RI 70 -13

Revised November 2001

Visit our web site at www.opm.gov/insure

Federal Employees Health Benefits

Enrollee Survey Results and

Benefit Information

Retirement and

Insurance Service
Medical error and patient safety aren't well understood by most Americans. When we need vital or risky

health care services, we want to believe that someone else has made sure that we'll get safe care. Sadly,

every hour, 10 Americans die in a hospital due to avoidable errors; another 50 are disabled. Too many

patients get the wrong medicines, the wrong tests and the wrong diagnosis. By asking questions, learning

more and understanding your risks, you can improve the safety of your own health care, and that of your

family members. Take these simple steps:

1 Speak up if you have questions or concerns. Choose a doctor who you feel comfortable talking to

about your health and treatment. Take a relative or friend with you if this will help you ask questions

and understand the answers. It's okay to ask questions and to expect answers you can understand. 

2 Keep a list of all the medicines you take. Tell your doctor and pharmacist about the medicines that

you take, including over-the-counter medicines such as aspirin, ibuprofen, and dietary supplements like

vitamins and herbals. Tell them about any drug allergies you have. Ask the pharmacist about side effects and

what foods or other things to avoid while taking the medicine. When you get your medicine, read the label,

including warnings. Make sure it is what your doctor ordered, and you know how to use it. If the medicine

looks different than you expected, ask the pharmacist about it. 

3 Make sure you get the results of any test or procedure. Ask your doctor or nurse when and how

you will get the results of tests or procedures. If you do not get them when expected -- in person, on the

phone, or in the mail - don't assume the results are fine. Call your doctor and ask for them. Ask what the

results mean for your care. 

4Talk with your doctor and health care team about your options if you need hospital care. If you

have more than one hospital to choose from, ask your doctor which one has the best care and results for

your condition. Hospitals do a good job of treating a wide range of problems. However, for some procedures

(such as heart bypass surgery), research shows results often are better at hospitals doing a lot of these

procedures. Also, before you leave the hospital, be sure to ask about follow-up care, and be sure you

understand the instructions. 

5 Make sure you understand what will happen if you need surgery. Ask your doctor and surgeon:

Who will take charge of my care while I'm in the hospital? Exactly what will you be doing? How long

will it take? What will happen after the surgery? How can I expect to feel during recovery? Tell the surgeon,

anesthesiologist, and nurses if you have allergies or have ever had a bad reaction to anesthesia. Make sure

you, your doctor, and your surgeon all agree on exactly what will be done during the operation. 

F EHB and You

Patient Safety
Table of Contents

i

The information in this Guide gives you an overview of the FEHB Program and its participating plans.

Before you make any final decisions about health plans, read the plan brochures.

Page:

FEHB and You ....................................................................................................................................1

Getting Information and Selecting a Health Plan

Quality

• Enrollee Survey Results

• Accreditation

Benefits

Cost

How the Plan Works

FEHB Web Resources....................................................................................................................................5

Program Features ............................................................................................................................6

Definitions ........................................................................................................................................7

Plan Comparisons

Nationwide Fee-For-Service Plans Open to All ..................................................................12

Nationwide Fee-For-Service Plans Open Only to Specific Groups ..................................14

Health Maintenance Organization Plans and Plans Offering 

a Point of Service Product ..................................................................................................16

Things to Remember

■✔ The choices available to you may have changed. 

A number of plans withdrew from the FEHB 

Program, plans have merged, and some options 

won’t be offered. Make sure your plan will 

be offered in 2002.

■✔ Be aware of benefit changes for 2002.

■✔ Check the premium for 2002.
Quality

Quality matters to your health. Some health plans, just

like doctors and hospitals, do a better job at caring for

patients than others. Health plans today play an important role in improving quality. They can provide services

for wellness and prevention; coordinate care; and help

doctors, patients, and families work together. These

things - when done well - can help produce good

results.

* Enrollee Survey Results in this Guide have been

collected, scored, and reported by an independent organization - not by the health plans. We list here the survey

categories and actions the health plan can take to make

things better. Note: A plan may not be rated for one of

three reasons: 1) It is new to the FEHB Program, 2) It

has fewer than 500 Federal enrollees, or 3) It did not

administer the survey as we asked; these plans are identified with an X.

Getting Needed Care. Did you have problems getting a

referral to a specialist or did you experience delays in

obtaining care?

• Health plans that do well on the survey educate members up-front about the scope and limitations of covered

benefits, referral requirements, and preauthorizations.

They speed-up referrals for routine preventive care or

established diagnoses, especially for chronic conditions.

They empower their own customer service staff to

resolve problems at the outset.

1

F EHB and You

T

he Federal Employees Health Benefits (FEHB) Program began operation in July 1960. It is the

nation's largest employer-sponsored health insurance program. Almost 9 million people, including 2.2 million federal employees, 1.9 million retirees, and their eligible family members, are

members of the Program.

Getting information and selecting a health plan

Use this Guide and plan brochures to make your health plan decision. The Guide is a summary of

FEHB plans; the plan brochures give specific benefit information. You can get brochures from the

health plans or your human resources office. Our web site, www.opm.gov/insure provides the Guide,

brochures, and other helpful information.

Before selecting a health plan:

• Consider quality (look for accreditation and survey results)

• Compare benefits in the brochures

• Review costs (premiums, deductibles, copayments, etc)

• Understand how the plan works
Getting Care Quickly. When you called during the

doctor's regular office hours, did you get the advice or

help you needed? Could you get an appointment for

regular or routine care as soon as you wanted?

• Health plans that score well track the performance of

doctors or medical groups to see if there are problems

with patients getting needed appointments. They use

members' definitions of "urgent" and "routine" needs -

and not physicians' - to measure providers' performance

against members' expectations.

How Well Doctors Communicate. Did your doctor listen carefully to you and explain things in a way you

could understand? Did he spend enough time with you?

• Plans that do well survey members of specific medical

groups or practices and provide physicians with feedback on their performance. They recruit physicians with

the best reputations in the community, and they develop

guidelines that aid physicians in communication with

patients with specific diseases or conditions.

Customer Service. When you called your plan's customer service department, were they helpful? Did you

have paperwork problems? Were the plan's written

materials understandable?

• The better performing plans train customer service

teams to deal solely with FEHB enrollees. They also

look for ways to reach out directly to members, to elicit

their concerns, and inform them about changes in policies and practices that would affect them. Just as importantly, they issue "report cards" to members about the

performance of medical groups on key measures of quality, including patients' reported experiences with each

group.

Claims Processing. Did your plan pay your claims correctly and in a reasonable time?

• A well-rated plan informs you if there will be a delay

in processing a claim, e.g., additional information is

needed from the doctor. The plan's Explanation of Benefits should be clear and understandable.

Overall Plan Satisfaction. How would you rate your

overall experience with your health plan?

• Health plans that do well on the survey value you as

a customer.

* Accreditation is the most widely accepted

way to measure and evaluate health system performance.

It is a rigorous and comprehensive evaluation by independent organizations that assess the quality of the key

systems and processes that health care organizations use.

It may also assess the care and service health plans deliver in areas such as immunization rates, mammography

rates, and member satisfaction. The National Committee

for Quality Assurance (NCQA), the Joint Commission on

Accreditation of Healthcare Organizations (JCAHO), and

the American Accreditation Healthcare

Commission/URAC (URAC) are independent, private,

not-for-profit organizations dedicated to the quality of

health care organizations.

Use the following key to compare the accreditation status of different health plans (a lower number means a

better accredited plan). See page 7 for definitions.

NCQA (www.ncqa.org):

N1 = Excellent

N2 = Commendable

N3 = Accredited

N4 = Provisional

N6 = New health plan accreditation

JCAHO (www.jcaho.org):

J1 = Accreditation with commendation

J2 = Accreditation without recommendations

J3 = Accreditation with recommendations

J5 = Provisional

J6 = Conditional

URAC (www.urac.org):

U1 = Accredited

2

F EHB and You
Benefits

Check to see if the plan offers the type of services you

might need. Does it offer a prenatal program or programs for people with chronic diseases? Can you get

preventive care or help to stop smoking? Given the

trend toward reducing hospital stays, will your plan pay

for care in a rehabilitation facility? See if there are limits

on the number of visits for the services you need. Don't

assume benefits will be the same as they were last year. 

• Read plan brochures carefully.

• Check the brochure’s Change page.

• Know what services are covered.

• Know what services are not covered.

Cost

The premium you pay is an important consideration.

When thinking about premiums, what can you afford

biweekly or monthly? Plans that offer two options distinguish the difference between the two by the benefits or

services provided, and this in turn affects the premium

and out-of-pocket costs you pay. What benefits and services do you need, and what are you willing to pay for?

You also need to consider other costs. Pay attention to

the plan's annual out-of-pocket (catastrophic) maximum

to see how you are protected. If you need to go to the

hospital, how much will you have to pay? What will you

pay for an emergency room visit? If you have children,

what will you pay for a well-child visit? What will you

pay for a prescription?

• Review the costs summarized in this Guide.

• Check plan brochures for specific information.

How the Plan Works 

Different types of plans help you get and pay for care

differently. Fee-For-Service (FFS) plans generally use

two approaches. You can choose your doctors and hospitals yourself. This approach may be more expensive

for you and require extra paperwork. You can generally

use a Fee-For-Service plan's Preferred Provider Organization (PPO), which offers you a choice of doctors and

hospitals within a network. Most networks are quite

wide, but they may not have all the doctors or hospitals

you want. This approach usually will save you money

and reduce your paperwork. 

Generally, enrolling in a FFS plan does not guarantee

that a PPO will be available in your area. PPOs have a

stronger presence in some regions than others, and in

areas where there are regional PPOs, the non-PPO benefit is the standard benefit. In “PPO-only” options, you

must use PPO providers to get benefits.

Be sure to look at the primary care physicians, specialists, and hospitals with whom your health plan contracts

(the provider network). Does it promote prevention and

early detection and intervention? Does it have the specialists to treat your chronic condition? Does it contract

with a hospital close to your home?

Health Maintenance Organizations (HMOs) use networks

of physicians and facilities that are generally limited.

You must use their network to get covered services and

follow the plan's rules for referrals and other services.

HMOs limit your out-of-pocket costs to the relatively low

amounts shown in the benefit brochures.

3

F EHB and You
Some plans are Point Of Service (POS) plans and have

features similar to both FFS plans and HMOs.

You are in a FFS plan and do not use the PPO (or

one is not available):

• You will generally pay more when you get care

• Fewer preventive health care services may be covered

• You will have to file claims for services yourself

You are in a FFS plan and use the PPO:

• You will generally pay less when you get care

• More preventive health care services may be covered

• You may have less paperwork

You are in a FFS plan’s “PPO-only” option:

• You must use network providers to get benefits

• You will generally pay copayments and have no

deductibles

• You will have little, if any, paperwork

You belong to an HMO:

• You will have limitations on the doctors and other

providers you can use

• You will usually pay less when you get care

• You will have little, if any, paperwork

• More preventive health care services may be covered

You belong to a POS plan and use only the

providers in that network:

• You will pay less when you get care

• You will get full network benefits and coverage

• You will have very little paperwork

You belong to a POS and do not use network

providers or referral procedures:

• You will pay more when you get care

• Some services may not be covered out of network 

at all

• You generally have to file claims for services yourself

Things to do to make a plan work

best for you

• When you need care, use your brochure to find out

about the plan's rules and coverage. Know what

services require precertification, prior approval, or

referral before you use them.

• Use your plan's home delivery drug program if it has

one. You generally get the convenience of a 90-day

supply instead of a 30-day supply, usually with lower

out-of-pocket expense.

• Request generic drugs instead of brand name drugs.

A generic medication is a copy of a brand name drug.

It has the same active ingredients and receives the

same Food and Drug Administration approval but

costs less.

• If you're in a FFS plan, use the plan's PPO if it has

one. (Be aware, however, that some of the services,

such as anesthesia and radiology, provided in a PPO

hospital may not be covered by PPO arrangements.)

• Ask questions. You deserve a voice in your own 

health care.

Nowadays, the distinctions among different plan types

(i.e., FFS, PPO, POS, HMO) are blurring. FFS plans use

networks of providers in their PPO arrangements; POS

plans let you get care in or out-of-network; HMOs allow

memebers to visit selected specialists without a referral

from the primary care physician. Rather than make decisions based on plan type, compare quality indicators,

compare benefits, compare premiums and out-of-pocket

costs, and look at the rules for getting care.

4

F EHB and You
5

Plan Comparisons

Visit us at www.opm.gov/insure to find

• Federal Employees Health Benefits (FEHB) 

Program home page

• FEHB Open Season Plan Comparison Page

Visit the FEHB Home Page and the FEHB Open Season

Plan Comparison Page for the most up-to-date information on the FEHB Program.

The FEHB Home Page has information on the FEHB

Program and important information on health care. On

this page you'll find:

• The FEHB Handbook for Enrollees and Employing

Offices - detailed and in-depth information about the

FEHB Program.

• The FEHB law and regulations.

• Information on disputed claims, patient safety, former

spouse coverage, FEHB and Medicare.

• Questions and Answers on prescription drugs, dental

benefits, premiums, enrollment and other topics. 

• FEHB Facts - Information for Federal Civilian Employees on the FEHB Program.

• A page for Agency Human Resources Personnel with

links to FEHB Benefits Administration Letters.

• Health plan information disclosure requirements under

the Patients’ Bill of Rights.

The FEHB Open Season Plan Comparison Page has

information you'll need to make an informed health

insurance election. Be sure to look at our new section

on how to use this web site. 

On this page you'll find:

• General information about plans including plan quality, benefits, and cost.

• Information on how to enroll or make changes to your

enrollment, including the enrollment form which you

can complete on-line, print and give to your personnel

office; information on Employee Express, and enrollment information for annuitants.

• Links to plan web sites and other web sites where you

can find more about health care quality.

You can also look at and download: 

• All of the FEHB Guides including the Guide For Federal Civilian Employees (Postal and Non-Postal), the

Guide for Federal Retirees and Their Survivors, the

Guide For Certain Temporary Employees, the Guide

For Individuals Receiving Compensation From the

Office of Workers' Compensation Programs, and the

Guide for Temporary Continuation of Coverage (TCC)

and Former Spouse Enrollees.

• Plan Brochures that include the benefits, cost, and

other major features and provisions of each health

plan.

F EHB Web Resources
6

Pr ogram Features

Better Information

Better Choices

Better Health

• No Waiting Periods. You can use your benefits as soon as your coverage becomes effective.

There are no pre-existing condition limitations.

• A Choice of Coverage. Choose between self only or self and family.

• A Choice of Plans and Options. Select from Fee-For-Service, Health Maintenance Organization,

or Point of Service plans.

• A Government Contribution. The Government pays 72 percent of the average premium toward

the total cost of your premium, but not more than 75 percent of the total premium for any plan.

• Salary Deduction. As a Federal employee, you pay your share of the premium through a payroll

deduction using pretax dollars.

• Annual Enrollment Opportunity. Each year you can enroll or change your health plan enrollment. This year the Open Season runs from November 12, 2001 through December 10, 2001.

• Continued Group Coverage. Eligibility for you or your family members may continue following

your retirement, divorce, death, or change in employment status. See your human resources office

for more information.

• Coverage After FEHB Ends. You or your family members may be eligible for temporary continuation of FEHB coverage or for conversion to non-group (private) coverage when FEHB coverage

ends. See your human resources office for more information.
Accreditation - A rigorous and comprehensive evaluation performed by independent organizations to

assess the quality of the key systems and processes

that managed care organizations use. Accreditation

may also include an assessment of the care and service plans are delivering in important areas of public

concern such as immunization, mammography,

patient safety, and member satisfaction. The following three organizations perform accreditation reviews

we recognize in this guide:

NCQA - The National Committee for Quality

Assurance. These are NCQA's accreditation levels:

• Excellent - NCQA's highest status. Levels

of service and clinical quality that meet or

exceed NCQA's requirements for consumer

protection and quality improvement AND

achieve HEDIS (see definition) results that

are in the highest range of national or

regional performance. Valid for 3 years.

• Commendable - Meets or exceeds NCQA's

requirements for consumer protection and

quality improvement. Valid for 3 years.

• Accredited - Meets most of NCQA's requirements for consumer protection and quality

improvement. Valid for 3 years.

• Provisional - Meets some but not all of

NCQA's requirements for consumer protection and quality improvement. Valid for 1

year.

• New Health Plan - Designed for health

plans that are less than 2 years old.

JCAHO - The Joint Commission on Accreditation

of Healthcare Organizations. These are JCAHO's

accreditation levels:

• Accreditation with commendation -

JCAHO's highest status. Awarded to a plan

that has demonstrated exemplary performance (category discontinued as of 2003).

Valid for 3 years.

• Accreditation without recommendations -

Demonstrates satisfactory compliance with

JCAHO standards in all performance areas.

Valid for 3 years.

• Accreditation with recommendations -

Demonstrates satisfactory compliance with

JCAHO standards in most performance

areas. Valid for 3 years.

• Provisional - Demonstrates satisfactory

compliance with a subset of standards.

Valid for 6 months until plan is re-surveyed.

• Conditional - Demonstrates the capability

of achieving satisfactory compliance but has

not done so.

URAC - Also known as the American Accreditation Healthcare Commission.

• Accredited - Demonstrates full compliance

with standards. Valid for 2 years.

Fee-For-Service (FFS) - Health coverage in which

doctors and other providers receive a fee for each service such as an office visit, test, procedure, or other

health care service. The plan will either pay the medical provider directly or reimburse you for covered

services after you have filed an insurance claim.

When you need medical attention, you visit the doctor

or hospital of your choice.

Things to consider:

Fee-For-Service PPOs, non-PPOs, and PPO-only all

work a little differently. See page 4 for things you

should know.

7

D efinitions
Health Maintenance Organization (HMO) - A health

plan that provides care through contracted or

employed physicians and hospitals located in particular geographic or service areas. HMOs emphasize

prevention and early detection of illness. Your eligibility to enroll in an HMO is determined by where

you live or, in some plans, where you work.

Things to consider:

• The HMO pays for all covered services as long

as you use the doctors, including specialists, and

hospitals in the HMO network.

• You will usually pay less than FFS when you get

care.

• You will have very little, if any, paperwork

• More preventive health care services may be 

covered

HEDIS 1 - Health Plan Employer Data and Information

Set. A set of health plan performance measures that

cover things such as preventive care, prenatal care,

treatment of acute and chronic diseases and member

satisfaction with health plans and doctors that look at

a plan's quality of care and services. NCQA requires

HEDIS and JCAHO accepts HEDIS in accrediting

health plans.

In-network - The doctors, clinics, health centers, hospitals, medical practices, and other providers that a

plan contracts with or employs to care for its members. Examples include a Fee-For-Service plan's PPO

or a Health Maintenance Organization. Members have

less out-of-pocket costs when they use in-network

providers.

Managed care - A very broad term that generally

refers to a system that manages the quality of health

care, access to care, and the cost of that care. For

example, a formulary controls the quality of medications dispensed to enrollees; a referral ensures that

you see the right specialist for your condition; and

going to a hospital that has an agreement with your

plan can save both you and the plan money.

Out-of-network - Members seek treatment from doctors, hospitals, and others outside the plan's panel of

contracted or employed providers, and pay more to

do so. Members in a PPO-only option who receive

services from outside the PPO network pay all

charges.

Point of Service (POS) - A product offered by an

HMO or FFS plan that has features of both. If you

join a POS offered by a Fee-For-Service plan, you

receive care from the plan's network of providers and:

• You will generally pay less when you get care

than you would under the traditional FFS 

coverage

• You will get full HMO-type benefits and 

coverage

• You will have very little paperwork

If you join a POS offered by an HMO, you are not

limited to the plan's network of providers and:

• You will generally pay more when you get care

than you would under an HMO arrangement

• Some services may not be covered out-of-network at all

• You generally have to file claims for services 

yourself

In a POS you don't have to use the plan's network of

providers, but there are advantages if you do.

Preferred Provider Organization (PPO) - Under the

FEHB Program, PPOs are only available through

enrollment in a Fee-For-Service plan. The PPO is similar to FFS insurance except it uses a network of

providers. PPO's give you the choice of using any

doctor or other provider you want, or using one who

is part of the plan's network. You don't have to use

the PPO, but there are advantages if you do (see FeeFor-Service).

Please note that some FFS plans may offer an enrollment option that is “PPO-only”. Under this option,

you must use network providers to get benefits.

Provider - A doctor, hospital, health care practitioner,

or health care facility.

8

D efinitions

1

HEDIS is a registered trademark of the National Committee for Quality Assurance.
9

Long Term Care Insurance Is 

Coming Later in 2002!

Long Term Care Insurance Is 

Coming Later in 2002!

➡➡ You should 

consider buying

long term 

care insurance.

The Office of Personnel Management (OPM) will sponsor

a high-quality long term care insurance program effective

in October 2002. As part of its educational effort, OPM

asks you to consider these questions: 

What is long term care (LTC) insurance? 

• It’s insurance to help pay for long term care services

you may need if you can’t take care of yourself because

of an extended illness or injury, or an age-related disease such as Alzheimer’s. 

• LTC insurance can provide broad, flexible benefits for

nursing home care, care in an assisted living facility,

care in your home, adult day care, hospice care, and

more. LTC insurance can supplement care provided by family members, reducing the burden you

place on them.

I’m healthy. I won’t need long term care. Or, will I? 

• Welcome to the club! 76% of Americans believe they

will never need long term care, but the facts are that

about half of them will. And it’s not just the old folks.

About 40% of people needing long term care are under

age 65. They may need chronic care due to a serious

accident, a stroke, or developing multiple sclerosis, etc. 

• We hope you will never need long term care, but

everyone should have a plan just in case. Many people now consider long term care insurance to be

vital to their financial and retirement planning.

Is long term care expensive? 

• Yes, it can be very expensive. A year in a nursing

home can exceed $50,000. Home care for only three

8-hour shifts a week can exceed $20,000 a year.

And that’s before inflation! 

• Long term care can easily exhaust your savings.

Long term care insurance can protect your 

savings. 

But won’t my FEHB plan, Medicare or Medicaid

cover my long term care? 

• Not FEHB. Look at the “Not covered” blocks in sections 5(a) and 5(c) of your FEHB brochure. Health

plans don’t cover custodial care, a stay in an assisted

living facility, or a continuing need for a home health

aide to help you with activities of daily living. Limited stays in skilled nursing facilities can be covered in

some circumstances. 

• Medicare only covers skilled nursing home care (the

highest level of nursing care) after a hospitalization

for those who are blind, age 65 or older or fully disabled. It also has a 100 day limit. 

• Medicaid covers long term care for those who meet

their state’s poverty guidelines, but has restrictions on

covered services and where they can be received.

Long term care insurance can provide choices of

care and preserve your independence.

When will I get more information on how to apply

for this new insurance coverage? 

• Employees will get more information from their agencies during the LTC open enrollment period in the

late summer/early fall of 2002. 

• Retirees will receive information at home. 

How can I find out more about the program NOW?

Our toll-free teleservice center will begin in mid-2002.

In the meantime, you can learn more about the program on our web site at www.opm.gov/insure/ltc. 

➡➡ Many FEHB enrollees think

that their health plan

and/or Medicare will cover

their long term care needs –

Unfortunately, they are

WRONG!

➡➡ How are YOU planning

to pay for the future

custodial or chronic

care you may need? 
10

Learning about today’s Federal Benefit 

Programs can be beneficial to your health.

Today’s Medicare offers more.

✔ More preventive benefits.

✔ More information.

✔ More help with your questions.

Medicare Questions?

www.medicare.gov

1-800-MEDICARE

(1-800-633-4227)

Medicare & You Handbook An education program of the Department of Health and Human Services

and the Center for 

Medicare and Medicaid Services

The Department of Defense’s New TRICAREFor-Life is an affordable alternative to FEHB.

✔ Available to Uniformed Services 

Retirees with Medicare Parts 

A and B.

✔ Comprehensive medical and 

pharmacy coverage.

✔ Low out-of-pocket costs.

TRICARE-for-Life 

Questions?

www.opm.gov/insure 

OR

www.tricare.OSD.mil

1-888-DOD-LIFE

(1-888-363-5433)
11

Notes

Benefit

type

Plan

Plan name code

Alliance Health Plan (AHP) 1R PPO $100 $200 $150 10% 10% 10% 10%

Non-PPO $300 $200 $250 30% 30% 30% 30%

APWU Health Plan (APWU) 47 PPO $275 None None 10% 10% 10% 10%

Non-PPO $350 None $200 30% 30% 30% 30%

Blue Cross and Blue Shield Service Benefit Plan-Std (BCBS) 10 PPO $250 None $100 10% Nothing Nothing 10%

Non-PPO $250 None $300 25% 30% 30% 25%

Blue Cross and Blue Shield Service Benefit Plan-Basic (BCBS) 11 PPO only None None $100/day;$500 $20/$30 Nothing Nothing $30 

GEHA Benefit Plan-High (GEHA) 31 PPO $300 None None 10% Nothing 10% 10%

Non-PPO $300 None None 25% Nothing 25% 25%

GEHA Benefit Plan-Std (GEHA) 31 PPO $450 None None 15% 15% 15% 15%

Non-PPO $450 None None 35% 35% 35% 35%

Mail Handlers-High (MH) 45 PPO $200 $250 None 10% Nothing Nothing 10%

Non-PPO $200 $250 $250 30% Nothing Nothing 30%

Mail Handlers-Std (MH) 45 PPO $250 $600 $150 10% Nothing Nothing 10%

Non-PPO $250 $600 $300 30% Nothing Nothing 30%

NALC (NALC) 32 PPO $250 None None 15% 10% 10% 15%

Non-PPO $300 $25 for Retail $100 30% 30% 30% 30%

PBP Health Plan-High (PBP) 36 PPO $200 $100 None 10% 10% 10% 10%

Non-PPO $400 $150 $150 20% 25% 25% 20%

PBP Health Plan-Std (PBP) 36 PPO $250 $100 None 10% 10% 10% 10%

Non-PPO $500 $150 $250 30% 30% 30% 30%

12

Nationwide Fee-for-Service Plans Open to All

How to read this chart:

The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures before

making your final decision. The chart does not show all of your possible out-of-pocket costs.

The Deductibles shown are the amount of covered expenses that you pay before your health plan begins to pay. 

Calendar Year deductibles for families are two or more times the per person amount shown. 

In some plans your combined Prescription Drug purchases from mail order and local pharmacies count toward the deductible. In other

plans only purchases from local pharmacies count. Some plans require each family member to meet a per person deductible. 

The Per Stay Hospital Inpatient deductible is what you pay each time you are admitted to a hospital.

What you pay for Doctors (inpatient visits and surgical services) and Outpatient Tests (provided, or ordered, and billed by a physician or

physicians’ group).

Deductible

Calendar

Year

Prescription

Drug

Per stay 

Hospital 

inpatient

Per Person

Copay ($)/Coinsurance (%)

Inpatient Outpatient

R&B other

Doctors &

Outpatient

Tests

Hospital

Other

Medical-Surgical — You pay
10%/50% + 10%/50% + 10%/50% + 20% 20%

10%/50% 10%/50% 10%/50% 20% 20% h fh h**

45% 45% 45% $10 20%

$7 25% 25% $10 20% h ** hhh

25% 25% 25% $10/25% $35/25%

45% 45% 45% 45% 45% * ** ***

$10 $25 $35 or 50% $10 $25

$5 or 50% $15/$30/50% $15/$30/50% $10 $35/$50

$5/50% $15/$30/50% $15/$30/50% $10 $35/$50 h *f *hh

$5 + 50% + 50% + $15 50%

$5 50% 50% $15 50% h *f *hh

25% 25% 25% $10 $30/$45 

50% 50% 50% $10 $30/$45 f ff f*f

30% 30% 30% $10 $40/$55 

50% 50% 50% $10 $40/$55 f ff f*f

40%+ 40%+ 40%+ $12 $25 

25% 25% 25% $12 $25 h hh hhh

$10 or 20% $25 or 20% $40 or 20% $10 $25 

20%+ 20%+ 20%+ $10 $25 f *h hff

$15 or 20% $30 or 20% $40 or 20% $15 $30 

30%+ 30%+ 30%+ $15 $30 f *h hff

13

Your share of Hospital Inpatient Room and Board and Other (e.g., nursing, supplies, and medications) covered charges are shown, usually after any per stay deductible. Services provided and billed by the hospital for outpatient care (other than surgery) are shown as Hospital Outpatient Other expenses.

A Generic drug is a copy of the manufacturer’s Brand Name drug and is approved by the Food and Drug Administration. 

Non-formulary drugs are Brand Names that are not on your health plan’s list of preferred drugs.

Prescription drug benefits have become more complex as you can see from the many variations. Multiple numbers for a plan mean there

are different levels of cost sharing. For instance, you may pay one amount for your first prescription (e.g., 10% or $5) and then a different

amount for some refills (e.g. 50%). You may have to pay the greater of a dollar amount or a percentage (e.g., $10 or 20%). In some cases,

you’ll pay less for a Brand Name drug that has no Generic equivalent than for a Brand Name that has a Generic (e.g., $15 versus $30). A

few plans have lower copays for Medicare members. Plans vary in the number of days supply of drugs you get for the copays shown, and

you’ll almost always pay more if you use a non-PPO pharmacy (e.g., the + sign means you pay the amount shown plus a differential).

Read the brochures for details.

Enrollee Survey Results — See pages 1-2 for a description.

Copay ($)/Coinsurance (%)

Prescription drugs

Generic Brand

Name

Generic Brand

Name

Nonformulary

Mail Order

Medical-Surgical — You pay Enrollee Survey Results

h above average, * average, f below average

Overall plan

satisfaction 

Getting 

needed care

Getting 

care quickly

How well 

doctors

communicate 

Customer 

service

Claims 

processing
Plan name

Association Benefit Plan (ABP) 42 PPO $300 None $100 10% Nothing Nothing 10%

Non-PPO $300 None $200 25% 25% 25% 25%

Foreign Service (FS) 40 PPO $300 None Nothing 10% Nothing Nothing 10% 

Non-PPO $300 None $200 30% 20% 20% 30% 

Panama Canal Area◊ (PCA) 43 No PPO None $400 $125 50% 50% 50% 50%

Rural Carrier Benefit Plan (Rural) 38 PPO $350 CY Applies Nothing 10% Nothing Nothing Nothing

Non-PPO $350 CY Applies $200 15% Nothing 20% Nothing

SAMBA (SAMBA) 44 PPO $300 None $200 10% Nothing 10% 10%

Non-PPO $300 None $300 30% 30% 30% 30%

Secret Service (SS) Y7 No PPO $200 $200 $100 20% Nothing Nothing Nothing

14 ◊ Offers a Point of Service product. See page 28.

Nationwide Fee-for-Service Plans Open Only to Specific Groups

How to read this chart:

The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures before

making your final decision. The chart does not show all of your possible out-of-pocket costs.

The Deductibles shown are the amount of covered expenses that you pay before your health plan begins to pay. 

Calendar Year deductibles for families are two or more times the per person amount shown. 

Some plans apply Prescription Drug purchases to the Calendar Year deductible. 

The Per Stay Hospital Inpatient deductible is what you pay each time you are admitted to a hospital.

What you pay for Doctors (inpatient visits and surgical services) and Outpatient Tests (provided, or ordered, and billed by a physician or

physicians’ group).

Benefit

type

Plan

code

Deductible

Calendar

Year

Prescription

Drug

Per stay 

Hospital 

inpatient

Per Person

Copay ($)/Coinsurance (%)

Inpatient Outpatient

R&B other

Doctors &

Outpatient

Tests

Hospital

Other

Medical-Surgical — You pay
$10 $20 $30 $15 $30/$45 

$10 $20 $30 $15 $30/$45 * ** fh*

$10 $20 $20 $15 $25 

$10 $20 $20 $15 $25 h ** fff

50% 50% 50% N/A N/A

25% 25% 25% $13 $18 

25% 25% 25% $13 $18 h hh *hh

$15 $25/$30 $25/$30 $15 $25/$30

$15 $25/$30 $25/$30 $15 $25/$30 * ff *ff

$10 $20 $20 $20 $40 f h* *ff

15

Your share of Hospital Inpatient Room and Board and Other (e.g., nursing, supplies, and medications) covered charges are shown, usually after any per stay deductible. Services provided and billed by the hospital for outpatient care (other than surgery) are shown as Hospital Outpatient Other expenses.

A Generic drug is a copy of the manufacturer’s Brand Name drug and is approved by the Food and Drug Administration. 

Non-formulary drugs are Brand Names that are not on your health plan’s list of preferred drugs.

Prescription drug benefits have become more complex as you can see from the many variations. Multiple numbers for a plan mean there

are different levels of cost sharing. For instance, you may pay one amount for your first prescription (e.g., 10% or $5) and then a different

amount for some refills (e.g. 50%). You may have to pay the greater of a dollar amount or a percentage (e.g., $10 or 20%). In some cases,

you’ll pay less for a Brand Name drug that has no Generic equivalent than for a Brand Name that has a Generic (e.g., $15 versus $30). A

few plans have lower copays for Medicare members. Plans vary in the number of days supply of drugs you get for the copays shown, and

you’ll almost always pay more if you use a non-PPO pharmacy (e.g., the + sign means you pay the amount shown plus a differential).

Read the brochures for details.

Enrollee Survey Results — See pages 1-2 for a description. 

Copay ($)/Coinsurance (%)

Prescription drugs

Generic Brand

Name

Generic Brand

Name

Nonformulary

Home Delivery

Medical-Surgical — You pay Enrollee Survey Results

h above average, * average, f below average

Overall plan

satisfaction 

Getting 

needed care

Getting 

care quickly

How well 

doctors

communicate 

Customer 

service

Claims 

processing
Health Maintenance Organization (HMO) and Point of Service (POS) Plans

How to read this chart: The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures

before making your final decision. This chart does not show all of your possible out-of-pocket costs.

Primary Care Doctor Office shows what you pay for each office visit to

your primary care doctor. 

16

Alabama

PrimeHealth of Alabama, Inc. AA $10 None $7 $12 $30 

The Oath - A Health Plan for Alabama, Inc . DF $15 $100 $5 $15 $25 **hh*f

Arizona

Aetna U. S. Healthcare, Inc. WQ $15 $100-$300 $10 $20 50% ffffff N2

Health Net of Arizona, Inc. A7 $10 $100 $10 $20 $40 ffff** N2

PacifiCare Health Plans A3 $10 None $5 $15 $15 fffff* N2

California

Aetna U. S. Healthcare, Inc. 2X $15 $100-$300 $10 $20 50% ffffff N2

Blue Cross- HMO M5 $10 None $5 $10 50% fffff* N2

Blue Shield of CA Access+ SJ $10 None $5 $10 $25 ffffff N2

CIGNA HealthCare of California 9T $10 None $5 $15 $35 ffffff N2

Health Net LB $10 None $5 $10 $35 fffff* N2

Kaiser Permanente 59 $10 None $10 $20 $20 *fffhf N1

Kaiser Permanente 62 $10 None $10 $20 $20 **ffh* N2

PacifiCare Health Plans CY $10 None $5 $15 $15 fffff* N2

UHP HEALTHCARE C4 $10 None $5 $5 $5 J3

Universal Care 6Q $10 None $5 $10 $30 ffffff N3

Western Health Advantage 5Z $10 None $5 $10 $20 hff**h N6

Hospital per Stay Deductible/Copay is the amount you pay when you

are admitted into a hospital.

Plan name

Prescription 

drugs

Enrollee Survey Results

h above average, * average, f below average

Generic

Primary

care 

doctor

office

copay

Hospital 

per 

stay

deductible/

copay Brand

Name

Nonformulary

Overall plan satisfactionGetting needed care Getting care quickly How well doctorscommunicate Customer service Claims processing Accredited

Plan

code
17

Colorado

Kaiser Permanente 65 $10 None $5 $15 $15 ***fh* N1

PacifiCare of Colorado-High D6 $10 None $5 $10 $20 ff**f* N2

PacifiCare of Colorado-Std D6 $15 $300 $10 $20 $30 ff**f* N2

Rocky Mountain HMO-High XJ $10 $200 $10 $20 $35 *hhhfh N1

Rocky Mountain HMO-Std XJ $25 $500 $10 $20 $35 *hhhfh N1

Connecticut

ConnectiCare TE $10 None $10 $20 $35 hhhhhh N1

Health Net, Inc. DP $10 None $10 $20 $35 hhh**h

Enrollee Survey Results — See pages 1-2 for a description. 

An (X) means the plan did not conduct the survey as we asked.

Accredited — The National Committee for Quality Assurance (N); 

the Joint Commission on Accreditation of Healthcare Organizations (J);

and/or the American Accreditation Healthcare Commission/URAC (U). 

See pages 2 and 7 for details. A lower number means a better accreditation.

Prescription drugs — Generic, Brand Name, and Non-formulary shows

what you pay for prescriptions when you use a plan pharmacy. Non-formulary

refers to prescriptions that are not on the plan’s preferred list. Some plans charge

different amounts for some drugs and for mail orders. In many plans, if you get

the brand name instead of the generic drug, you also pay the difference between

the two.

Plan name

Prescription 

drugs

Enrollee Survey Results

h above average, * average, f below average

Generic

Primary

care 

doctor

office

copay

Hospital 

per 

stay

deductible/

copay Brand

Name

Nonformulary

Overall plan satisfactionGetting needed care Getting care quickly How well doctorscommunicate Customer service Claims processing Accredited

Plan

code
Health Maintenance Organization (HMO) and Point of Service (POS) Plans

How to read this chart: The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures

before making your final decision. This chart does not show all of your possible out-of-pocket costs.

Primary Care Doctor Office shows what you pay for each office visit to

your primary care doctor. 

18

District of Columbia

Aetna U. S. Healthcare, Inc.-High JN $15 $100-$300 $10 $20 50% fff*ff N2

Aetna U. S. Healthcare, Inc.-Std JN $20 $200-$600 $10 $20 50% fff*ff N2

CareFirst BlueChoice* 2G $10 None $10 $20 $35 ****ff N2

Kaiser Permanente E3 $10 $100 $10 $20 $20 *f*fhf N2

MD-IPA JP $10 None $5 $15 $30 hh**h* N1

Florida

Av-Med Health Plan EM $10 $100 $5 $10 $25 *ff*h* N2,J2

Capital Health Plan EA $10 $100 $7 $20 $35 hhhhhh N1

Foundation Health 5E $10 $200 per yr $7 $14 $34 ffffff N4

HIP Health Plan of FL 3N $10 $250 $5 $10 $35 fff*** N2

Humana Medical Plan EE $10 None $5 $20 $40 ffff** N2,U1

Total Health Choice 4A $10 $100 $5 $15 $15 

Hospital per Stay Deductible/Copay is the amount you pay when you

are admitted into a hospital.

Plan name

Prescription 

drugs

Enrollee Survey Results

h above average, * average, f below average

Generic

Primary

care 

doctor

office

copay

Hospital 

per 

stay

deductible/

copay Brand

Name

Nonformulary

Overall plan satisfactionGetting needed care Getting care quickly How well doctorscommunicate Customer service Claims processing Accredited

Plan

code

* Previously CapitalCare, which had Commendable NCQA accreditation.
19

Georgia

Aetna U. S. Healthcare, Inc. 2U $15 $100-$300 $10 $20 50% fff*ff N1

Kaiser Permanente F8 $10 None $5/$11 Comm $5/$11 Comm $5/$11 Comm hh*fh* N1

Guam

PacifiCare Asia Pacific-High JK $10 None $5 $20 $20 h*f**f

PacifiCare Asia Pacific-Std JK $15 $150 $5 $20 $20 h*f**f

Hawaii

HMSA 

- In-Network

87

20% None $5 $15 $15 or 50% hhhhhh

- Out-of-Network 30% 30% $5 + 20% $15+20%+ $15 or 50%+

Kaiser Permanente-High 63 $10 None $7 $7 $7 hh*hhh N1

Kaiser Permanente-Std 63 $15 None $7 $7 $7 hh*hhh N1

Idaho

Group Health Cooperative VR $10 $100-$300 $10 $20 $20 ****** N1

Enrollee Survey Results — See pages 1-2 for a description. 

An (X) means the plan did not conduct the survey as we asked.

Accredited — The National Committee for Quality Assurance (N); 

the Joint Commission on Accreditation of Healthcare Organizations (J);

and/or the American Accreditation Healthcare Commission/URAC (U). 

See pages 2 and 7 for details. A lower number means a better accreditation.

Prescription drugs — Generic, Brand Name, and Non-formulary shows

what you pay for prescriptions when you use a plan pharmacy. Non-formulary

refers to prescriptions that are not on the plan’s preferred list. Some plans charge

different amounts for some drugs and for mail orders. In many plans, if you get

the brand name instead of the generic drug, you also pay the difference between

the two.

Plan name

Prescription 

drugs

Enrollee Survey Results

h above average, * average, f below average

Generic

Primary

care 

doctor

office

copay

Hospital 

per 

stay

deductible/

copay Brand

Name

Nonformulary

Overall plan satisfactionGetting needed care Getting care quickly How well doctorscommunicate Customer service Claims processing Accredited

Plan

code
Health Maintenance Organization (HMO) and Point of Service (POS) Plans

How to read this chart: The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures

before making your final decision. This chart does not show all of your possible out-of-pocket costs.

Primary Care Doctor Office shows what you pay for each office visit to

your primary care doctor. 

20

Illinois

BlueCHOICE 9C1 $10 None $5 $10 $15 f*hh** N2 

Mercy Health Plans/Premier

- In-Network

7M

$10 None $7 $12 $25 hhh*hh

- Out-of-Network 30% 30% N/A N/A N/A

Group Health Plan MM $10 $100 $8 $20 $35 **hh*h

Health Alliance HMO FX $10 $100 $7 $14 $25 hhhh*h N1 

Humana Health Plan Inc. 75 $10 None $3 $10 $25 f*ffff N2

John Deere Health Plan YH $15 $100 $10 $20 $35 hhhhhh N1

OSF HealthPlans 9F $10 $100-$300 $7 $15 $25 **hh*h N3

PersonalCare's HMO GE $10 $100 $5 $15 $35 hhh*hh N1

UNICARE HMO 17 $15 None $5 $15 $25 ffffff N2

Union Health Service 76 $10 None $10 $10 $10 

Indiana

Advantage Health Plan, Inc. 6Y $10 $200 $10 $20 $45 N6

Aetna U. S. Healthcare, Inc. 7L $20 $200-$600 $10 $20 50% ff*hff

Aetna U. S. Healthcare, Inc. RD $20 $200-$600 $10 $20 50% f*hhff

Arnett HMO G2 $10 None $5 $15 $30 hhhhhh N1

Health Alliance HMO FX $10 $100 $7 $14 $25 hhhh*h N1

Humana Health Plan D2 $10 None $5 $20 $40 *f**ff N2

Humana Health Plan Inc. 75 $10 None $3 $10 $25 f*ffff N2

M*Plan IN $10 None $5 $10 $30 ****** N1

Physicians HP of N. Indiana DQ $10 20%of$2500 $5 $15 $40 hhh*hh

UNICARE HMO 17 $15 None $5 $15 $25 ffffff N2

Welborn HMO H3 $10 None $5 $15 $25 hhh**h

Hospital per Stay Deductible/Copay is the amount you pay when you

are admitted into a hospital.

Plan name

Prescription 

drugs

Enrollee Survey Results

h above average, * average, f below average

Generic

Primary

care 

doctor

office

copay

Hospital 

per 

stay

deductible/

copay Brand

Name

Nonformulary

Overall plan satisfactionGetting needed care Getting care quickly How well doctorscommunicate Customer service Claims processing Accredited

Plan

code
21

Iowa

Avera Health Plan AV1 $10 $250 $10 $20 $35

Coventry Health Care of Iowa SV $10 None $5 $15 $30 fhh*f* N2

Health Alliance HMO FX1 $10 $100 $7 $14 $25 hhhh*h N1

John Deere Health Plan YH $15 $100 $10 $20 $35 hhhhhh N1

SecureCare of Iowa 3Q $10 $100 $5 or 25% $5 or 25% $5 or 25%

Kansas

Coventry HC Kansas Cty formerly Kaiser HA $10 None $5 $15 $45 

Coventry Health Care of Kansas 7W $10 None $5 $10 $20 *fh**h

Humana Health Plan, Inc.-High MS $10 None $5 $20 $40 ff*fff N2

Humana Health Plan, Inc.-Std MS $15 $100 $10 $25 $45 ff*fff N2

Preferred Plus of Kansas VA $10 $50/day$500 $5 $15 $15 J3

Kentucky

Aetna U. S. Healthcare, Inc. 7L $20 $200-$600 $10 $20 50% ff*hff

Aetna U. S. Healthcare, Inc. RD $20 $200-$600 $10 $20 50% f*hhff

Humana Health Plan D2 $10 None $5 $20 $40 *f**ff N2

United Health Care of Ohio, Inc. 3U $15 $100 $10 $15 $30 *h***f N1

Enrollee Survey Results — See pages 1-2 for a description. 

An (X) means the plan did not conduct the survey as we asked.

Accredited — The National Committee for Quality Assurance (N); 

the Joint Commission on Accreditation of Healthcare Organizations (J);

and/or the American Accreditation Healthcare Commission/URAC (U). 

See pages 2 and 7 for details. A lower number means a better accreditation.

Prescription drugs — Generic, Brand Name, and Non-formulary shows

what you pay for prescriptions when you use a plan pharmacy. Non-formulary

refers to prescriptions that are not on the plan’s preferred list. Some plans charge

different amounts for some drugs and for mail orders. In many plans, if you get

the brand name instead of the generic drug, you also pay the difference between

the two.

Plan name

Prescription 

drugs

Enrollee Survey Results

h above average, * average, f below average

Generic

Primary

care 

doctor

office

copay

Hospital 

per 

stay

deductible/

copay Brand

Name

Nonformulary

Overall plan satisfactionGetting needed care Getting care quickly How well doctorscommunicate Customer service Claims processing Accredited

Plan

code
Health Maintenance Organization (HMO) and Point of Service (POS) Plans

How to read this chart: The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures

before making your final decision. This chart does not show all of your possible out-of-pocket costs.

Primary Care Doctor Office shows what you pay for each office visit to

your primary care doctor. 

22

Louisiana

Amcare Health Plans ZH $10 None $5 $15 50% N6

Amcare Health Plans ZQ $10 None $5 $15 50% N6

Coventry Healthcare Louisiana BJ $15 $100/day $10 $20 $45 former Maxicare LA

Coventry Healthcare Louisiana JA $15 $100/day $10 $20 $45 XXXXXX

former Maxicare LA

Vantage Health Plan AQ $15 $250 $10 $20 $35 

Vantage Health Plan MV $15 $250 $10 $20 $35 

Maryland

Aetna U. S. Healthcare, Inc.-High JN $15 $100-$300 $10 $20 50% fff*ff N2

Aetna U. S. Healthcare, Inc.-Std JN $20 $200-$600 $10 $20 50% fff*ff N2

CareFirst BlueChoice* 2G $10 None $10 $20 $35 ****ff N2

Kaiser Permanente E3 $10 $100 $10 $20 $20 *f*fhf N2

MD-IPA JP $10 None $5 $15 $30 hh**h* N1

Massachusetts

Blue Chip, Coord Hlth Partners

- In-Network

DA

$10 None $5 $15 $30 hhhhh* N1

- Out-of-Network 20% None $30 + 20% $30 + 20% $30 + 20%

Fallon Community Health Plan JV $10 None $5 $10 $10 hhhhh* N1

Hospital per Stay Deductible/Copay is the amount you pay when you

are admitted into a hospital.

Plan name

Prescription 

drugs

Enrollee Survey Results

h above average, * average, f below average

Generic

Primary

care 

doctor

office

copay

Hospital 

per 

stay

deductible/

copay Brand

Name

Nonformulary

Overall plan satisfactionGetting needed care Getting care quickly How well doctorscommunicate Customer service Claims processing Accredited

Plan

code

* Previously CapitalCare, which had Commendable NCQA accreditation.
23

Michigan

Bluecare Network of MI G7 $10 None $10 $20 $20 *fhhf* N1

Bluecare Network of MI K5 $10 None $10 $20 $20 *fhhf* N1

Bluecare Network of MI KF $10 None $10 $20 $20 *fhhf* N1

Bluecare Network of MI KN $10 None $10 $20 $20 *fhhf* N1

Bluecare Network of MI KR $10 None $10 $20 $20 *fhhf* N1

Bluecare Network of MI LN $10 None $10 $20 $20 *fhhf* N1

Bluecare Network of MI LX $10 None $10 $20 $20 *fhhf* N1

Grand Valley Health Plan RL $10 None $5 $5 $5 h*hhhh N1

Health Alliance 52 $10 None $2 $2 $2 h***** N1

HealthPlus MI X5 $10 None $5 $5 $5 hhhhhh N1

M-Care EG $10 None $5 $10 $10 h***hh N1

OmniCare KA $10 None $2 $2 $2 ffffff N4

The Wellness Plan K3 $10 None $5 $5 $5 ffffff

Total Health Care N2 $10 None Nothing Nothing Nothing

Minnesota

HealthPartners Classic-High 53 $15 None $10 $20 $20 *h**** N1

HealthPartners Classic-Std 53 $20 $200 $11 $22 $22 *h**** N1

HealthPartners Primary Clinic Plan HQ $15 None $10 $10 $10 *h**** N1

Enrollee Survey Results — See pages 1-2 for a description. 

An (X) means the plan did not conduct the survey as we asked.

Accredited — The National Committee for Quality Assurance (N); 

the Joint Commission on Accreditation of Healthcare Organizations (J);

and/or the American Accreditation Healthcare Commission/URAC (U). 

See pages 2 and 7 for details. A lower number means a better accreditation.

Prescription drugs — Generic, Brand Name, and Non-formulary shows

what you pay for prescriptions when you use a plan pharmacy. Non-formulary

refers to prescriptions that are not on the plan’s preferred list. Some plans charge

different amounts for some drugs and for mail orders. In many plans, if you get

the brand name instead of the generic drug, you also pay the difference between

the two.

Plan name

Prescription 

drugs

Enrollee Survey Results

h above average, * average, f below average

Generic

Primary

care 

doctor

office

copay

Hospital 

per 

stay

deductible/

copay Brand

Name

Nonformulary

Overall plan satisfactionGetting needed care Getting care quickly How well doctorscommunicate Customer service Claims processing Accredited

Plan

code
Health Maintenance Organization (HMO) and Point of Service (POS) Plans

How to read this chart: The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures

before making your final decision. This chart does not show all of your possible out-of-pocket costs.

Primary Care Doctor Office shows what you pay for each office visit to

your primary care doctor. 

24

Missouri

Mercy Health Plans/Premier

- In-Network

7M

$10 None $7 $12 $25 hhh**h

- Out-of-Network 30% 30% N/A N/A N/A

BlueCHOICE 9G $10 None $5 $10 $15 f*hh** N2

Coventry HC Kansas Cty formerly Kaiser HA $10 None $5 $15 $45 XXXXXX

Group Health Plan MM $10 $100 $8 $20 $35 **hh*h

Humana Kansas City, Inc.-High MS $10 None $5 $20 $40 ff*fff N2

Humana Kansas City, Inc.-Std MS $15 $100 $10 $25 $45 ff*fff N2

Nevada

Health Plan of Nevada

- In-Network

NM

$10 $100/dayX2 $5 $20 $35 ffffff N3

- Out-of-Network 20% 20% 20% 20% 20% 

Aetna U. S. Healthcare, Inc. 8L $15 $100-$300 $10 $20 50% ffff*f N6

PacifiCare Health Plans K9 $10 None $5 $15 $15 fffff* N2

Hospital per Stay Deductible/Copay is the amount you pay when you

are admitted into a hospital.

Plan name

Prescription 

drugs

Enrollee Survey Results

h above average, * average, f below average

Generic

Primary

care 

doctor

office

copay

Hospital 

per 

stay

deductible/

copay Brand

Name

Nonformulary

Overall plan satisfactionGetting needed care Getting care quickly How well doctorscommunicate Customer service Claims processing Accredited

Plan

code
25

New Jersey

GHI Health Plan

- In-Network

80

$15 None $10 $20 $50 hh**ff

- Out-of-Network 50% of sch. None N/A N/A N/A

Aetna U. S. Healthcare, Inc. P3 $15 $100-$300 $10 $20 50% *hhh** N1

AmeriHealth HMO FK $30 None $15 $25 $35 *hh*** N1

HealthNet of Pennsylvania 27 $10 None $10 $20 $35 **hhf*

New Mexico

Cimarron Health Plan PX $10 None $5 $8 $8 fff*f* N3

Lovelace Health Plan Q1 $10 None $5 $15 $35 *hff*f N2

Presbyterian Health Plan P2 $10 None $5 $15 $15 *fff** N2

Enrollee Survey Results — See pages 1-2 for a description. 

An (X) means the plan did not conduct the survey as we asked.

Accredited — The National Committee for Quality Assurance (N); 

the Joint Commission on Accreditation of Healthcare Organizations (J);

and/or the American Accreditation Healthcare Commission/URAC (U). 

See pages 2 and 7 for details. A lower number means a better accreditation.

Prescription drugs — Generic, Brand Name, and Non-formulary shows

what you pay for prescriptions when you use a plan pharmacy. Non-formulary

refers to prescriptions that are not on the plan’s preferred list. Some plans charge

different amounts for some drugs and for mail orders. In many plans, if you get

the brand name instead of the generic drug, you also pay the difference between

the two.

Plan name

Prescription 

drugs

Enrollee Survey Results

h above average, * average, f below average

Generic

Primary

care 

doctor

office

copay

Hospital 

per 

stay

deductible/

copay Brand

Name

Nonformulary

Overall plan satisfactionGetting needed care Getting care quickly How well doctorscommunicate Customer service Claims processing Accredited

Plan

code
Health Maintenance Organization (HMO) and Point of Service (POS) Plans

How to read this chart: The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures

before making your final decision. This chart does not show all of your possible out-of-pocket costs.

Primary Care Doctor Office shows what you pay for each office visit to

your primary care doctor. 

26

New York

GHI Health Plan

- In-Network

80

$15 None $10 $20 $50 hh**ff

- Out-of-Network 50% of sch. None N/A N/A N/A

Aetna U. S. Healthcare, Inc. JC $20 $200-$600 $10 $20 50% **f**f N1

Aetna U. S. Healthcare, Inc. TG $20 $200-$600 $10 $20 50% **f**f N1

Blue Choice MK $10 None $5 $15 $30 hhhhhh N2

C.D.P.H.P. PW $10 None $5 $20 $20 hhh*hh N1

C.D.P.H.P. QB $10 None $5 $20 $20 hhh*hh N1

C.D.P.H.P. SG $10 None $5 $20 $20 hhh*hh N1

GHI HMO Select 6V $10 None $10 $20 $30 ffh*ff N6

GHI HMO Select X4 $10 None $10 $20 $30 ffh*ff N6

Health Net, Inc. PD $10 None $10 $20 $35 *h***f

HIP of Greater New York 51 $10 None $10 $15 $35 **ff*f N2

HMO Blue AH $10 None $5 $20 $35 *hh*ff N1

HMO-CNY EB $10 None $5 $20 $35 *hhh** N1

Independent Health Assoc QA $10 None $5 $15 $30 hhhhhh N1

MVP Health Plan GA $10 None $5 $20 $20 hhhhhh N2

MVP Health Plan M9 $10 None $5 $20 $20 hhhhhh N2

MVP Health Plan MX $10 None $5 $20 $20 hhhhhh N2

Preferred Care GV $10 None $10 $20 $35 hhhhhh N1

Univera Healthcare - CNY QE $10 None $5 $15 $35 *hh*** N3

Univera Healthcare - CNY SH $10 None $5 $15 $35 *hh*** N3

Univera Healthcare - WNY Q8 $10 None $5 $15 $35 hhhhhh N1

Vytra Health Plans J6 $10 None $5 $5 $5 hh****

Hospital per Stay Deductible/Copay is the amount you pay when you

are admitted into a hospital.

Plan name

Prescription 

drugs

Enrollee Survey Results

h above average, * average, f below average

Generic

Primary

care 

doctor

office

copay

Hospital 

per 

stay

deductible/

copay Brand

Name

Nonformulary

Overall plan satisfactionGetting needed care Getting care quickly How well doctorscommunicate Customer service Claims processing Accredited

Plan

code
27

North Dakota

Heart of America HMO RU $10 None 50% 50% 50%

Ohio

Aetna U. S. Healthcare, Inc. 7D $20 $200-$600 $10 $20 50% N2

Aetna U. S. Healthcare, Inc. RD $20 $200-$600 $10 $20 50% f*hhff N2

AultCare HMO 3A $10 None $5 $10 $10 hhhhhh

Health Maintenance Plan(HMP) R5 $10 None $8 $15 $25 *hhh**

Health Plan Upper OH Valley U4 $10 None $10 $20 $35 hhhhhh N1

HMO Health Ohio L4 $10 None $10 $20 $20 ****ff N2

Kaiser Permanente 64 $10 None $5 $15 $15 *h*fh* N1

Paramount Health Care U2 $10 None $5 $15 $25 hhhhhh N2

SummaCare Health Plan 5W $10 None $5 $10 $10 hhhh** N1

SuperMed HMO 5M $10 None $10 $20 $20 ****ff N2

United Health Care of Ohio, Inc. 3U $15 $100 $10 $15 $30 *h***f N1

Enrollee Survey Results — See pages 1-2 for a description. 

An (X) means the plan did not conduct the survey as we asked.

Accredited — The National Committee for Quality Assurance (N); 

the Joint Commission on Accreditation of Healthcare Organizations (J);

and/or the American Accreditation Healthcare Commission/URAC (U). 

See pages 2 and 7 for details. A lower number means a better accreditation.

Prescription drugs — Generic, Brand Name, and Non-formulary shows

what you pay for prescriptions when you use a plan pharmacy. Non-formulary

refers to prescriptions that are not on the plan’s preferred list. Some plans charge

different amounts for some drugs and for mail orders. In many plans, if you get

the brand name instead of the generic drug, you also pay the difference between

the two.

Plan name

Prescription 

drugs

Enrollee Survey Results

h above average, * average, f below average

Generic

Primary

care 

doctor

office

copay

Hospital 

per 

stay

deductible/

copay Brand

Name

Nonformulary

Overall plan satisfactionGetting needed care Getting care quickly How well doctorscommunicate Customer service Claims processing Accredited

Plan

code
Health Maintenance Organization (HMO) and Point of Service (POS) Plans

How to read this chart: The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures

before making your final decision. This chart does not show all of your possible out-of-pocket costs.

Primary Care Doctor Office shows what you pay for each office visit to

your primary care doctor. 

28

Oklahoma

Amcare Health Plans ZX $10 None $5 $15 50% N6

PacifiCare Health Plans 2N $10 None $5 $15 $15 *fff*h N1

Oregon

Kaiser Permanente-High 57 $10 None $10 $20 $20 *hffhh N1

Kaiser Permanente-Std 57 $15 None $15 $30 $30 *hffhh N1

PacifiCare Health Plans 7Z $10 None $5 $15 $15 ff**fh N1

Panama

Panama Canal Area

- In-Network

43

$10 $75 50% 50% 50%

- Out-of-Network 50% $125 50% 50% 50%

Hospital per Stay Deductible/Copay is the amount you pay when you

are admitted into a hospital.

Plan name

Prescription 

drugs

Enrollee Survey Results

h above average, * average, f below average

Generic

Primary

care 

doctor

office

copay

Hospital 

per 

stay

deductible/

copay Brand

Name

Nonformulary

Overall plan satisfactionGetting needed care Getting care quickly How well doctorscommunicate Customer service Claims processing Accredited

Plan

code
29

Pennsylvania

Aetna U. S. Healthcare, Inc. P3 $15 $100-$300 $10 $20 50% N1

HealthAmerica Pennsylvania 26 $10 None $8 $14 $35 hhhhhh N1

HealthAmerica Pennsylvania SW $10 None $8 $14 $35 hhhhhh N1

HealthGuard NQ $10 None $10 $25 $40 hhh*hh N1

Keystone Health Plan Central S4 $10 None $10 $10 $10 hhhhhh N1

Keystone Health Plan East ED $10 None $5 $5 $5 *hhhhh N1

KeystoneBlue EF $10 $100 $8 $14 $14 hhh*hh N1

HealthNet of Pennsylvania 27 $10 None $10 $20 $35 **hhf*

HealthNet of Pennsylvania 2K $10 None $10 $20 $35 

UPMC Health Plan 8W $10 None $5 $15 $15 XXXXXX

Puerto Rico

Triple-S

- In-Network

89

$7.50 None $2 $5/$10 $10 or 20% hhfhhf

- Out-of-Network $7.50 + 10% Most 25% 25% 25%

Enrollee Survey Results — See pages 1-2 for a description. 

An (X) means the plan did not conduct the survey as we asked.

Accredited — The National Committee for Quality Assurance (N); 

the Joint Commission on Accreditation of Healthcare Organizations (J);

and/or the American Accreditation Healthcare Commission/URAC (U). 

See pages 2 and 7 for details. A lower number means a better accreditation.

Prescription drugs — Generic, Brand Name, and Non-formulary shows

what you pay for prescriptions when you use a plan pharmacy. Non-formulary

refers to prescriptions that are not on the plan’s preferred list. Some plans charge

different amounts for some drugs and for mail orders. In many plans, if you get

the brand name instead of the generic drug, you also pay the difference between

the two.

Plan name

Prescription 

drugs

Enrollee Survey Results

h above average, * average, f below average

Generic

Primary

care 

doctor

office

copay

Hospital 

per 

stay

deductible/

copay Brand

Name

Nonformulary

Overall plan satisfactionGetting needed care Getting care quickly How well doctorscommunicate Customer service Claims processing Accredited

Plan

code
Health Maintenance Organization (HMO) and Point of Service (POS) Plans

How to read this chart: The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures

before making your final decision. This chart does not show all of your possible out-of-pocket costs.

Primary Care Doctor Office shows what you pay for each office visit to

your primary care doctor. 

30

Rhode Island

Blue Chip, Coord Hlth Partners

- In-Network

DA

$10 None $5 $15 $30 hhhhh* N1

- Out-of-Network 20% None $30 + 20% $30 + 20% $30 + 20%

South Dakota

Sioux Valley Health Plan

- In-Network AU $10 $100 $10 $20 $20 J3,N6

- Out-of-Network 40% 40% 40% 40% 40% 40%

Avera Health Plan AV $10 $250 $10 $20 $35 

Tennessee

Aetna U. S. Healthcare, Inc. 6J $20 $200-$600 $10 $20 50% ff**ff N1

Aetna U. S. Healthcare, Inc. UB $20 $200-$600 $10 $20 50% **f*** N1

HealthSpring 6K $10 None $10 $20 $35 N1

Hospital per Stay Deductible/Copay is the amount you pay when you

are admitted into a hospital.

Plan name

Prescription 

drugs

Enrollee Survey Results

h above average, * average, f below average

Generic

Primary

care 

doctor

office

copay

Hospital 

per 

stay

deductible/

copay Brand

Name

Nonformulary

Overall plan satisfactionGetting needed care Getting care quickly How well doctorscommunicate Customer service Claims processing Accredited

Plan

code
31

Texas

Mercy Health Plans/Premier -

In-Network

HM

$10 None $7 $12 $25 hh*hhh

- Out-of-Network 40% 40% N/A N/A N/A

Amcare Health Plans 2V $10 None $5 $15 50% XXXXXX N6

Amcare Health Plans ZG $10 None $5 $15 50% N6

FIRSTCARE 6U $10 None $10 $20 $30 f**h**

FIRSTCARE CK $10 None $10 $20 $30 hhhhhh

HMO Blue Texas YM $10 $100 $5 $10 $25 fff*ff N2

HMO Blue Texas YX $10 $100 $5 $10 $25 fff*** N2

Humana Health Plan of Texas UR $10 None $5 $20 $40 ffff*f

PacifiCare Health Plans GF $10 None $5 $15 $15 fff*ff N2

Utah

Altius Health Plans 9K $10 None $10 $15 $30 f*f*ff

Vermont

MVP Health Plan VW $10 None $5 $20 $20 *hhhhh N2

Enrollee Survey Results — See pages 1-2 for a description. 

An (X) means the plan did not conduct the survey as we asked.

Accredited — The National Committee for Quality Assurance (N); 

the Joint Commission on Accreditation of Healthcare Organizations (J);

and/or the American Accreditation Healthcare Commission/URAC (U). 

See pages 2 and 7 for details. A lower number means a better accreditation.

Prescription drugs — Generic, Brand Name, and Non-formulary shows

what you pay for prescriptions when you use a plan pharmacy. Non-formulary

refers to prescriptions that are not on the plan’s preferred list. Some plans charge

different amounts for some drugs and for mail orders. In many plans, if you get

the brand name instead of the generic drug, you also pay the difference between

the two.

Plan name

Prescription 

drugs

Enrollee Survey Results

h above average, * average, f below average

Generic

Primary

care 

doctor

office

copay

Hospital 

per 

stay

deductible/

copay Brand

Name

Nonformulary

Overall plan satisfactionGetting needed care Getting care quickly How well doctorscommunicate Customer service Claims processing Accredited

Plan

code
Health Maintenance Organization (HMO) and Point of Service (POS) Plans

How to read this chart: The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures

before making your final decision. This chart does not show all of your possible out-of-pocket costs.

Primary Care Doctor Office shows what you pay for each office visit to

your primary care doctor. 

32

Virginia

Piedmont Community Healthcare

- In-Network

2C

$10 None $5 $15 $15 

- Out-of-Network 30% None $5 $15 $15 

Aetna U. S. Healthcare, Inc.-High JN $15 $100-$300 $10 $20 50% fff*ff N2

Aetna U. S. Healthcare, Inc.-Std JN $20 $200-$600 $10 $20 50% fff*ff N2

CareFirst BlueChoice* 2G $10 None $10 $20 $35 ****ff N2

HealthKeepers X8 $10 $100 $5 $10 $25 **f**h N1

Kaiser Permanente E3 $10 $100 $10 $20 $20 *f*fhf N2

MD-IPA JP $10 None $5 $15 $30 hh**h* N1

OPTIMA Health Plan 9R $10 None $10 $20 $40 hhhhhh N1

Washington

Aetna U. S. Healthcare, Inc. 8J $15 $100-$300 $10 $20 50% ff**ff

Group Health Cooperative 54 $10 $100-$300 $10 $20 $20 ****** N1

Group Health Cooperative VR $10 $100-$300 $10 $20 $20 ****** N1

Kaiser Permanente-High 57 $10 None $10 $20 $20 *hffhh N1

Kaiser Permanente-Std 57 $15 None $15 $30 $30 *hffhh N1

Kitsap Physicians Service-High VT $10 $200 50% 50% 50% hhhhhh

Kitsap Physicians Service-Std VT 20% None $5 $15 $100 or 50% hhhhhh

PacifiCare Health Plans 7Z $10 None $5 $15 $15 ffh*ff N1

PacifiCare Health Plans WB $10 None $5 $15 $15 ffh*ff N1

Hospital per Stay Deductible/Copay is the amount you pay when you

are admitted into a hospital.

Plan name

Prescription 

drugs

Enrollee Survey Results

h above average, * average, f below average

Generic

Primary

care 

doctor

office

copay

Hospital 

per 

stay

deductible/

copay Brand

Name

Nonformulary

Overall plan satisfactionGetting needed care Getting care quickly How well doctorscommunicate Customer service Claims processing Accredited

Plan

code

* Previously CapitalCare, which had Commendable NCQA accreditation.
33

West Virginia

Health Plan Upper OH Valley U4 $10 None $10 $20 $35 hhhhhh N1

Wisconsin

Dean Health Plan WD $10 None $10 $15 $15 hhhhhh N1

Group Health Coop WJ $10 None $6 $12 $12 hhhhhh N1

Group Hlth Coop/Eau Claire WT $10 None $10 $10 $10 hhhhhh

HealthPartners Classic-High 53 $15 None $10 $20 $20 *h**** N1

HealthPartners Classic-Std 53 $20 $200 $11 $22 $22 *h**** N1

HealthPartners Primary Clinic HQ $15 None $10 $10 $10 *h**** N1

Unity Health Plans W4 $10 None $6 $12 $24 hhh**h

Wyoming

WINhealth Partners PV $10 None $10 $15 $40

Enrollee Survey Results — See pages 1-2 for a description. 

An (X) means the plan did not conduct the survey as we asked.

Accredited — The National Committee for Quality Assurance (N); 

the Joint Commission on Accreditation of Healthcare Organizations (J);

and/or the American Accreditation Healthcare Commission/URAC (U). 

See pages 2 and 7 for details. A lower number means a better accreditation.

Prescription drugs — Generic, Brand Name, and Non-formulary shows

what you pay for prescriptions when you use a plan pharmacy. Non-formulary

refers to prescriptions that are not on the plan’s preferred list. Some plans charge

different amounts for some drugs and for mail orders. In many plans, if you get

the brand name instead of the generic drug, you also pay the difference between

the two.

Plan name

Prescription 

drugs

Enrollee Survey Results

h above average, * average, f below average

Generic

Primary

care 

doctor

office

copay

Hospital 

per 

stay

deductible/

copay Brand

Name

Nonformulary

Overall plan satisfactionGetting needed care Getting care quickly How well doctorscommunicate Customer service Claims processing Accredited

Plan

code
34

Notes
35

Notes