablc Not Available Not Available Not Available Not Availabk Not Available Not Available Not Available Not Available Not Available NotA\'ailablc NO[ Available Not Avail:lble Not Available Not Available Not Available Not Available
Yes Not Available Not Available
Yes Not Avail:lblc Not Available Not Available NotAvailablc Not Available Not Available Not Avaibbk

UNITE(}HEALl HCARE
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ye, Yes Yes Yc, Yes Yes Yes Yt;:s Yc, Yes Yes

COUNTY Of ReSIDENCE
Richmond Rockd:J1e Screven seminole Spalding Stcphens SleWart Talbot Taliaferro ';IIIn:l1l 'nlylur Thomas Tift Toombs Troup Turner Twiggs Upson Walker Walton Ware \Varl't'n W,lshinglOn Wayne \Vhile Whilfield Wilkes Wilkinson Wonh

BLueCIlOI(.E'
Yes
Yes
Not AV"dilable NO! Available
Yes
Not Available Yes Yes
Not Available Not Available Not Available Not Available NotA\'3i1able Not Available Not Available Not Available
Y,..
Not Avotilable Not Available::
Yes Not Available
Ye, Ye,
Not Available
Yes
Not AV"diJable
Ye,
Yes Not Available

CIGNA
Yes Yes Yc.:s Not Available
Yes
Not A\<-dilable Not Available NOl Available Not Available
Yes Ycs Not A\~dilable Not Available Not Available Not Available Not A\'OliJabk Not t\\""dilable Not Available
Ye,
Yes Not Available Not Available Not Available Not Available Not A\"3ilable
Yes
Yes Yes Not Available

KAISER PERMi\NENl'E
Not A\"diJablc Yes
Not Available Not Available
Yes
Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available
Yes NOl Availabk Not Available Not Available Not Available Not Available Not Available Not Available Not Av-dilable Not Available

.
UN lTEOHEAL1'IICARE
Yes Yes
Yes
Yes Yes Yes Ycs Yes Yes YeS Yes Yes Yc:.'i
Ye,
Y<.."S Yes
Ye,
Yes Ye.:s Yes Yes Yes Not Available.: Ye.:s
Y",
Yes
Ycs
Yes Yes

HEALTH I IS RANCE PORTABILITY A 0 ACCOU TABILITY ACT
(HIPAA) ANNUAL NOTICE

This section describes certain rights available to yOli under the Health Insul"'J.llcc Ponabiliry and Accountability Act (HIPAA) when you enroll in the SHBP.
The PPO, PPO Choice and Indcmnil}' Options (Basic and Premier) cOlHain a pre-existing cOlldi~ tion (PEe) limitatioll. Specifically, the Health Plan will not pay charges lhal arc over S.I ,000 for the treatmcm of any pre-exisling condilion during the first 12 months of a patient's coverage, unless the patiem gives satisfactory documentation that he or sht: has been free of treatment or medicat.ion for that condition for at I~lst six consecutive C'dlendar months. If you are enrolling as a new hire, this 12-month period begins on your hire dale. However, a I>re-existing condition limitation does not apply to coverage for:
~ Pregnancy; Of
~ Newborns or children under age 18 who are adopted or placed for adoplion. if the child becomes covered widlin 31 days after birth, adoplion or placemem for adoption.
In cerlain situations, SHBP members and dependents can reduce the 12-mOlllh pre-existing condition limitation period. The reduction is possible by using what is called ~credit'able coverage" to offset a pre-exisling condilion period, Creditable coverage generall)' includes the health coverage yOll or a f:mlily member hOld immediately prior (0 joining the SIIBP Cover:lge undc.:r most group healtll plans. as well as coverage under individual health policies and gO\'emmelllal health programs, qualifies as creditable covernge.
To redu<:c the pre-existing condition Iimilalion period for your own covemge, you m1lst provide the SHIlP with a certificate of credit:lble coverage from one or more former heahh pbns or insurers that states when rour prior covernge staned and

endcd.Any period of prior Covcr:lge will reduce the 12-month limitation period if the limt: between losing coverage and your first da)' of SHBP covemge does nUl exceed 63 days. If you are enrolling as a new hire, the 63-day period is nH;:asured from your last day of prior cover:lge up 10 your dale of hire.
To reduce the prc-cxisling condition Limil<llion peri<X! for your dependents (including your spousc), you mUSl prO\'ide the SHBP with a eenilil".ate of crediL'tbk coverage stating when coverage started and ended for each dependent Ihal you wallI to COVCl'. Again, ,Illy period of prior coverage for that dependem will reduce the 12-monrh limiL:llion
period if no more lhan 63 days h:I\'c elapsed
between the dependent's loss of prior covcrnge and lhe first day of Covt:r;:lge under Ihe SI-IBr (or your date of hire, if you are enrolling as " nnv hire::).
If yOll or a dc.:pendel1t (including a spouse) had any hR"ak in cO\'erage lasting mOrt: than 63 days, yOLi or your t1epclldem will rccei\'e creditable coverage only for the period of liml after the break ended.
Within twO years after your fonner con:ragc tnmin:ued, yOll have the right 10 ohtain ,I certificale of creditable co\'er:lgc from your former cmp[oyt:r(s) to offSCi the prc-c.xisting condition limitation pcrilXi under the simp TIle $1 iUP will evalu:nl' rour cenificalc of crcdirable Co\'(;r:lge or othcr documentation to dctermine whether any of the pre-existing condition limitation period \v1l1 be reduced or eliminated. After eomplcling the evalualion, the SI-IUP will notify rou as lO how the pre-existing condition limit:llion period will be reduced or eliminated.
Please submit your certificate of creditable coverage to the Plan with your enrolJmcnt paperwork. If you rc(}uire assistance in obtaining a letter from a former employer, contact your pcrsonneJlpayroll office,

o DEPARTMENT OF COMMUNITY HEAl.TH PRIVACY NOTICE

This notice describes how medical informalion about you may be used and disclosed and how you can get access (0 this information. Please review it carefully.
THE PLAN'S PRIVACY COMMITMENT TO You
The Georgia Depanmcl1t Of Community Health (DeH) understands that information about you and your tlmily is personal. OCH is committed 10 protecting your information. This IlOliCl~ tdls yOll how DCH uses and discloses information about you. It {clls )'Otl your fights and tht: Plan's requirements about your information.
UNDERSTANDING THE TYPE Of INFORMATION THAT THE PLAN HAS
YOllf employer (state agem.:)', schoo] system, amhority, etc.) sent information about you to DCH.This information included your name, address, birth date, phone number, Social Security Number and otlll;( health insurance policies that you may havc. It may also have included health information. When your healthcare providers send claims to the Plan's claim administr.ltor for payment, the c1aim.s include your diagnoses and the medic:ll treatments yOll received. For some medical treatments, your healthcare providers send additional medical information to the Plan such as doctor's statements, x-rays or lab lest results.
YOUR HEALTH INFORMATION RIGHTS
You have the following rights regarding the health information that DCH has about you_
.. You have the right to SCe and obtain a copy of your health information.An exception is psychotherapy notes. Another exception is information that is needed for a legal action relating to OCH.
.. YOll have the right ro aSk OCH to change health inform:uion that is incorrect or incomplete. DCH m:l)' dcny your request under certain circumst:mces.

.. YOll have the right to request :l list of the disdosures that DCH has made of your health information beginning in April 2003.
.. YOll have the right [Q requcst a rcstriction on certain uses or disclosurcs of your health information. DeH is not reqllin;d lO agree with your request.
.. You have the right to request that DCH communicates with you about your health in a way or at a location that will help you keep your inform:ltioll (:onfidcIUial.
.. YOll have the right (() receive a paper copy of this notice. YOll 1ll:IY :lsk DCH staff to give you another copy of this noticc, 01' you may obtain a copy from DeH's Web sile, www.dch.state.ga.lIs (dick on "Privacy").
PRIVACY LAW'S REQUIREMENTS
Deli is required by law to:
.. Maintain the priv:lCy of your infonn:ltion.
.. Give yOll this llotice of DeII's Ieg:11 dulies :lnd privacy practices regarding the information that Dell has about yOli.
.. Follow the terms of this Ilotice.
.. Not use or disclose any information about you without rour wrinen permission, except for the reasons givc.:n in this notice. You may take away your permission at any time. in writing, except for the information that DeH disclosed before yOll Stopped your permission. If yOll cannot give your permission due to an emergency, DCII Illa)' release the information if it is in your best illleresl. DCB lllUSt notify you :IS soon as possible after releasing the information.
[11 the future, DCB may change its privacy practices. If ilS privacy pr:l<:tiCes change significantly. DCH will provide :t new nOli<:c to yOLl. DCH will post tbe new notice on its Wcb site at www,dch.stat(,~.g:t.llS (dick on "Privacy"). This notice is effective April 14.200:;.

How DCH USES i\NO DISCLOSI:S
HEAtTllCARE r:'~FORMATlON
TIler(' are some services the Plan provides through contr.l<:IS with prh'atc companies, 1;01' exampit:. Bllll' Cross and Blue Shield of Georgia pays most mediC::11 c1;lims 10 your healthcan: pro\'iders, \'('hen serykes arc COntrdClecL the Pl:ln ma), disclose some or all of your information 10 the compan}' so Ihat the)' f...m perform the job Ihe Pl:m has asked Ihem to do.To pmteCI yOur iitlormaiion, Ihe P\;m requires Ihe comp:m}' to safeguard rour information in accordance with the law,
TIn.' following cllegories descrilx different wars thai the Plan uses and discloses your health informal ion, For each f....ltcgor~f, we will explain what we llle;m and gil'e an example,
FOR PAYMENT
'111e Plan Ill:l}' LIS(: and disclose information about }'ou so that it C:lIl authorize payment for the hc:altll serviCes that you received. For exampfl', WhCll rou receive a service co\'ered by the Plan, rOllr he:dthearl' provider sends a claim for paynlt::nl to tlu.: claims adruirlistr.ltor. The claim inchrdes information lll;ll idcnli.tks rOll, as wt::11 as your dia~l1oses and lreatmcnls,

FOK MEDICAL TIHAHH .... T
Tht:: Plan m:l)' lise or disclose informaLion aoom rou to ensure that you receive necessary medicd! trt:::llmel1l and services. For example. if rou panicipate in a Disease St:lte ~Ianagcmcnt Program, the Plan may senti rou iJtlonnation aboul rour condiLion.
To OPERATE VARIOt;S PLAN PROGRAMS
TIlC Plan ma)' use or disclose information aboUI rOll 10 run various Plan p~rams :llld ellsun: lhal rou rccci\'e quality eire. For example,thc Plan may contract with a comp;lJ1y that rt.'views hospital records [0 check on Ihe qualily of C:lre (hat YOll rect:i\'etl amJ Ihe outcome of YOllf care.
To OTHER GOVERNMENT AGENCIES PROVIDING BENEFITS OR SERVICES
The Pl:in may give inform:uion abollt yOll 10 othcr ~Overnlllenl agencies that arc giving YOll bend'its or services. The informatiOll must be necessary for rOll LO recdvc those bend'its or services and will be aUlhOrized b)' rou or hy law,

To KEEP You INFORMED
The Plan may mail you information about your health and well-being. Examples arc information about managing II disease that you have, information about your managed care choices, lind inform:uion abOlit prescription drugs yOli arc t;lking.
FOR OVERSEEING HEALTHCARE PROVIDERS
The Plan may disclose information about you to the government agencies that license and inspect medical facilities, such as hospitals, as required by law.
FOR RESEARCH
The Pl:lIl may disclose information about you for a research project that has been :lpproved by a review boanl.The review board must review the research project :llld its rules co ensure the privacy of your information.Tile research must be for the purpose of helping the Plan.
As REQUIRED BY LAW The Plan will disclose information about you as required by law.

FOR MORE INFORMATION AND TO REPORT A PROBLEM
If yotl have questions and WOuld like additional informlltioll, you may contact the SHBP at (404) 656-6322 (Atlanta calling area) or (800) 610-1863 (outside of AtJanta calling area).
If yOll believe your privaq' rights have been violated:
.. You can me a complainr with the Plan by CalliJlg the SHBP at (404) 656-6322 (Atlanta calling area) or (800) 61().1863 (outside of Atlanta calling area), or by writing to: SHBP - HPU, I~O. Box 38342,ALlanta, GA 30334.
.. YOli can file a compl;tint with the Health and Human Services' Office for Civil Rights b)' writing to: U.S. Department of Health and Human Services Office for Civil Rights, Region TV, Atlanta Federal Center,61 Forsyth Street SW, Suite 3B70,Atlama, GA 30303-8909. Phone (404) 562-7886; rax (404) 5627881; TOO (404) 331-2867.
.. YOll also may cOntaCl the HHS Office for Civil Rights by calling (866) OCRPRJY (866) 627-7748 m (886) 788-4989TIY
There will be no retaliation for filing a complaint.

WOME 'S HEALTH & CANCER RIGHTS ACT
The Plan complies with the Women's Health and Cancer Rights Act of 1998. MastccLOmy, inclmling reconstructive surgery, is covered the same as other surgery under your Plan option.
Following cancn surgery, the slmp covers: ~ AU stages of reconstruction of the breast on
which the mastenomy has been performed. ~ Ikconstnlction of lhe mha bre:lst 10 achieve
a symmetrical appt:'olr:mcc.
~ Prosthescs and masleCLOmy bms. ~ Treatment of physical complications of
mastectomy, including lymphedema.
Notf!: Reconstructive surge')1 requil"(!s prior appro/1t"11 and all inpatient (Idmissions require MCP pl'ecel'tijicatio1/.
For more del:liled information on the mastectomyrelated benefits available under the Plan, yOli can COntact the Member Services llnit for your coverage option.Telephone numbers arc 011 the inside front cover.

o PENALTIES FOR MISREPRESENTATION
If a SHBP participant misrepresents eligibility information when appl)'ing For covcmge, during change of coverage or filing for benefits, the SHBP may lake adverse action against the participant, including but not limited to terminaling coverage (for the panicipant and his or her dcpclldem(s) or imposing liability to the SHOP for fraud or indemnification (reqUiring payment for benefits (0 whicll the participant or his or her beneficiaries were not entitled). Penallks may include a laWSuit, which may rt:slIh i.n payment of charges to the Plan or criminal prosecution in a coun of l:Iw.
In order to avoid enforcement of the penalties.lhe participant must notify lhe Stomp immediately if a depcndem is no longer eligible for coverage or if the participant has questions or reserv:ltions about the eligibility of a dependent.This policy may be enforced to lhe fullest extent of the law.

Disclaimer
This material is for inforn/ational purposes and is 1I0t a contmct.1t is intended only to bigblight prinCipal benefits of tbe mediull plans. Every effort /)(IS been made to be as accurate as possible; 1.JQlvelle'; sbollid there be a difference between tbis InformaNorl and tbe PIa" documents, the Pkm dOCU11Je1Its govem.lt Is the respmlsibifity of each member, active or retired, to read all Plan materials provided in order to fully understand {be provisions of tbe option cboselJ.