Introducing the 2009 Guide to

Federal Benefits

For Federal Civilian Employees

Federal Employees Health

Benefits (FEHB) Program p. 6

Federal Employees

Dental and Vision

Insurance Program (FEDVIP) p. 9

Federal Flexible

Spending Account

Program (FSAFEDS) p. 13

Federal Employees’

Group Life Insurance

(FEGLI) Program p. 16

Federal Long Term

Care Insurance

Program (FLTCIP) p. 19

Center for RI 70 ­1

Retirement and Revised November 2008

Insurance Services
Are you using the right Guide?

We have different editions of the Guide to Federal Benefits.

If you are:

Federal Civilian Employee

United States Postal Employee

United States Postal Inspector and Office of

Inspector General Employee

National Postal Professional Nurse

Covered under the Spouse Equity Provisions of

FEHB Law or similar statutes providing coverage

to former spouses.

Temporary Continuation of Coverage (TCC)

Receiving Compensation from the Office of

Workers’ Compensation Programs (OWCP)

Certain Temporary Employees

Those eligible to enroll in the FEHB

Program under 5 U.S.C. 8906a

Certain Temporary (Non­Career) United States

Postal Service Employees

Federal Retiree or Survivor

Federal Deposit Insurance Corporation

Employee

Your Guide is:

Federal Civilian Employees

(RI 70­1)

USPS Career Employees

(RI 70­2)

United States Postal Inspectors and Office of

Inspector General Employees

(RI 70­2IN)

United States Postal Service Professional Nurses

(RI 70­2NU)

Temporary Continuation of Coverage (TCC) and

Former Spouse Enrollees

(RI 70­5)

Temporary Continuation of Coverage (TCC) and

Former Spouse Enrollees

(RI 70­5)

Individuals Receiving Compensation From the Office

of Workers' Compensation Programs (OWCP)

(RI 70­6)

Certain Temporary Employees

(RI 70­8)

Certain Temporary (Non­Career) United States Postal

Service Employees

(RI 70­8PS)

Federal Retirees and Their Survivors

(RI 70­9)

For Federal Deposit Insurance Corporation (FDIC)

Employees

(RI 70­14)

Contact your Agency Benefits Office to request the appropriate copy of the Guide to Federal Benefits or visit

http://www.opm.gov/insure/health/planinfo/guides/guides.asp
Introduction to Federal Benefits and This Guide

As a Federal employee, the benefits available to you represent a significant piece of your

compensation package. They may provide important insurance coverage to protect you and

your family, and/or, in some cases, offer tax advantages that reduce the burden in paying for

some health products and services, or dependent or elder care services.

The purpose of this Guide is to provide you basic information about the benefits offered to

you as a Federal employee, and assist you in making informed choices about these benefits as

you move through your career and prepare for retirement.

Benefits Programs Included in this Guide

In addition to your Civil Service or Federal Employees Retirement System benefits and the

Thrift Savings Plan, the Federal government offers five benefits programs to eligible employees

and retirees. This Guide includes information on the five programs:

• Federal Employees Health Benefits Program

• Federal Employees Dental and Vision Insurance Program

• Federal Flexible Spending Account Program

• Federal Employees’ Group Life Insurance Program

• Federal Long Term Care Insurance Program

If you are a new Federal employee or have recently become eligible for benefits, the Guide

will walk you through the benefits offered, and provide information of how and when to

make your choices. If you are a current employee, it will provide the most current information

regarding the benefit programs, and will support you as you make decisions during the

annual Federal Benefits Open Season, or experience life events that cause you to reconsider

previous choices.

The Guide also contains some tips on what to consider as you make your decisions. For

instance, did you know that the Federal Employees Health Benefits (FEHB) Program, the

Federal Employees Dental and Vision Insurance Program (FEDVIP) and/or the Federal Flexible

Spending Account Program (FSAFEDS) can potentially provide you with greater benefits

without costing you much more? As a Federal employee, you can choose to pay the FEDVIP

and FEHB premiums with pre­tax dollars and you can use pre­tax FSA dollars to pay for

eligible expenses including FEDVIP and FEHB copays and deductibles. Dental and vision care

are also eligible FSA expenses, whether combined with FEDVIP coverage or not. Please take a

moment to review the information in this Guide and decide upon the right choices for you.

Additional Information

You will find references throughout the Guide to websites or other locations to obtain more

detailed information than is available here. We encourage you to access these sites to become

a more educated decision­maker and consumer of Federal benefit programs.

i
Federal Employees Health Benefits (FEHB) Program

Health Information Technology and Price/Cost Transparency Leaders

Over the past few years, OPM has encouraged FEHB health benefits plans to increase their use of

health information technology (HIT). HIT can help your health plan and healthcare providers

deliver safer more efficient care. Using HIT, your health plan can offer you tools to help you

organize your health information, access information targeted to your health needs, and determine

the quality and price/cost of the doctors, hospitals and other providers that you and your family use

for day­to­day healthcare needs.

HIT based on broadly accepted standards, allows patients, healthcare providers and health plans to

share information securely, driving down costs by avoiding duplicate procedures and manual

transactions. More importantly, HIT reduces medical errors; for instance, from misread handwritten

prescriptions, and emergency care medical decisions made without complete and accurate health

information. HIT can also help you find appropriate health information to aid you and your doctor

in making appropriate clinical decisions regarding your care. Since privacy and security

considerations are vitally important, safeguards have been established to keep your records safe from

inappropriate disclosure.

Personal Health Records

The health plans listed below have made a commitment to offer you and your family access to

internet based personal health records (PHR). PHRs come in a variety of forms but what they all

have in common is that they give you a convenient way to track, view, and manage your personal

health information. PHRs also allow you to share your health information with your healthcare

providers so they have a better picture of your health history. When providers know your health

history they can make more accurate diagnoses and provide you with safer more efficient care.

Quality and Price/Cost Transparency On­line Tools

The health plans listed here have also made a commitment to offer you and your family access to

healthcare quality and price/cost information so you can make more informed choices on which

providers to use to receive care. The web site information available includes online decision tools

with cost estimators and quality indicators for physician and hospital services and prescription drugs

used to treat common or chronic illnesses and conditions. These health plans describe the sources

of this health information and any limitations so you can understand what the information means.

Some examples of the types of surgical procedures for which you can obtain cost and quality

information include: arthroscopy knee/shoulder, breast biopsy, cataract repair, cesarean delivery,

colonoscopy, corneal surgery, gall bladder removal, heart catheterization, hysterectomy, inguinal

hernia repair, knee replacement, and tonsillectomy. This information helps you understand the true

price/cost and quality of your healthcare and enhances your ability to compare hospital, physician,

prescription and other provider value as you make healthcare choices. FEHB health plans are

working to expand the price/cost and quality information they provide to you.

The health plans listed on the following page met OPM's HIT, quality and price/cost transparency

standards at the time this Guide went to press. As other plans bring these tools on line, we will add

them to the list on our website. So, please check the updated information at www.opm.gov/insure

before you make your healthcare decisions.

ii
Federal Employees Health Benefits (FEHB) Program

Health Information Technology and Price/Cost Transparency Leaders

The following health plans have demonstrated their commitment to efficiency, safety and quality

through computer system enhancements that offer PHRs, quality information, and price/cost

transparency decision support tools:

Aetna Health Plans

Altius Health Plans

Anthem Blue Cross HMO

APWU Health Plans

AvMed Health Plans

BlueCross BlueShield Government Wide

Service Benefit Plan
 

Blue Cross & Blue Shield of RI
 

CareFirst BlueChoice, Inc
 

ConnectiCare, Inc
 

Coventry Health Care Plans
 

Blue Care Network of Michigan
 

Blue Preferred HMO
 

Geisinger Health Plan
 

GHI Health Plan
 

Government Employees
 

Health Association, Inc. (GEHA)

Group Health Plan

Health Alliance Plan (HAP)

Health America Pennsylvania

Health Net of Arizona, Inc.

Health Net of California

HealthPartners, Inc.

HealthPlus of Michigan

HIP Health Plan of New York

HMO Health Ohio

Humana Health Plans

Independent Health Association

Kaiser Foundation Health Plans

KPS Health Plans

Mail Handlers Benefit Plan

M.D. IPA

Medica Health Plans

MVP Health Care, Inc.

NALC Health Benefit Plan

Optima Health

PacifiCare Health Plans

PersonalCare of Illinois

Physicians Health Plan of Northern Indiana, Inc.

Preferred Care

SAMBA

UniCare Health Plans of the Midwest, Inc.

UnitedHealthcare (except the River Valley, Inc.,

in Iowa and Illinois)

UPMC Health Plan

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iv
 
Table of Contents

Page:

Federal Benefits Open Season Snapshot .............................................................................................................................. 1
 

Federal Benefits Snapshot ...................................................................................................................................................... 2
 

Thinking about Retiring? ........................................................................................................................................................ 3
 

Federal Employees Health Benefits (FEHB) Program ........................................................................................................ 6
 

Federal Employees Dental and Vision Insurance Program (FEDVIP) .............................................................................. 9
 

Federal Flexible Spending Account Program (FSAFEDS) ................................................................................................ 13
 

Federal Employees’ Group Life Insurance (FEGLI) Program .......................................................................................... 16
 

Federal Long Term Care Insurance Program (FLTCIP) .................................................................................................... 19
 

Appendix A: FEHB Program Features ................................................................................................................................ 21
 

Appendix B: Choosing an FEHB Plan ................................................................................................................................ 22
 

Appendix C: Qualifying Life Events that May Permit a Change in Your FEHB Enrollment .......................................... 27
 

Appendix D: FEHB Member Survey Results ...................................................................................................................... 28
 

Appendix E: FEHB Plan Comparison Charts .................................................................................................................... 29
 

• Fee­for­Service .......................................................................................................................................................... 30
 

• Health Maintenance Organization Plans and Plans Offering a Point­of­Service Product ................................ 35
 

• High Deductible and Consumer­Driven Health Plans ..........................................................................................60
 

Appendix F: FEDVIP Program Features ............................................................................................................................ 99
 

Appendix G: FEDVIP Definitions ...................................................................................................................................... 100
 

Appendix H: FEDVIP Qualifying Life Events for Enrollment Changes ........................................................................ 101
 

Appendix I: FEDVIP Plan Comparison Charts ................................................................................................................ 102
 

• Nationwide and International Dental Plans Open to All .................................................................................. 103
 

• Regional Dental Plans ............................................................................................................................................ 104
 

• Nationwide and International Vision Plans Open to All .................................................................................... 105
 

Appendix J: FEDVIP Dental Rating Regional Chart ........................................................................................................ 106
 

Appendix K: FEDVIP Premium Rate Charts .................................................................................................................... 109
 

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vi
 
Federal Benefits Open Season Snapshot

Current Employees

During Open Season, you have the opportunity to make changes in the Federal Employees Health

Benefits (FEHB) Program, the Federal Employees Dental and Vision Insurance Program (FEDVIP)

and the Federal Flexible Spending Account Program (FSAFEDS). You can use this chart to assist you

with the decision­making process of selecting plans and enrolling in these benefit programs.

If Currently Enrolled in the Program If Not Enrolled in the Program

FEHB 1. Check your plan’s 2009 premiums and satisfaction survey

results in Appendix E;

2. Examine your plan’s 2009 brochure for benefit and

enrollment/service area changes;

3. Check Appendix E for any new plans and plan options

available to you;

4. If satisfied with your plan’s rates, survey results and

benefits for 2009, do nothing – your enrollment will

continue automatically;

5. If not satisfied with your current plan for 2009, see

Appendix B for guidance on choosing another plan.

1. See page 6 for general information on FEHB (including

eligibility) and Appendix B for guidance on choosing a

plan;

2. If you decide to enroll, examine the 2009 brochure of

each plan you consider to ensure the benefits and

premiums meet your needs and the plan is available in

your area;

3. Contact the human resources office of your agency for

information on how to enroll.

FEDVIP 1. Check your plan’s 2009 premiums in Appendix K and

examine your plan’s 2009 brochure for benefit and

enrollment/service area changes;

2. If also enrolled in FEHBP, check your 2009 FEHBP

brochure for any changes in dental and/or vision benefits;

3. If satisfied with your plan’s rates and benefits for 2009, do

nothing – your enrollment will continue automatically;

4. If not satisfied with your current plan for 2009, see

page 9 for guidance on choosing another plan and for

information on how to change your enrollment;

5. If you no longer want FEDVIP, you must cancel during

Open Season by contacting BENEFEDS; after Open

Season you cannot cancel; see Appendix H for details.

1. See page 9 for general information on FEDVIP

(including eligibility) and for guidance on choosing a

FEDVIP plan;

2. If you decide to enroll, examine the 2009 brochure of

the plans in which you are interested to ensure the

benefits and premiums meet your needs and the plan

is available in your area;

3. See page 11 for information on how to enroll.

FSAFEDS 1. If you want to participate in 2009, you must make a

new election. Keep in mind your election and

enrollment do not carry over from year to year; see page

for information on how to enroll;

2. Check your 2009 FEHBP and 2009 FEDVIP plan brochures

to see how any benefit changes may affect your out­ofpocket health care expenses;

3. See page 13 for any updated information about

the Program.

1. See page 13 for general information on FSAFEDS

(including eligibility) and for guidance on making a

decision whether to participate;

2. See page 15 for information on how to enroll.

1
Federal Benefits Snapshot

New or Newly Eligible Employees

As a new or newly eligible employee, you may have the opportunity to enroll in the benefit

programs noted below. Use this chart to assist you with the decision­making process of

selecting and enrolling in the benefit programs below that meet your needs. The chart gives

you things to consider as you make your decisions.

FEHBP 1. See page 6 for general information on FEHBP (including eligibility) and for guidance on

choosing a plan;

2. If you decide to enroll, examine the 2009 brochure of each plan you consider to ensure

the benefits and premiums meet your needs and the plan is available in your area;

3. Contact the human resources office of your agency for information on how to enroll.

FEDVIP 1. See page 9 for general information on FEDVIP (including eligibility) and for guidance on

choosing a FEDVIP dental plan and/or vision plan;

2. If you decide to enroll, examine the 2009 brochure of each plan you consider to ensure

the benefits and premiums meet your needs and the plan is available in your area;

3. See page 11 for information on how to enroll.

FSAFEDS 1. See page 13 for general information on FSAFEDS (including eligibility) and for guidance

on making a decision whether to participate;

2. See page 15 for information on how to enroll.

FEGLI 1. See page 16 for general information on FEGLI (including eligibility) and for guidance on

making a decision whether to select optional insurance (basic FEGLI is automatic);

2. See page 18 for information on how to enroll.

1. See page 19 for general information on FLTCIP (including eligibility) and for guidance

FLTCIP on making a decision whether to apply;

2. See page 20 for information on how to apply for coverage.

2
Thinking About Retiring?

Federal Benefits Facts

FEHB

• When you retire, you are eligible to continue health benefits coverage if you meet all of the

following requirements:

– you are entitled to retire on an immediate annuity under a retirement system for civilian

employees (including the Federal Employees Retirement System (FERS) Minimum

Retirement Age (MRA) + 10 retirement); and

– you have been continuously enrolled (or covered as a family member) in any FEHB

plan(s) for the 5 years of service immediately before the date your annuity starts, or for

the full period(s) of service since your first opportunity to enroll (if less than 5 years).

• The 5 year requirement period can include the following:

– the time you are covered as a family member under another person's FEHB enrollment; or

– the time you are covered under the Uniformed Services Health Benefits Program (also

known as TRICARE) as long as you were covered under an FEHB enrollment at the time

of your retirement.

• As an annuitant, you are entitled to the same benefits and Government contributions as

Federal employees enrolled in the same plan.

• The event of retirement is not a qualifying life event (QLE); however, there are other

opportunities to change FEHB enrollment including during Open Season or when you

experience a QLE.

• If you are not enrolled in FEHB (or covered as a family member) at the time of your
 

retirement, you cannot enroll when you retire.
 

• If you are enrolled in a High Deductible Health Plan (HDHP) with a Health Savings Account

(HSA) at the time of your retirement, you can still contribute to your HSA provided you have

no other insurance coverage other than those specifically allowed, and are not claimed as a

dependent on someone else’s tax return. Some examples of other coverage that would cause

ineligibility are: Medicare, TRICARE, other non­high deductible health insurance, or having

received VA benefits within the previous three months. If you don’t qualify for an HSA, your

plan will enroll you in a Health Reimbursement Arrangement (HRA).

• If you cancel your FEHB enrollment as an annuitant, you will never be able to re­enroll in

FEHB unless you had suspended your FEHB enrollment in order to enroll in a Medicare

Advantage plan, TRICARE or CHAMPVA, or Medicaid or similar State­sponsored program of

medical assistance.

• If you want your surviving family members to continue your health benefits enrollment after

your death, you must be enrolled for Self and Family at the time of your death, and at least

one family member must be entitled to an annuity as your survivor.

• Consider whether you need to sign­up for Medicare when you become eligible.

FEDVIP

• There is no 5 year requirement for continuing FEDVIP coverage into retirement.

• Your coverage will continue as a retiree. Retirees may also enroll during the annual Federal

Benefits Open Season or when you experience a qualifying life event (QLE). Keep in mind

that retirement is not a QLE.

3
Thinking About Retiring?

Federal Benefits Facts continued

• In most cases, changing from payroll deduction to annuity deduction is automatic, but may

take one to three months to occur.

• BENEFEDS cannot deduct premiums from your annuity while you are receiving “special” or

“interim” pay. Once your annuity is finalized, premium deductions will begin. If you miss one

or more premium payments before your annuity is final, BENEFEDS will make double

deductions until any balance due is paid. They will notify you before deducting this additional

premium amount. Once there is no past due balance, the amount of premium deducted will

return to the regular monthly premium.

FSAFEDS

• When you retire, you will no longer be able to participate in FSAFEDS. Your FSA will

terminate as of the date of your retirement, and you will not be eligible to enroll as an

annuitant. When you make your annual election for the year that you plan to retire, keep in

mind that any remaining funds for which you have not incurred eligible expenses while

employed will be forfeited.

• You can still submit claims for eligible medical expenses incurred prior to the date of your

retirement.

• You can continue to use the remaining balance in your Dependent Care Flexible Spending

Account (DCFSA) to pay for eligible dependent care expenses until the end of the Benefit

Period or until your account balance is used up, whichever comes first.

• If you used your entire elected amount before you contributed all of it from your pay, you

will not be responsible for the remaining payments.

FEGLI

• When you retire, you are eligible to continue your FEGLI life insurance coverage(s) if you

retire on an immediate annuity and had the coverage for:

– the five years of service immediately before the starting date of your annuity or, for

annuitants retiring under FERS who postpone receiving their annuity, the five years

immediately before their separation date for annuity purposes, or

– all period(s) of service during which that coverage was available to you if it is less than

five years, and

– you (or your assignees) do not convert the coverage to a private policy.

• If you are eligible, you will choose via Standard Form (SF) 2818 how you wish your
 

coverage(s) to continue during your retirement.
 

• If you are not enrolled in FEGLI at the time of your retirement, you cannot enroll when

you retire.

• You cannot newly elect or increase existing coverage after you retire. You may only reduce or

cancel coverage.

• Your premiums are subject to change in the future. Your premium could change based on

your age and the experience of the Program. You will be notified if there is any change in

your deductions from your annuity.

4
Thinking About Retiring?

Federal Benefits Facts continued

FLTCIP

• Your coverage continues into retirement provided you continue to pay premiums.

• If you pay premiums via payroll deduction, then shortly before you retire, you should

notify Long Term Care Partners (LTCP) at 1­800­582­3337 to make other arrangements for

premium payment.

• You may elect annuity deduction if you desire. LTCP cannot deduct your premium from

“special” or “interim” pay. LTCP will send you a direct bill during this time. Premium

deduction will begin from your annuity once it is finalized.

5
Federal Employees Health Benefits (FEHB) Program

What does this Program offer?

The FEHB Program offers a wide variety of plans and coverage to help you meet your health care

needs. It is group coverage available to employees, retirees and their dependents. If you continuously

maintain your FEHB enrollment, or are covered by the FEHB enrollment as a family member, or a

combination of both, for the five years of service immediately preceding your retirement, and you

retire on an immediate annuity, you can continue to participate in the FEHB after retirement. The

Program benefits you receive as a retiree are the same coverage Federal employees receive and at the

same cost. If you leave government employment before retiring, the Program offers temporary

continuation of coverage (TCC) and an opportunity to convert your enrollment to non­group (private)

coverage.

If you are currently enrolled in the FEHB and do not want to change plans or enrollment type, you do

not need to do anything. Your enrollment will continue automatically.

Appendix E includes a comparison chart of all the plans in the FEHB with information comparing

basic benefits and costs.

Key FEHB facts

• The FEHB Program is part of the annual Federal Benefits Open Season.

• FEHB coverage continues each year. You do not need to re­enroll each year. If you are happy

with your current coverage, do nothing. Please note that your premiums and benefits may change.

• You can choose from Consumer­Driven and High Deductible plans that offer catastrophic risk

protection with higher deductibles, health savings/reimbursable accounts and lower premiums, or

Health Maintenance Organizations or Fee­for­Service plans with comprehensive coverage and

higher premiums.

• There are no waiting periods and no pre­existing condition limitations, even if you change plans.

• If you are an active Federal employee, you can use your Health Care Flexible Spending Account

or Limited Expense Health Care Flexible Spending Account with your FEHB plan.

• If you participate in premium conversion, enrollment changes can only be made during Open

Season or if you experience a qualifying life event. Premium conversion allows Federal employees

to use pre­tax dollars to pay their FEHB health insurance premiums.

• All nationwide FEHB plans offer international coverage.

• There are separate and/or different provider networks for each plan.

• Utilizing an in­network provider will reduce your out­of­pocket costs.

What enrollment types are available?

• Self Only, which covers only the enrolled employee;

• Self and Family, which covers the enrolled employee and all eligible family members.

6
Federal Employees Health Benefits (FEHB) Program

How much does it cost?

The premiums for your enrollment are shared by you and your Federal agency or retirement system.

The government pays the lesser of: 72% of the average total premium of all plans weighted by the

number of enrollees in each, or 75% of the premium for the specific plan you choose. If you are an

employee, you automatically pay your share of the premium through a payroll deduction using pretax dollars, unless you elect not to participate in Premium Conversion. The charts in Appendix E

provide cost information for all plans in the FEHBP.

Am I eligible to enroll?

Most employees are eligible; those who are not eligible usually have limited appointments of short

duration, or work sporadically only during certain seasons or when needed by their Federal agency.

If you have an appointment other than a career or career conditional appointment and your agency

has not provided you information about enrollment, you should contact your human resources office

for information.

When you retire, you are eligible to continue health benefits coverage if you retire on an immediate

annuity under a retirement system for civilian employees (including FERS MRA + 10 retirement) and

you have been continuously enrolled (or covered as a family member) in any FEHB plan(s) for the 5

years of service immediately before the date your annuity starts, or for the full period(s) of service

since your first opportunity to enroll (if less than 5 years).

If you suspend your FEHB coverage as a retiree because you are covered by TRICARE, a Medicare

Advantage Plan, Medicaid, or Peace Corps volunteer coverage, you may reenroll under certain

conditions. (You should contact your retirement system for information on your eligibility.) If you

are not enrolled in or covered as a family member under FEHB when you retire, you will not

be able to enroll after retirement.

When can I enroll?

If you are a new employee who is eligible for FEHB or an employee who has become newly

eligible to enroll, you may enroll within 60 days of becoming eligible. You may also enroll during

the annual Open Season held from the Monday of the second full work week in November through

the Monday of the second full work week in December. Furthermore, you may enroll, change your

enrollment type, or change plans outside of Open Season if you experience a qualifying life event

such as a change in family or other insurance coverage status. Appendix C contains more specific

information about qualifying life events that permit employees to enroll or change enrollment in the

FEHB Program.

For new or newly eligible employees who elect to enroll, coverage will be effective on the first day

of the first pay period that begins after your agency receives your enrollment. An Open Season

enrollment or change is effective on the first day of the first full pay period that begins in January.

7
Federal Employees Health Benefits (FEHB) Program

How do I enroll?

You may be able to enroll using the Health Benefits Election Form (SF 2809) or through an agency

self­service system such as Employee Express, MyPay, Employee Personal Page, or EBIS. Contact the

human resources office of your employing agency for details.

How do I get more information about this Program?

Visit the FEHBP online at www.opm.gov/insure/health for information including:

• How to compare and choose among health plans

• Health plan websites and plan brochures

• How to file a disputed claim request

• Getting quality healthcare

• Medicare and FEHB

8
Federal Employees Dental and Vision Insurance Program (FEDVIP)

What does this Program offer?

The Federal Employees Dental and Vision Insurance Program provides comprehensive dental and

vision insurance at competitive group rates. There are seven dental plans and three vision plans from

which to choose. FEDVIP features nationwide, international, and regional plans.

A dental or vision insurance plan is much like a health insurance plan; you may be required to meet

a deductible and provide a copay or coinsurance payments for your dental or vision services. With

any plan choice, you should look at all the information and find a plan that will best fit your needs.

You should also review your FEHB plan brochure to determine what dental and/or vision coverage

the FEHB plan provides.

If you are currently enrolled in FEDVIP and you take no action during Open Season, your current

coverage will continue in 2009, provided you remain eligible for the program. Enrollment continues

year to year, automatically. Please Note: your premiums and benefits may change for 2009.

Key FEDVIP Facts

• FEDVIP is part of the annual Federal Benefits Open Season.

• FEDVIP is separate and different from the FEHB Program.

• FEDVIP coverage continues each year. You do not need to re­enroll each year. If you do not

want to change plans or enrollment type, do nothing.

• You can only cancel FEDVIP coverage during Open Season, upon deployment to active

military duty or upon transfer to another agency where you enroll in their dental and/or vision

plan and the agency pays at least 50% of the premium. You cannot cancel just because you

retire or because you can no longer afford the premiums.

• Coordination of benefits (COB) with your FEHB plan, if you are enrolled in an FEHB plan, is a

requirement under the FEDVIP law. The FEDVIP plan is always secondary to the FEHB plan.

• You can use your Flexible Spending Account (FSA) with FEDVIP. You can submit your FEDVIP

copayments and deductibles as eligible expenses against your FSA account.

• Cancellation of coverage can only be made during Open Season or upon deployment to active

military duty.

• All nationwide FEDVIP plans provide international coverage.

• There are separate and/or different provider networks for each plan.

• Utilizing an in­network provider will reduce your out­of­pocket costs.

• There are no pre­existing condition limitations.

• There is no opportunity to convert to a private plan when your FEDVIP coverage ends. There

is no 31­day extension of coverage, Temporary Continuation of Coverage (TCC), Spouse Equity

coverage, or right to convert to an individual policy (conversion policy).

9
Federal Employees Dental and Vision Insurance Program (FEDVIP)

What enrollment types are available?

• Self Only, which covers only the enrolled employee or retiree;

• Self Plus One, which covers the enrolled employee or retiree plus one eligible family
 

member specified by the enrollee; and
 

• Self and Family, which covers the enrolled employee or retiree and all eligible family
 

members.
 

Appendix I lists the available dental and vision insurance plans along with basic benefit information.

How much does it cost?

You pay the entire premium. There is no government contribution to the premium. If you are an

active employee, your premiums are taken from your salary on a pre­tax basis if your salary is

sufficient to make the premium withholding. When you retire, premiums are withheld from your

monthly annuity check on a post­tax basis if your annuity is sufficient.

Premiums for the nationwide dental plans and one regional dental plan are based on where you

live. This is called your rating region. Your home ZIP code is used to find your rating region. Rating

regions vary by carrier. The vision plans do not have rating regions. Enrolling in a FEDVIP plan will

not reduce your FEHB premium.

See Appendices J and K to find 1) the rating region assigned to the area where you live by the

different dental plans and 2) the related premium you will pay. You may also go to our website at

www.opm.gov/insure/dental and www.opm.gov/insure/vision for premium and rating region

information.

Am I eligible to enroll?

In general, Federal employees eligible for FEHB coverage (whether or not actually enrolled) and

retirees (regardless of FEHB status) are eligible to enroll in a dental and/or vision plan. Former

spouses and deferred annuitants are NOT eligible to enroll. Anyone receiving an insurable interest

annuity who is not also an eligible family member is NOT eligible to enroll.

When can I enroll?

If you are a new employee eligible for FEDVIP, or an employee who has become newly eligible to

enroll, you may enroll within 60 days of first becoming eligible. This is a one­time opportunity

outside of Open Season to enroll. There is a separate 60 day enrollment period for dental and vision.

For example: you may enroll in a dental plan on day 30 and a vision plan on day 59. Once you

enroll, your 60 day opportunity for that type of plan ends.

An eligible employee or retiree may also enroll during the annual Federal Benefits Open Season,

which runs from the Monday of the second full work week in November through the Monday of the

second full work week in December. An eligible employee or retiree may enroll, cancel, change

enrollment type, or options during Open Season. They may enroll or make changes outside of Open

10
Federal Employees Dental and Vision Insurance Program (FEDVIP)

Season if they experience a qualifying life event (QLE) such as a change in family or other insurance

coverage status. Please see Appendix H for more information about QLEs that permit employees and

retirees to enroll or make changes in FEDVIP.

If you enroll during Open Season, premiums are deducted beginning the first full pay period on or

after January 1. For new or newly eligible employees who elect to enroll, coverage is effective the

first day of the pay period following the one in which BENEFEDS receives your enrollment. An

Open Season enrollment or change is effective January 1.

How do I enroll?

You may enroll on the Internet at www.BENEFEDS.com. BENEFEDS is a secure enrollment website

sponsored by OPM. For those without access to a computer, please call 1­877­888­FEDS (1­877­888­

3337) (TTY number, 1­877­889­5680).

You cannot enroll in a FEDVIP plan using the Health Benefits Election Form (SF 2809) or through an

agency self­service system, such as Employee Express, MyPay or Employee Personal Page. However,

those sites may provide a link to BENEFEDS.

What should I consider in making my decision to participate in this Program?

There are questions you should ask yourself when deciding to enroll in FEDVIP or selecting a

FEDVIP plan. By considering these questions thoroughly, you will be able to determine if FEDVIP

is a good option for you.

1. Does my FEHB plan provide dental or vision coverage?

2. How does the FEDVIP plan coordinate benefits with the FEHB plan and how is the
 

coordination of benefits calculated?
 

3. How affordable is the plan?

• How much will it cost me on a bi­weekly or monthly basis? Can I afford that for the

entire year?

• Must I pay a deductible?

• If I use a FEDVIP provider outside of the network, how much will I pay to get care?

• How frequently can I visit the dentist and how much do I have to pay at each visit?

• Will the plan provide benefits if I am also covered by another dental or vision plan?

4. Do I have access to any provider?

• Does the plan give me the freedom to choose my own dentist or am I restricted to a panel

of dentists selected by the plan?

• Are there enough of the kinds of dentists I want to see?

• Where will I go for care? Are these places near where I work or live?

• Do I need to get permission before I see a dental specialist?

• Will the plan allow referrals to specialists? Will my dentist and I be able to choose the

specialist?

11
Federal Employees Dental and Vision Insurance Program (FEDVIP)

5. Does the plan provide coverage for specialty services?

• Are dentures, orthodontics, implants or replacement of missing teeth covered?

• What are the plan’s limitations or exclusions?

• Are there annual limits on the types of services included?

How do I find my premium rate?

If you live outside the United States:

Go to Appendix K for your dental and vision premium rates.

If you live inside the United States:

Go to Appendix K for your vision premium rate. To find your bi­weekly or monthly dental premium,

you must first find your rating area on the chart in Appendix J. Some plans may have changed their

rating regions for the upcoming plan year.

Please Note: If you are currently enrolled and have moved or your postal service has assigned you

a new ZIP code, your rating region may have changed.

1. To find your dental rating area:

a. Go to the chart in Appendix J.

b. Find your state and your corresponding Zip code (1st 3 digits).

c. Look under the plan name and you will find your rating area.

2. To find your bi­weekly or monthly dental premium, match your rating area with your desired

FEDVIP plan on the chart in Appendix K.

Making an informed choice

• Before selecting a plan that best suits your needs, ask your carrier or access the OPM website

for a copy of the plan brochure.

• If you have questions about coverage, exclusions, limitations or payment of benefits, ask the

plan before making your plan selection.

• Find out which plan your provider participates in and why. Keep in mind that if your provider

leaves the plan, this is not a qualifying life event allowing a change.

How do I get more information about this Program?

Visit FEDVIP on­line at www.opm.gov/insure/dental and www.opm.gov/insure/vision for

information including:

• How to enroll

• FEDVIP plan websites, brochures, and provider searches

• Dental premium rates

• Vision premium rates

12
Federal Flexible Spending Account Program (FSAFEDS)

What does this Program offer?

The Federal Flexible Spending Account Program, known as FSAFEDS, is a benefit that can save you

money. It offer accounts where you contribute money from your salary BEFORE taxes are withheld,

incur eligible expenses, and get reimbursed. It’s a way to save money on dependent care and health

care services and items for you and your family. It’s a way to pay less tax and save money!

Let’s say you make $1,000 per pay date – that means you pay taxes on $1,000 per pay date. If you

put $20 per pay date in FSAFEDS then you only pay taxes on $980 per pay date. You save money by

paying less tax. Then you get the money in your account(s) back when you timely file claims for

eligible expenses.

Key FSAFEDS facts

• FSAFEDS is part of the annual Federal Benefits Open Season.

• Retirees cannot enroll in FSAFEDS.

• Employees MUST re­enroll each year – coverage does not automatically carry over to the next

benefit period.

• If you enroll during Open Season you will have 14­1/2 months to spend your annual election.

• Enrollees must incur eligible expenses for their current benefit period by March 15th of the

following year.

• Enrollees must file claims for their current benefit period by April 30th of the following year.

• Enrollees can use FSAFEDS accounts for copayments and deductibles from their FEHB and/or

FEDVIP enrollments.

• Plan your contribution carefully and conservatively – you will lose any money in your
 

account(s) for which you do not incur eligible expenses and timely file claims.
 

What enrollment types are available?

There are three types of FSAs. Each type has a minimum annual election of $250 and a maximum

of $5,000:

• Dependent Care FSA (DCFSA) – Used for eligible dependent care (non­medical) expenses that

allow you and your spouse (if married) to work, look for work (as long as you have earned

income at some point during the year), or attend school full­time. Eligible expenses include

child care, before and after school care, late pick­up fees, and adult daycare. Dependents

covered under a DCFSA include your children before their 13th birthday, and may also include

any person you claim as a dependent on your Federal Income Tax return who is mentally or

physically incapable of self care.

13
Federal Flexible Spending Account Program (FSAFEDS)

• Health Care FSA (HCFSA) – Used for eligible health care expenses for you, your spouse, and

your dependents that are not covered or reimbursed by FEHB, FEDVIP or other insurance.

Common expenses that are reimbursable by an HCFSA include:

­ Chiropactic services
 

­ Coinsurance, copays and deductibles (but not insurance premiums)
 

­ Contact lenses, solutions, and cleaners and cases
 

­ Dental care and procedures
 

­ Eye surgery
 

­ Eyeglasses and prescription sunglasses
 

­ Hearing aids and batteries
 

­ Infertility treatments
 

­ Over­the­counter medicines and products
 

An HCFSA is not health insurance and does not replace your insurance plan. It is a separate

program that reimburses you for eligible out­of­pocket health care expenses. It can also

reimburse you for over­the­counter products that are not covered by FEHB or FEDVIP –

common items like ibuprofen, acetaminophen, aspirin, antacids, bandages, home diagnostic

tests, and sunscreen.

If you participate in an HCFSA and you are enrolled in a High Deductible Health Plan you may

also have a Health Reimbursement Arrangement (HRA) but you cannot have a Health Savings

Account (HSA).

• Limited Expense Health Care FSA (LEX HCFSA) – Designed for employees enrolled in or

covered by a High Deductible Health Plan with a Health Savings Account. Eligible expenses are

limited to dental and vision care expenses for you, your spouse, and your dependents that are

not covered or reimbursed by FEHB, FEDVIP or other insurance. By opening a Limited Expense

Health Care FSA you can save money on taxes by using your LEX HCFSA dollars for dental and

vision care while preserving your Health Savings Account funds for other purposes.

Eligible expenses include your out­of­pocket costs for services and products such as:

– Dental care (e.g., cleanings, fillings, crowns, orthodontics, etc.)

– Vision care (e.g., contact lenses, eyeglasses, refractions, vision correction procedures, etc.)

Am I eligible to enroll?

Most Federal employees in the Executive branch and many in non­Executive branch
 

agencies are eligible. For specifics on eligibility, visit www.FSAFEDS.com or call an
 

FSAFEDS Benefits Counselor toll­free at 1­877­FSAFEDS (1­877­372­3337) TTY: 1­800­952­0450,
 

Monday through Friday, 9 a.m. until 9 p.m., Eastern Time. Retirees cannot enroll.
 

14
Federal Flexible Spending Account Program (FSAFEDS)

When can I enroll?

If you are a newly hired eligible employee or an employee who has become newly eligible to enroll,

you may enroll within 60 days of becoming eligible. You may also enroll during the annual Federal

Benefits Open Season, which runs from the Monday of the second full work week in November to

the Monday of the second full work week in December. You may also enroll or make changes to

your enrollment if you experience a qualifying life event such as a change in family status. You can

find more information about qualifying life events at www.FSAFEDS.com.

Enrollment does not carry over from year to year – you must make an election every year

to participate!

Your Open Season election is effective on January 1 of the benefit year. If you are a newly hired or

newly eligible employee enrolling outside of Open Season, your effective date is the day after your

election is accepted by FSAFEDS.

How do I enroll?

You enroll at www.FSAFEDS.com or by calling 1­877­372­3337.

What should I consider in making my decision to participate in this Program?

• Do I want to participate this year? You must make a new election every year. Enrollment does

not carry over from year to year.

• What do my annual medical/dependent care out­of­pocket expenses run each year?

• Will my health, dental or vision insurance coverage be different this year? Am I changing plans

or adding other coverage? Are my copayments changing?

• Will I still have the same number of dependents?

• Plan your contribution carefully and conservatively – you will lose any money in your

account(s) for which you do not incur eligible expenses and timely file claims

How do I get more information about this Program?

Call 1­877­372­3337, TTY 1­800­952­0450, or visit www.FSAFEDS.com.

15
Federal Employees’ Group Life Insurance Program (FEGLI)

What does this Program offer?

The FEGLI Program offers group term life insurance.

Key FEGLI facts

• The FEGLI Program is not part of the annual Federal Benefits Open Season.

• Employees in eligible positions are automatically covered under Basic life insurance, unless they

choose to waive that coverage.

• Employees must have Basic insurance in order to have or elect Optional insurance.

• Employees must take action, within strict time limits, to elect Optional insurance. Coverage is

not automatic.

• The Government pays one­third of the cost of Basic insurance. Enrollees pay 100% of the cost

of Optional insurance.

• FEGLI does not have any cash or paid­up value. You cannot get a loan by borrowing from this

insurance.

• Retirees may be able to continue their FEGLI coverage into retirement, but they cannot elect

FEGLI coverage as a retiree.

• Living benefits are life insurance benefits paid to you while you are still living, rather than paid

to a beneficiary or survivor when you die. You are eligible to elect a living benefit if you are an

employee, retiree, or compensationer covered under the FEGLI Program who has been

diagnosed as terminally ill with a life expectancy of nine months or less, and you have not

assigned your insurance.

What coverage is available?

Basic insurance – your annual salary, rounded up to the next even $1,000, plus $2,000. Basic

insurance includes accidental death and dismemberment coverage for employees (not for retirees).

Optional insurance

• Option A ­ Standard – $10,000 of insurance. Option A includes accidental death and
 

dismemberment coverage for employees (not retirees).
 

• Option B ­ Additional – 1, 2, 3, 4 or 5 times your annual rate of basic pay after rounding it up

to the next even $1,000.

• Option C ­ Family – coverage for your spouse and all of your eligible dependent children. You

can elect 1, 2, 3, 4 or 5 multiples. Each multiple is equal to $5,000 for your spouse and $2,500

for each eligible child.

16
Federal Employees’ Group Life Insurance Program (FEGLI)

How much does it cost?

You pay two­thirds of the premium for Basic life insurance and the Government pays one­third. Your

cost for Basic life insurance is $0.15 biweekly, per $1,000 of coverage. Your age does not affect the cost

of Basic insurance.

You pay 100% of the premium for Optional insurance. The cost depends on your age, based on

5­year age groups.

Am I eligible to enroll?

Most Federal employees are eligible to enroll in FEGLI unless they are excluded by law or regulation.

Federal retirees are eligible to carry their FEGLI into retirement if they meet the following requirements:

eligible to retire on an immediate annuity (including FERS MRA+10 retirement), have not converted the

coverage to a private plan, and have been insured under FEGLI for the five years immediately

preceding retirement or for all periods of service during which FEGLI was available to them if they

have been covered for less than five years. There is no waiver of this five­year rule.

When can I enroll?

The FEGLI Program does not participate in the annual Federal Benefits Open Season.

If you are a new employee who is eligible for FEGLI, or an employee who has become newly eligible

to enroll, you will be automatically enrolled in Basic. If you do not want Basic, you must file a waiver

with your agency.

As a new or newly eligible employee, you may enroll in Optional insurance within 31 days of

becoming eligible. If you take no action, you will have Basic and will not have any Optional insurance.

If you are not a new employee or newly eligible, you may enroll in Basic life insurance and, if you

wish, Option A and/or Option B coverage by providing satisfactory medical information at your own

expense using the Request for Life Insurance (Standard Form 2822). You cannot enroll in Option C this

way.

If you already have Basic insurance, you may elect or increase Option B and/or Option C within 60

days of experiencing a qualifying life event (marriage, divorce, death of a spouse, or birth or adoption

of children). You cannot enroll in Option A this way.

You may also enroll during a FEGLI Open Season, which is held infrequently. You will receive plenty

of notice when there is a FEGLI Open Season. The most recent FEGLI Open Seasons were held in

2004 and in 1999.

17
Federal Employees’ Group Life Insurance Program (FEGLI)

How do I enroll?

You may be able to enroll using the Life Insurance Election Form (Standard Form 2817) or through an

agency self­service system such as EBIS. Contact the human resources office of your employing

agency for details on how you can enroll.

Who gets the benefits paid after my death?

When you die, the Office of Federal Employees’ Group Life Insurance (OFEGLI), an administrative

unit of Metropolitan Life Insurance Company (MetLife), will pay life insurance benefits in a particular

order set by law. The FEGLI Program Booklet, available from your human resources office and at

www.opm.gov/insure/life, contains more details.

How does my beneficiary file a claim?

He or she must use a specific form (FE­6) to claim FEGLI benefits, available from your human

resources office or retirement system or at www.opm.gov/insure/life.

How do I get more information about this Program?

Contact your agency human resources office. If you are retired, contact OPM’s Retirement Operations

Center at retire@opm.gov or by calling 1­888­767­6738. Neither OFEGLI nor OPM’s Insurance Services

Program offices maintain records for active Federal employees or retirees.

18
Federal Long Term Care Insurance Program (FLTCIP)

What does this Program offer?

The FLTCIP offers insurance that helps cover the costs of certain long term care services. Long term

care is the assistance you receive to perform activities of daily living – such as bathing or dressing

yourself – or supervision you receive because of a severe cognitive impairment. Long term care can

be provided in a facility, like a nursing home, but is mostly provided at home.

Key FLTCIP facts

• The FLTCIP is not part of the annual Federal Benefits Open Season.

• You must apply and answer questions about your health to find out if you are eligible to enroll.

• You can apply for coverage at any time using the full underwriting application; you do not

have to wait for an Open Season.

• New/newly eligible employees and their spouses and newly married spouses of employees can

apply with abbreviated underwriting (fewer questions about their health) within 60 days of

becoming eligible.

• Qualified family members can also apply, with full underwriting.

• Once enrolled, you can keep your coverage even if you are no longer in an eligible group (for

example, you leave your job with the Federal Government).

• The FLTCIP is sponsored by OPM and insured by John Hancock and MetLife.

How much does it cost?

If you are approved for coverage, your premium is based on your age on the date your application

is received and on the benefit options you select. You may pay your premiums through deductions

from pay or annuity, by automatic bank withdrawal, or by direct bill.

Am I eligible to apply?

Most Federal employees are eligible to apply for coverage; those who are not eligible usually have

limited appointments of short duration, or work sporadically only during certain seasons or when

needed by their Federal agency. If you are eligible for the FEHB Program you are eligible to apply

for coverage under the FLTCIP, even if you are not enrolled in the FEHB Program. Retirees are

eligible to apply. Spouses and adult children of eligible employees and retirees may also apply, as

well as parents, parents­in­law, and stepparents of employees (but not of retirees).

19
Federal Long Term Care Insurance Program (FLTCIP)

How do I apply?

You apply by completing an application found at www.ltcfeds.com or by calling 1­800­LTC­FEDS.

You must pass a medical screening (called underwriting). Certain medical conditions, or

combinations of conditions, will prevent some people from being approved for coverage. By

applying while you’re in good health, you could avoid the risk of having a future change in your

health disqualify you from obtaining coverage. Also, the younger you are when you apply, the lower

your premiums.

If you are a new or newly eligible employee, you (and your spouse, if applicable) have 60 days to

apply using the abbreviated underwriting application, which asks fewer questions about your health.

Newly married spouses of employees also have 60 days to apply using abbreviated underwriting.

Open Seasons for the FLTCIP are infrequent, but you don’t have to wait for an Open Season – you

may apply anytime using the full underwriting application.

What should I consider in making my decision to participate in this Program?

Remember that FEHB plans do not cover the cost of long term care. While Medicare covers some

care in nursing homes and at home, it does so only for a limited time, subject to restrictions. The

need for long term care can strike anyone at any age and the cost of care can be substantial.

Be sure to visit www.ltcfeds.com for the most up­to­date information about the FLTCIP before

deciding whether to apply.

How do I get more information about this Program?

Call 1­800­LTC­FEDS (1­800­582­3337), (TTY 1­800­843­3557) or visit www.ltcfeds.com.

20
Appendix A
 

FEHB Program Features
 

No waiting periods. You can use your benefits as soon as your coverage becomes effective. There

are no pre­existing condition limitations even if you change plans.

A choice of coverage. You can choose Self Only coverage just for you, or Self and Family

coverage for you, your spouse, and unmarried dependent children under age 22. Under certain

circumstances, your FEHB enrollment may cover your disabled child 22 years old or older

who is incapable of self­support.

A choice of plans and options. Fee­for­Service plans, plans offering a Point­of­Service

product, Health Maintenance Organizations, High Deductible Health Plans, and Consumer­Driven

Health Plans.

A Government contribution. The Government pays 72 percent of the average premium of all

plans toward the total cost of your premium, but not more than 75 percent of the total premium for

any plan.

Salary deduction. You pay your share of the premium through a payroll deduction and have the

choice of doing so using pretax dollars.

Annual enrollment opportunities. Each year you can enroll or change your health plan

enrollment during Open Season. Open Season runs from the Monday of the second full work week

in November through the Monday of the second full work week in December. Other events allow

for certain types of changes throughout the year; see your human resources office or retirement

system for details.

Continued group coverage. The FEHB Program offers continued FEHB coverage:

* for you and your family when you retire from Federal service (normally you need to be covered

under the FEHB Program for the five years of service immediately before you retire),

* for your former spouse if you divorce and he or she has a qualifying court order (see your

human resources office for more information),

* for your family if you die, or

* for you and your family when you move, transfer, go on leave without pay, or enter

military service (certain rules about coverage and premium amounts apply; see your human

resources office).

Coverage after FEHB ends. The FEHB Program offers temporary continuation of coverage (TCC)

and conversion to non­group (private) coverage:

* for you and your family if you leave Federal service (including when you are not eligible to

carry FEHB into retirement),

* for your covered dependent child if he or she marries or turns age 22, or

* for your former spouse if you divorce and he or she does not have a qualifying court order (see

your human resources office for more information).

If you lose coverage under the FEHB Program, you should automatically receive a Certificate of

Group Health Plan Coverage from the last FEHB plan to cover you. If not, the plan must give you

one on request. This certificate may be important to qualify for benefits if you join a non­FEHB plan.

21
Appendix B

Choosing an FEHB Plan

Worksheets and Definitions

What type of health plan is best for you?

You have some basic questions to answer about how you pay for and access medical care.

Here are the different types of plans from which to choose.

Choice of doctors, Specialty care Out­of­pocket costs Paperwork

hospitals, pharmacies,

and other providers

Fee­for­Service

w/PPO (Preferred

Provider

Organization)

You must use the

plan’s network to reduce

your out­of­pocket costs.

Not using PPO providers

Referral not required

to get benefits.

You pay fewer costs if

you use a PPO

provider than if you

don’t.

Some, if you don’t use

network providers.

means only some or

none of your claims will

be paid.

Health Maintenance You generally must Referral generally Your out­of­pocket Little, if any.

Organization use the plan’s network required from primary costs are generally

to reduce your out­of­ care doctor to get limited to copayments.

pocket costs. benefits.

Point­of­Service You must use the

plan’s network to

reduce your out­ofpocket costs. You may

go outside the

network but you will

Referral generally

required to get

maximum benefits.

You pay less if you use

a network provider

than if you don’t.

Little, if you use the

network. You have to

file your own claims if

you don’t use the

network.

pay more.

Consumer­Driven

Plans

You may use network

and non­network

Referral not required

to get maximum

You will pay an

annual deductible and

Some, if you don’t use

network providers.

providers. You will pay benefits from PPOs. cost­sharing. You pay

more by not using the less if you use the

network. network.

High Deductible Some plans are Referral not required You will pay an If you have an HSA or

Health Plans w/Health network only, others to get maximum annual deductible and HRA account, you may

Savings Account (HSA) pay something even if benefits from PPOs. cost­sharing. You pay have to file a claim to

or Health you do not use a less if you use the obtain reimbursement.

Reimbursement network provider. network.

Arrangement (HRA)

22
Appendix B
 

Choosing an FEHB Plan
 

Worksheets and Definitions

Cost and benefits

Work Sheet For Picking A Health Plan

An easy­to­use tool allowing you to compare plans is available on the web at www.opm.gov/insure/spmt/plansearch.aspx. If

you do not have Internet access, complete the chart below by using this Guide and the health plan’s brochures to review your

costs, including premiums, and estimate what you might spend on health care next year. Plan brochures can be obtained from

your human resources office or on the OPM website at www.opm.gov/insure/health. The side­by­side comparison can help

you pick a plan with the benefits you need at a cost you can afford.

Type of Plan: HMO, Fee­for­Service, Point­of­Service, High Deductible, Consumer­Driven

Plan: Plan: Plan: Plan: Plan: Plan:

Annual Premium

Annual Deductible

(if any)

Office visit to primary

care doctor (cost x

estimated # of visits)

Office visit to

specialist (cost x

estimated # of visits)

Hospital inpatient

deductible, copay, or

coinsurance

Prescription drugs

Maximum out­ofpocket limit for year

Durable medical

equipment

Preventive care

Maternity care

Well child care

Routine physicals

TOTAL COST

23
Appendix B
 

Choosing an FEHB Plan
 

Worksheets and Definitions

Think Quality

Pay attention to how a plan performs on measures of quality. We have several sources for reviewing

quality information: accreditation (independent evaluations from private accrediting organizations),

member survey results (evaluations by current plan members), and effectiveness of care (how the

plan performs in preventing and treating common conditions). Check your health plan’s brochure for its

accreditation level or look for the Health Plan Accreditation link at www.opm.gov/insure/health. Member

survey results are posted within the health plan benefit chart in this Guide. And a plan’s effectiveness of

care is measured by the Healthcare Effectiveness Data and Information Set found on our website at

www.opm.gov/insure/health/hedis2009.

Enrollment Checklist

❐ The plans I can choose based upon where I live

❐ The total of all family members’ visits to primary care doctors last year

❐ The total of all family members’ visits to specialists last year

❐ The total of all family members’ visits to hospitals last year

❐ The total number of prescriptions for the family each month

❐ Do I have to choose a primary care physician

❐ Do I need a referral to see a specialist

❐ Will I receive benefits if I go outside the plan’s network

❐ Is there a discount prescription drug mail order service

❐ Prescription drugs ­ a flat fee or percentage

❐ How are routine physicals covered

❐ The annual deductible

❐ The hospital deductible, copayment, or coinsurance

❐ Maximum out­of­pocket costs (catastrophic protection) for the year

Review the Member Survey Results:

❐ Overall Plan satisfaction

❐ Getting needed care

❐ Getting care quickly

❐ How well doctors communicate

❐ Customer service

❐ Claims processing

24
Appendix B

Choosing an FEHB Plan

Worksheets and Definitions

Dental

❐ Does the health plan have a dental benefit

❐ Expected number of visits to the dentist for treatment other than routine cleaning

❐ Total visits of all family members to the dentist for treatment last year

❐ How much did it cost for all dental expenses last year

❐ Do you have higher dental expenses planned for next year

❐ Compare the cost of next year’s premiums with the amount you expect to spend out

of pocket on dental care next year. If the premiums are more, or equal to the amount

you expect to spend, you may not need additional dental insurance.

Vision

❐ Are routine vision exams covered under my health plan

❐ Does any family member need vision correction

❐ How much did the family spend on vision correction last year

❐ Does the vision plan cover the correction methods the family needs

❐ Is my total premium for next year more than my expected benefit? If yes, you may

not need to purchase additional vision coverage

Flexible Spending Account

❐ How much did the family spend on items such as: over­the­counter medicines and

products, insurance co­pays and coinsurance

❐ Are you or any family member planning to receive health services not covered by the

health plan? How much will it cost?

Add the amount in the 2 rows above and you may consider setting that amount aside for your FSA

25
Appendix B
 

Choosing an FEHB Plan
 

Definitions

Brand name drug ­ A prescription drug that is protected by a patent, supplied by a single company,

and marketed under the manufacturer’s brand name.

Coinsurance ­ The amount you pay as your share for the medical services you receive, such as a

doctor’s visit. Coinsurance is a percentage of the plan’s allowance for the service (you pay, 20%, for

example).

Copayment ­ The amount you pay as your share for the medical services you receive, such as a

doctor’s visit. A copayment is a fixed dollar amount (you pay $15, for example).

Deductible ­ The dollar amount of covered expenses an individual or family must pay before the

plan begins to pay benefits. There may be separate deductibles for different types of services. For

example, a plan can have a prescription drug benefit deductible separate from its calendar year

deductible.

Formulary or Prescription Drug List ­ A list of both generic and brand name drugs, often made up

of different cost­sharing levels or tiers, that are preferred by your health plan. Health plans choose

drugs that are medically safe and cost effective. A team including pharmacists and physicians

determines the drugs to include in the formulary.

Generic Drug ­ A generic medication is an equivalent of a brand name drug. A generic drug

provides the same effectiveness and safety as a brand name drug and usually costs less. A generic

drug may have a different color or shape than the brand name, but it must have the same active

ingredients, strength, and dosage form (pill, liquid, or injection).

In­Network ­ You receive treatment from the doctors, clinics, health centers, hospitals, medical

practices, and other providers with whom your plan has an agreement to care for its members.

Out­of­Network ­ You receive treatment from doctors, clinics, health centers, hospitals, and medical

practices other than those with whom the plan has an agreement at additional cost. Members who

receive services outside the network may pay all charges.

Premium Conversion ­ A program to allow Federal employees to use pre­tax dollars to pay health

insurance premiums to the Federal Employees Health Benefits (FEHB) Program. Based on Federal

tax rules, employees can deduct their share of health insurance premiums from their taxable income,

which reduces their taxes.

Provider ­ A doctor, hospital, health care practitioner, pharmacy, or health care facility.

Qualifying Life Events ­ An event that may allow participants in the FEHB Program to change their

health benefits enrollment outside of an Open Season. These events also apply to employees under

premium conversion and include such events as change in family status, loss of FEHB coverage due

to termination or cancellation, and change in employment status.

26
Appendix C
 

Qualifying Life Events (QLEs)
 

that May Permit a Change in Your FEHB Enrollment
 

Premium Conversion allows employees who are eligible for FEHB the opportunity to pay their

share of FEHB premiums with pre­tax dollars. Premium conversion plans are governed by the

Internal Revenue Code, and IRS rules govern when a participant may change his or her

enrollment outside of the annual Open Season. When an employee experiences a qualifying life

event, changes to the employee’s FEHB enrollment may be permitted. Individuals who don’t

participate in Premium Conversion (retirees and employees who waived participation) may

cancel their enrollment or change to Self Only at any time.

Below is a brief list of the more common QLEs. Be aware that time limits apply for requesting

changes. A complete listing of QLEs can be found at www.opm.gov/forms/pdf_fill/sf2809.pdf.

For more details about these and other QLEs, contact the human resources office of your

employing agency.

From Not Enrolled

to Enrolled

From Self Only to

Self and Family

From One Plan or

Option to Another

Cancel or Change

to Self Only

Change in family status that

results in increase or decrease in

number of eligible family

members.

Any change in employee’s

employment status that could

result in entitlement to coverage.

Employee restored to civilian

position after serving in

uniformed services

Employee (or covered family

member) enrolled in an FEHB

health maintenance organization

(HMO) moves or becomes

employed outside the geographic

area from which the FEHB carrier

accepts enrollment or, if already

outside the area, moves further

from this area.

Employee or eligible family

member loses coverage

under FEHB or another group

insurance plan.

Enrolled employee or eligible

family member gains coverage

under FEHB or another group

insurance plan.

Yes

Yes

Yes

Not

Applicable

Yes

No

Yes

Not

Applicable

Yes

Yes

Yes

No

Yes

Not

Applicable

Yes

Yes

Yes

No

Yes

Not

Applicable

Yes

Not

Applicable

Yes

Yes

27
Appendix D
 

FEHB Member Survey Results
 

Each year Federal Employees Health Benefits plans with 500 or more subscribers mail the

Consumers Assessment of Healthcare Providers and Systems (CAHPS)1 to a random sample of plan

members. For Health Maintenance Organizations (HMO)/Point­of­Service (POS) and High

Deductible Health Plans (HDHP) and Consumer­Driven Health Plans (CDHP), the sample includes

all commercial plan members, including non­Federal members. For Fee­for­Service (FFS)/Preferred

Provider Organization (PPO) plans, the sample includes Federal members only. The CAHPS survey

asks questions to evaluate members’ satisfaction with their health plans. Independent vendors

certified by the National Committee for Quality Assurance administer the surveys.

OPM reports each plan’s scores on the various survey measures by showing the percentage of

satisfied members on a scale of 0 to 100. Also, we list the national average for each measure. Since

we offer HMO plans, FFS/PPO plans, HDHP, and CDHP plans, we compute a separate national

average for each plan type.

Survey findings and member ratings are provided for the following key measures of

member satisfaction:

• Overall Plan Satisfaction – This measure is based on the question, “Using any number from 0 to

10, where 0 is the worst health plan possible and 10 is the best health plan possible, what

number would you use to rate your health plan?” We report the percentage of respondents

who rated their plan 8 or higher.

• Getting Needed Care – How often was it easy to get an appointment, the care, tests, or
 

treatment you thought you needed through your health plan?
 

• Getting Care Quickly – When you needed care right away, how often did you get care as soon

as you thought you needed? Not counting the times you needed care right away, how often did

you get an appointment at a doctor's office or clinic as soon as you thought you needed?

• How Well Doctors Communicate – How often did your personal doctor explain things in a way

that was easy to understand? How often did your personal doctor listen carefully to you, show

respect for what you had to say, and spend enough time with you?

• Customer Service – How often did the written materials or the Internet provide the information

you needed about how your health plan works? How often did your health plan’s customer

service give you the information or help you needed? How often were the forms from your

health plan easy to fill out?

• Claims Processing – How often did your health plan handle your claims quickly and correctly?

• Shared Decision Making – Did your doctor talk with you about the pros and cons of each

choice for your treatment or health care? When there was more than one choice for your

treatment or health care, did your doctor ask which choice was best for you?

In evaluating plan scores, you can compare individual plan scores against other plans and against

the national averages. Generally, new plans and those with fewer than 500 FEHB subscribers do not

conduct CAHPS. Therefore, some of the plans listed in the Guide will not have survey data.

1 CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

28
Appendix E
 

FEHB Plan Comparison Charts
 

Nationwide Fee­for­Service Plans

(Pages 30 through 33)

Fee­for­Service (FFS) plans with a Preferred Provider Organization (PPO) – A Fee­for­Service

plan provides flexibility in using medical providers of your choice. You may choose medical providers

who have contracted with the health plan to offer discounted charges. You may also choose medical

providers who do not contract with the plan, but you will pay more of the cost.

Medical providers who have contracts with the health plan (Preferred Provider Organization or PPO)

have agreed to accept the health plan’s reimbursement. You usually pay a copayment or a coinsurance

amount and do not file claims or other paperwork. Going to a PPO hospital does not guarantee PPO

benefits for all services received in the hospital, however. Lab work, radiology, and other services from

independent practitioners within the hospital are frequently not covered by the hospital’s PPO

agreement. If you receive treatment from medical providers who are not contracted with the health

plan, you either pay them directly and submit a claim for reimbursement to the health plan or the

health plan pays the provider directly according to plan coverage, and you pay a deductible,

coinsurance or the balance of the billed charge. In any case, you pay a greater amount in out­ofpocket costs.

PPO­only – A PPO­only plan provides medical services only through medical providers that have

contracts with the plan. With few exceptions, there is no medical coverage if you or your family

members receive care from providers not contracted with the plan.

Fee­for­Service plans open only to specific groups – Several Fee­for­Service plans that are

sponsored or underwritten by an employee organization strictly limit enrollment to persons who are

members of that organization. If you are not certain if you are eligible, check with your human

resource office first.

29
Nationwide Fee­for­Service 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. The chart does not show all of your possible out­of­pocket 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 Hospital Inpatient deductible is what you pay each time you are admitted to a hospital.
 

Doctors shows what you pay for inpatient surgical services and for office visits.
 

Your share of Hospital Inpatient Room and Board covered charges is shown.
 

Plan Name: Open to All Telephone

Number

Enrollment

Code

Your Share of Premium

Monthly Biweekly

Self

only

Self &

family

Self

only

Self &

family

Self

only

Self &

family

APWU Health Plan (APWU) ­high 800­222­2798 471 472 107.18 242.34 49.47 111.85

Blue Crossand BlueShieldService Benefit Plan (BCBS) ­std Localphone# 104 105 152.06 356.59 70.18 164.58

Blue Crossand BlueShieldService Benefit Plan (BCBS) ­basic Localphone# 111 112 92.44 216.48 42.66 99.91

GEHA Benefit Plan (GEHA) ­high 800­821­6136 311 312 198.23 401.57 91.49 185.34

GEHA Benefit Plan (GEHA) ­std 800­821­6136 314 315 74.26 168.77 34.27 77.89

Mail Handlers Benefit Plan (MH) ­std 800­410­7778 454 455 129.70 278.76 59.86 128.66

Mail Handlers Benefit Plan Value (MHV) 800­410­7778 414 415 46.65 111.22 21.53 51.33

NALC ­high 888­636­6252 321 322 122.42 252.14 56.50 116.37

SAMBA­high 800­638­6589 441 442 212.10 529.88 97.89 244.56

SAMBA­std 800­638­6589 444 445 102.46 234.00 47.29 108.00

Association Benefit Plan (ABP) ­high

Plan Name: Open Only to Specific Groups

800­634­0069 421 422 122.72 295.73 56.64 136.49

Foreign Service Benefit Plan (FS) ­high 202­833­4910 401 402 104.87 272.89 48.40 125.95

Panama CanalArea Benefit Plan (PCABP) ­high 800­424­8196 431 432 99.33 207.33 45.84 95.69

Rural Carrier Benefit Plan (Rural) ­high 800­638­8432 381 382 179.47 287.45 82.83 132.67

30
Prescription Drug Payment Levels Plans use a variety of terms to define what you pay for prescription drugs such as generic, brand

name, Tier I, Tier II, Level I, etc. The 2 to 3 payment levels that plans use follow: Level I includes most generic drugs, but may include some

preferred brands. Level II may include generics and preferred brands not included in Level I. Level III includes all other covered drugs, with

some exceptions for specialty drugs. Many plans are basing how much you pay for prescription drugs on what they are charged.

Mail Order Discounts If your plan has a Mail Order progrram and that program is superior to the purchase of medications at the pharmacy

(e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program

or it is not superior to its pharmacy benefit, the plan’s response is “no.”

The prescription drug copayments or coinsurances described in this chart do not represent the complete range of cost­sharing under these

plans. Many plans have variations in their prescription drug benefits (e.g., you pay the greater of a dollar amount or a percentage, or you pay

one amount for your first prescription and then a different amount for refills). You must read the plan brochure for a complete 

description of prescription drug and all other benefits. 

Medical­Surgical – You Pay

Deductible Copay ($)/Coinsurance (%)

Plan

Benefit

Type Calendar

Year

Prescription

Drug

Per Person

Hospital

Inpatient

Doctors

Office

Visits

Inpatient

Surgical

Services R&B

Hospital

Inpatient

Level I

Prescription Drugs

Level II Level III Mail Order

Discounts

APWU ­high PPO

Non­PPO

$275

$500

None

None

None

$300

$18

30%+diff.

10%

30%+diff.

10%

30%

$8

50%

25%/25%

50%/50%

Yes

Yes

BCBS­std PPO

Non­PPO

$300

$300

None

None

$200

$300 + 30%

$20

30%

15%

 

$200

$300 + 30%

20%

45% +

30%/30%

45%+/45%+

Yes

Yes

BCBS­basic PPO None None $100/dayx5 $25 $100 Nothing $10 $35/$45or50% No

GEHA­high PPO

Non­PPO

$350

$350

None

None

$100

$300

$20

25%

10%

25%

Nothing

Nothing

$5

$5

25%/N/A

25%+/N/A

Yes

Yes

GEHA­std PPO

Non­PPO

$350

$350

None

None

None

None

$10

35%

15%

35%

15%

35%

$5

$5

50%/50%

50%+/50%+

Yes

Yes

MH ­std PPO

Non­PPO

$350

$500

None

None

$200

$400

$20/Nothing

30%

10%

30%

Nothing

30%

$10

50%

$40/$60

50%/50%

Yes

Yes

MH Value PPO

Non­PPO

$500

$800

None

Not Covered

None

None

$30

40%

20%

40%

20%

40%

$10

Not Covered

50%/50%

Not Covered

Yes

No

NALC ­high PPO

Non­PPO

$250

$300

None

$25

$100

$100

$15

25%

10%

25%

Nothing

30%

25%

50%+

25%/25%

50%+/50%+

Yes

Yes

SAMBA­high PPO

Non­PPO

$250

$250

None

None

$200

$300

$20/$0

30%

10%

30%

Nothing

30%

$10

$10

$30/$45

$30/$45

Yes

Yes

SAMBA­std PPO

Non­PPO

$300

$300

None

None

$200

$300

$20/$0

30%

15%

30%

Nothing

30%

$10

$10

25% $60max/35% $90max

25% $60max/35% $90max

Yes

Yes

ABP PPO $300 None $150 $10 10% Nothing $5 $30/30% or$45 Yes

Non­PPO $300 None $350 30% 30% Nothing $5 $30/30% or$45 Yes

FS PPO $300 None Nothing 10% 10% Nothing $10 25%/$25min/30%/$40min Yes

Non­PPO $300 None $200 30% 30% 20% $10 25%/$25min/30%/$40min Yes

PCABP POS None None $50 $10 Nothing Nothing 40% 40%/40% No

FFS None None $125 50% 50% 50% 40% 40%/40% No

Rural PPO $350 $200 $100 $20 10% Nothing 30% 30%/30% Yes

Non­PPO $400 $200 $300 25% 20% Nothing 30% 30%/30% Yes

31

30%
Nationwide Fee­for­Service Plans

Member Survey results are collected, scored, and reported by an independent organization – not by the health plans.

See Appendix D for a fuller explanation of each survey category.

Overall Plan Satisfaction • How wouldyou rate youroverall experience with your health plan?

Getting Needed Care • Was it easy togetan appointment with specialists?

• Was it easy toget the care, tests,or treatment you thought you needed?

Getting Care Quickly • Didyou get theadviceor helpyou needed when you calledyourdoctorduringregularoffice hours?

• Couldyou getan appointment for regularor routine careas soon as you thought you needed?

How Well Doctors

Communicate

• Didyourdoctor listen carefully toyou andexplain things in a way you could understand?

• Didyourdoctor spendenough time with you?

CustomerService • Was yourplan helpful when you calledits customer service?

• Didtheplan’s written materialsor the Internetprovide you with the information you neededabout how theplan works?

Claims Processing • Didyourplan pay your claimsquicklyandcorrectly?

Shared Decision Making • Didyourdoctor talk with you about theprosandconsof each choice for your treatmentor health care?

• When there was more than one choice for your treatmentor health care,didyourdoctorask which choice wasbest for you?

Plan Name: Open to All

Member Survey Results 

(with national averages for Fee­for­Service plans in each category)

Plan

Code

Overall plan

satisfaction

81.3

Getting

needed care

91.9

Getting

care quickly

92.4

How well

doctors

communicate

94.5

Customer

service

89.5

Claims

processing

94

Shared

Decision

Making

56.8

APWU Health Plan ­high 47 82.3 92 92.2 95.9 84.4 92.1 53

Blue Crossand BlueShieldService Benefit Plan ­std 10 82.1 92.5 91 94 89.1 94.5 65.2

Blue Crossand BlueShieldService Benefit Plan ­basic 11 71.4 88.7 89.3 92.1 86 93 57.3

GEHA Benefit Plan ­high 31 85.1 93.2 93.2 95.1 92.9 96 52.9

GEHA Benefit Plan ­std 31 77.5 90.2 89.5 93.6 88.8 94 53

Mail Handlers Benefit Plan ­std 45 76.1 90.1 91.5 94 89 94.3 58.6

Mail Handlers Benefit Plan Value 41

NALC ­high 32 86.9 92.8 91.5 95.3 89.7 95 52.4

SAMBA­high 44 84.1 93.1 93.9 95.8 90.4 94.7 61.9

SAMBA­std

Association Benefit Plan

Plan Name: Open Only to Specific Gr

44

42

oups

74.7

86.4

93.2

93.6

94.6

95.8

95.7

93.5

87.7

94.7

91.2

97.4

59.8

56.8

Foreign Service Benefit Plan 40 81.9 89.3 93.2 94.9 87.3 90 55.1

Panama CanalArea Benefit Plan 43

Rural Carrier Benefit Plan 38 83.7 94.3 95.7 95.5 93.9 94.3 58

32
Fee­for­Service Plans – Blue Cross and Blue Shield Service Benefit Plan –

Member Survey Results for Select States

Again this year we are providing more detailed information regarding the quality of services provided by our health plans. We are including the

results of the Member Satisfaction survey at the state level for eight local Blue Cross Blue Shield (BCBS) Plans. Prior to 2003, BCBS conducted a

single survey representing all of its members nationwide. We now provide local member satisfaction results for both the Standard Option plan

and the Basic Option plan.

In the future, we expect to increase the number of plans conducting local or regional Member Satisfaction surveys. We look forward to making

those results available to help you select quality health plans.

Below are Member Survey ratings for local BCBS plans by location.

Plan Name Location

Member Survey Results 

(with national averages for Fee­for­Service plans in each category)

Plan

Code

Overall plan

satisfaction

81.3

Getting

needed care

91.9

Getting

care quickly

92.4

How well

doctors

communicate

94.5

Customer

service

89.5

Claims

processing

94

Shared

Decision

Making

56.8

Blue Crossand BlueShieldService ­ Standard Arizona 10 85.3 91.9 88.6 93.7 94.5 96.5 54.8

Benefit Plan ­ Basic 11 74.5 87.1 84.3 90.4 86.2 91 57.5

Blue Crossand BlueShieldService ­ Standard California 10 81.1 90.8 89.9 91.5 85.1 93.6 58.7

Benefit Plan ­ Basic 11 64.4 85.9 83.2 92.3 88 93.2 55.1

Blue Crossand BlueShieldService ­ Standard Districtof Columbia 10 82.8 92 91.4 95.4 91.2 90.9 61.6

Benefit Plan ­ Basic 11 67.9 81.7 77.9 91.2 85.2 89.6 55.4

Blue Crossand BlueShieldService ­ Standard Florida 10 85.5 92.6 90.3 93.4 90.2 92.7 58.1

Benefit Plan ­ Basic 11 74.9 89 87.8 90.3 87.5 91.6 61.1

Blue Crossand BlueShieldService ­ Standard Illinois 10 82 92.2 89.1 94.1 90.2 94 65.4

Benefit Plan ­ Basic 11 79.1 91.3 86.4 92.6 87.6 91 54.3

Blue Crossand BlueShieldService ­ Standard Maryland 10 84.9 92 90.6 94.3 88.5 94.6 62.8

Benefit Plan ­ Basic 11 73.3 86.2 85.7 92.1 80.7 92.8 54.8

Blue Crossand BlueShieldService ­ Standard Texas 10 81.8 92.3 90.6 94.4 86.8 94.6 58.4

Benefit Plan ­ Basic 11 79.7 91 86.2 92.3 88.7 93.6 58

Blue Crossand BlueShieldService ­ Standard Virginia 10 87.5 92.4 91.2 94.9 91 95.8 65.3

Benefit Plan ­ Basic 11 77.2 88.1 86.6 92.2 89.5 96.3 56

33
This page intentionally left blank

34
 
Appendix E
 

FEHB Plan Comparison Charts
 

Health Maintenance Organization Plans and

Plans Offering a Point­of­Service Product

(Pages 36 through 59)

Health Maintenance Organization (HMO) – A Health Maintenance Organization provides care through a network of

physicians and hospitals in particular geographic or service areas. HMOs coordinate the health care service you receive and free

you from completing paperwork or being billed for covered services. Your eligibility to enroll in an HMO is determined by where

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

•	 The HMO provides a comprehensive set of services – as long as you use the doctors and hospitals affiliated with

the HMO. HMOs charge a copayment for primary physician and specialist visits and sometimes a copayment for

in­hospital care.

•	 Most HMOs ask you to choose a doctor or medical group as your primary care physician (PCP). Your PCP provides

your general medical care. In many HMOs, you must get authorization or a “referral” from your PCP to see other

providers. The referral is a recommendation by your physician for you to be evaluated and/or treated by a different

physician or medical professional. The referral ensures that you see the right provider for the care appropriate

to your condition.

•	 Medical care from a provider not in the plan’s network is not covered unless it’s emergency care or your plan has an

arrangement with another plan.

Plans Offering a Point­of­Service (POS) Product – A Point­of­Service plan is like having two plans in one – an

HMO and an FFS plan. A POS allows you and your family members to choose between using, (1) a network of providers in a

designated service area (like an HMO), or (2) Out­of­Network providers (like an FFS plan). When you use the POS network

of providers, you usually pay a copayment for services and do not have to file claims or other paperwork. If you use non­HMO

or non­POS providers, you pay a deductible, coinsurance, or the balance of the billed charge. In any case, your out­of­pocket

costs are higher and you file your own claims for reimbursement.

The tables on the following pages highlight what you are expected to pay for selected features under each plan. Always consult

plan brochures before making your final decision.

Primary care/Specialist office visit copay – Shows what you pay for each office visit to your primary care doctor and

specialist. Contact your plan to find out what providers it considers specialists.

Hospital per stay deductible – Shows the amount you pay when you are admitted into a hospital.

Prescription drugs – Plans use a variety of terms to define what you pay for prescription drugs such as generic, brand, Level I,

Level II, Tier I, Tier II, etc. In capturing these differences we use the following: Level I includes most generic drugs, but may

include some preferred brands. Level II may include generics and preferred brands not included in Level I. Level III includes all

other covered drugs with some exceptions for specialty drugs. The level in which a medication is placed and what you pay for

prescription drugs is often based on what the plan is charged.

Mail Order Discount – If your plan has a mail order program and that program is superior to the purchase of medications at

the pharmacy (e.g., you get a greater quantity or pay less through mail order), your plan’s response is “yes.” If the plan does not

have a mail order program or it is not superior to its pharmacy benefit, the plan’s response is “no.”

Member Survey Results – See Appendix D for a description.

35
Health Maintenance Organization (HMO) and Point­of­Service (POS) Plans

See page 35 for an explanation of the columns on these pages.

Telephone

Enrollment

Code

Your Share of Premium

Monthly Biweekly

Self Self & Self Self & Self Self &

Arizona

Aetna Open Access ­high­ Phoenixand Tucson Areas

Plan Name – Location

877­459­6604

Number

WQ1

only

WQ2

family

106.77

only

303.94

family

49.28

only

140.28

family

Health NetofArizona, Inc. ­high­ Maricopa/Pima/OtherAZcounties 800­289­2818 A71 A72 105.50 304.27 48.69 140.43

Health NetofArizona, Inc. ­std­ Maricopa/Pima/OtherAZcounties 800­289­2818 A74 A75 95.49 241.92 44.07 111.66

PacifiCareofArizona­high­ Maricopa, Pimaand Pinal Counties

California

Aetna HMO ­ LosAngelesandSan DiegoAreas

866­546­0510

877­459­6604

A31

2X1

A32

2X2

137.24

84.60

375.03

208.41

63.34

39.04

173.09

96.19

Anthem Blue Cross ­ HMO ­high­ Mostof California 800­235­8631 M51 M52 183.30 535.15 84.60 246.99

BlueShieldof CAAccess+HMO ­high­ Southern Region 800­880­8086 SI1 SI2 110.74 259.35 51.11 119.70

BlueShieldof CAAccess+HMO ­high­ Northern Region 800­880­8086 SJ1 SJ2 270.47 639.95 124.83 295.36

Health Netof California­high­ Northern Region 800­522­0088 LB1 LB2 258.10 612.58 119.12 282.73

Health Netof California­std­ Northern Region 800­522­0088 LB4 LB5 230.21 548.21 106.25 253.02

Health Netof California­high­ Southern Region 800­522­0088 LP1 LP2 119.30 291.79 55.06 134.67

Health Netof California­std­ Southern Region 800­522­0088 LP4 LP5 108.25 250.28 49.96 115.51

KaiserFoundation Health Plan of California­high­ Northern California 800­464­4000 591 592 190.32 495.54 87.84 228.71

KaiserFoundation Health Plan of California­std­ Northern California 800­464­4000 594 595 99.44 237.36 45.89 109.55

KaiserFoundation Health Plan of California­high­ Southern California 800­464­4000 621 622 110.82 260.65 51.15 120.30

KaiserFoundation Health Plan of California­std­ Southern California 800­464­4000 624 625 70.04 161.87 32.32 74.71

PacifiCareof California­high­ Mostof California

Colorado

KaiserFoundation Health Plan of Colorado­high­ Denver/ColoradoSpringsareas

866­546­0510

800­632­9700

CY1

651

CY2

652

109.87

122.20

250.84

288.28

50.71

56.40

115.77

133.05

KaiserFoundation Health Plan of Colorado­std­ Denver/ColoradoSpringsareas 800­632­9700 654 655 75.10 171.98 34.66 79.38

PacifiCareof Colorado­high­ Metro Denver/Boulder/ColoradoSprings

Connecticut

Aetna Open Access ­high­ Allof Connecticut

866­546­0510

877­459­6604

D61

JC1

D62

JC2

189.05

160.81

480.63

462.11

87.25

74.22

221.83

213.28

Aetna Open Access ­basic­ Allof Connecticut 877­459­6604 JC4 JC5 111.95 324.22 51.67 149.64

ConnectiCare ­high­ Allof Connecticut 800­251­7722 TE1 TE2 148.14 340.56 68.37 157.18

ConnectiCare ­basic­ Allof Connecticut 800­251­7722 TE4 TE5 97.87 222.69 45.17 102.78

36
Primary

care/

Specialist

office copay Plan Name – Location

Hospital

per stay

deductible

Prescription Member Survey Results

Drugs (with national averages for HMO/POS plans in each category)

Mail

Level II/ order

Level I Level III discount

Overall plan

satisfaction 62.8

Getting needed

care 84

Getting care

quickly 85.6

How well

doctors

communicate 92.6

Customerservice 82.1

Claimsprocessing 85.7

Shared decision

making 58.7

Arizona

Aetna Open Access­High $20/$30 $150/dayx5 $10 $25/$50 Yes 56.7 78.6 80.5 89 76.6 82.5 57

Health NetofArizona, Inc.­Std $15/$40 $250/day X 3 $10 $40/$70 Yes 65.6 85 81.8 89.8 77.8 88.7 60.8

Health NetofArizona, Inc.­High $15/$30 $200/day X 3 $10 $30/$50 Yes 65.6 85 81.8 89.8 77.8 88.7

PacifiCareofArizona­High $20/$30 $150/dayx5 $10 $30/$50 Yes 58.6 83.2 83.5 92 80.9 86.7 55.4

California

Aetna Open Access­High

BlueShieldof CAAccess­High

Health Netof California­High

Health Netof California­High

KaiserFoundation HP­High

KaiserFoundation HP­High

PacifiCareof California­High

$20/$30

$15/$15

$15/$30

$15/$30

$15/$15

$15/$15

$15/$30

$150/dayx5

$100/dayx3

$100/dayx3

$100/dayx3

$250

$250

$100/dayx5

$10

$10

$10

$10

$10

$10

$10

$25/$50

$35/$50

$35/$50

$35/$50

$30/$30

$30/$30

$35/$50

Yes

Yes

Yes

Yes

Yes

Yes

Yes

60.2

63.7

63.7

66.5

68.9

61.4

75.4

76.6

76.6

81.4

76.1

79.4

74.2 87.9 76.1 81.8 48

76.2 87.8 74.6 78 54.5

76.2 87.8 74.6 78 54.5

82.2 91 77.3 79.4 58.5

76.2 90.9 78 75.1 55.7

78.5 92.4 79 84.7 49.1

Anthem Blue Cross ­ HMO­High $25/$25 $200/dayx3 $10/$30/45%$30or45%/45% Yes 60.8 80.7 77.1 86.8 84.9 78.7 53.3

BlueShieldof CAAccess­High $15/$15 $100/dayx3 $10 $35/$50 Yes 60.8 76.7 79.7 89.5 75 80.1 57.4

Health Netof California­Std $25/$25 $300 $10 $35/$50 Yes 63.7 76.6 76.2 87.8 74.6 78 54.5

Health Netof California­Std $25/$25 $300 $10 $35/$50 Yes 63.7 76.6 76.2 87.8 74.6 78 54.5

KaiserFoundation HP­Std $30/$30 $500 $15 $35/$35 Yes 66.5 81.4 82.2 91 77.3 79.4 58.5

KaiserFoundation HP­Std $30/$30 $500 $15 $35/$35 Yes 68.9 76.1 76.2 90.9 78 75.1 55.7

Colorado

KaiserFoundation HP­High $20/$30 $250 $10 $25/$50 Yes 59.6 80.6 84.1 92.7 79.5 73.5 55.6

PacifiCareof Colorado­High $20/$40 $250/dayx5 $10 $35/$50 Yes 60.5 81.2 88.7 94.8 80.4 84.4 61

KaiserFoundation HP­Std $25/$45 $250/dayx3 $15 $35/$70 Yes 59.6 80.6 84.1 92.7 79.5 73.5

Connecticut

Aetna Open Access­High $20/$30 $150/dayx5 $10 $25/$50 Yes 62.9 83.5 90.2 91.2 78 86.8 56.7

Aetna Open Access­Basic $15/$30 20% Plan Allow $5 $30/$50 Yes 62.9 83.5 90.2 91.2 78 86.8 56.7

ConnectiCare­High $20/$40 $250perday/$1250ma $15 $30/50% or$60 max Yes 62.9 85 86.6 93.4 89.9 90.3 64.5

ConnectiCare­Basic $25/$45 Nothingafterded $15 $30/50% or$60 max Yes 62.9 85 86.6 93.4 89.9 90.3 64.5

37

60.8

55.6
Health Maintenance Organization (HMO) and Point­of­Service (POS) Plans

See page 35 for an explanation of the columns on these pages.

Telephone

Enrollment

Code

Your Share of Premium

Monthly Biweekly

Self Self & Self Self & Self Self &

Delaware

Aetna Open Access ­high­ Kent/New Castle/Sussexareas

Plan Name – Location

877­459­6604

Number

P31

only

P32

family

288.04

only

744.88

family

132.94

only

343.79

family

Aetna Open Access ­basic­ Kent/New Castle/Sussexareas 877­459­6604 P34 P35 106.92 246.90 49.35 113.95

Coventry Health Care ­high­ Allof Delaware 800­833­7423 2J1 2J2 213.33 612.54 98.46 282.71

Coventry Health Care ­std­ Allof Delaware

District of Columbia

Aetna Open Access ­high­ Washington, DC Area

800­833­7423

877­459­6604

2J4

JN1

2J5

JN2

114.36

230.06

365.06

506.85

52.78

106.18

168.49

233.93

Aetna Open Access ­basic­ Washington, DC Area 877­459­6604 JN4 JN5 93.09 217.85 42.96 100.54

CareFirst BlueChoice ­high­ Washington, D.C. MetroArea 866­296­7363 2G1 2G2 112.82 253.13 52.07 116.83

KaiserFoundation Health Plan Mid­AtlanticStates ­high­ Washington, DC area 1­877­574­3337 E31 E32 126.75 323.14 58.50 149.14

KaiserFoundation Health Plan Mid­AtlanticStates ­std­ Washington, DC area 1­877­574­3337 E34 E35 66.13 157.36 30.52 72.63

M.D. IPA­high­ Washington, DC area

Florida

Av­Med Health Plan ­high­ Broward, Dadeand Palm Beach

877­835­9861

800­882­8633

JP1

ML1

JP2

ML2

111.20

107.87

261.82

271.70

51.32

49.78

120.84

125.40

Av­Med Health Plan ­std­ Broward, Dadeand Palm Beach 800­882­8633 ML4 ML5 83.22 199.75 38.41 92.19

Capital Health Plan ­high­ Tallahasseearea 850­383­3311 EA1 EA2 95.99 254.36 44.30 117.40

Humana, Inc. ­high­ South Florida 888­393­6765 EE1 EE2 107.99 248.38 49.84 114.64

Humana, Inc. ­std­ South Florida 888­393­6765 EE4 EE5 85.30 196.20 39.37 90.55

Humana, Inc. ­high­ Tampa 888­393­6765 LL1 LL2 109.98 252.96 50.76 116.75

Humana, Inc. ­std­ Tampa 888­393­6765 LL4 LL5 99.17 228.11 45.77 105.28

JMH Health Plan ­high­ Broward­Dade counties 800­721­2993 J81 J82 113.04 350.70 52.17 161.86

JMH Health Plan ­std­ Broward­Dade counties 800­721­2993 J84 J85 98.26 251.41 45.35 116.04

United HealthcareofFlorida­high­ Central andSouthwestFlorida 877­835­9861 R31 R32 110.88 251.71 51.18 116.17

Vista Healthplan ofSouth Florida­high­ Southern Florida 800­441­5501 5E1 5E2 88.66 243.85 40.92 112.54

Vista Healthplan ofSouth Florida­std­ Southern Florida

Georgia

Aetna Open Access ­high­ AtlantaandAthensAreas

800­441­5501

877­459­6604

5E4

2U1

5E5

2U2

77.55

161.92

213.28

381.53

35.79

74.73

98.44

176.09

Humana, Inc. ­high­ Atlanta 888­393­6765 DG1 DG2 102.79 236.41 47.44 109.11

Humana, Inc. ­std­ Atlanta 888­393­6765 DG4 DG5 93.44 214.92 43.12 99.19

KaiserFoundation Health Plan of GA, Inc. ­high­ Atlanta,Athens,Columbus, Macon.Savannah 888­865­5813 F81 F82 107.21 245.50 49.48 113.31

KaiserFoundation Health Plan of GA, Inc. ­std­ Atlanta,Athens,Columbus, Macon.Savannah 888­865­5813 F84 F85 73.29 167.85 33.83 77.47

38
Delaware

Aetna Open Access­High $20/$30 $150/dayx5 $10 $25/$50 Yes 52.9 79.7 86.7 94.8 78.7 81.9 61.2

Aetna Open Access­Basic $15/$30 20% Plan Allow $5 $30/$50 Yes 52.9 79.7 86.7 94.8 78.7 81.9 61.2

Coventry Health Care­High $10/$20 $100 $10 $20/$45 Yes 53.9 83.9 85.6 91.7 79.4 80.6 59.9

Coventry Health Care­Std $10/$20 $200/dayx3 $10 $20/$45 Yes 53.9 83.9 85.6 91.7 79.4 80.6 59.9

District of Columbia

Aetna Open Access­High $15/$25 $150/dayx3 $5 $25/$50 No 59.2 81.6 89.1 92.9 84.7 85.1 57.4

Aetna Open Access­Basic $20/$30 10% Plan Allow $10 $25/$50 No 59.2 81.6 89.1 92.9 84.7 85.1 57.4

CareFirst BlueChoice­High $20/$30 $100 $10 $25/$40 Yes 60.5 80.2 83.9 90.9 70.6 85.2 53

KaiserFoundation HP­High $10/$20 $100 $7/$17 Net$30/$50/$45/$65 Yes 63.6 74.5 75.6 88.6 77 79.3 54

KaiserFoundation HP­Std $20/$30 $250/dayx3 $12/$22Net$35/$55/$50/$70 Yes 63.6 74.5 75.6 88.6 77 79.3 54

M.D. IPA­High $20/$30 $150/dayx3 $7 $25/$50 No 58 80.4 82.4 91 81.6 80.9 54.7

Florida

Av­Med Health Plan­High $15/$40 $150/dayx5 $15 $30/$50/30% No 74.4 82.6 85.1 90.6 87.9 84.6 64.1

Av­Med Health Plan­Std $25/$45 $175/dayx5 $20 $40/$60/30% No 74.4 82.6 85.1 90.6 87.9 84.6 64.1

Capital Health Plan­High $15/$25 $250 $15 $30/$50 No 80.6 87.4 85.3 93.7 90.3 95.5 55.6

Humana, Inc.­High $15/$25 $200/dayx3 $10 $30/$50 Yes 56.7 82.4 85.6 92 81.1 93 56.8

Humana, Inc.­Std $20/$30 $400/dayx3 $10 $30/$50 Yes 56.7 82.4 85.6 92 81.1 93 56.8

Humana, Inc.­High $15/$25 $200/dayx3 $10 $30/$50 Yes 56.7 82.4 85.6 92 81.1 93 56.8

Humana, Inc.­Std $20/$30 $400/dayx3 $10 $30/$50 Yes 56.7 82.4 85.6 92 81.1 93 56.8

JMH Health Plan­ In­Network $15/$25 $100/dayx5 $10 $20/$30 Yes

JMH Health Plan­ Out­Network 30%/30% 30% 30% 30%/30% N/A

JMH Health Plan­Std $30/$40 $150/dayx5 $10 50%/50% Yes

United Healthcare­High $20/$30 $150adayx3 $7 $30/$50 Yes 57.3 84.2 82.7 94.3 72.3 85.2 50.6

Vista Healthplan­High $15/$30 Ded. + $150x3days $20 $40/$60/20% No 44.9 75.3 72.8 85.3 83.7 80.6 51.7

Vista Healthplan­Std $20/$40 Ded +$200x3 $10 $10/$60/20(3) No

Georgia

Aetna Open Access­High $20/$30 $150/dayx5 $10 $25/$50 Yes 60.9 87.6 85 93.4 81.1 84.7 62.7

Humana, Inc.­High $15/$25 $200/dayx3 $10 $30/$50 Yes

Humana, Inc.­Std $20/$30 $400/dayx3 $10 $30/$50 Yes

KaiserFoundation HP­High $10/$20 $250 $10/$16 Comm$25/$31 Comm/$25/$31 CommYes 62.9 79.8 82.1 93.2 80.1 76 56

KaiserFoundation HP­Std $20/$30 $250/dayx3 $20/$26 Comm$30/$36 Comm/$30/$36 CommYes 62.9 79.8 82.1 93.2 80.1 76 56 Claims processing 85.7 Shared decision making 58.7 Overall plan satisfaction 62.8 Getting needed care 84 Getting care quickly 85.6 How well doctors communicate 92.6 Customer service 82.1

Prescription

Drugs

Member Survey Results

(with national averages for HMO/POS plans in each category)

Hospital

per stay

deductible

Primary

care/

Specialist

office

copay

Level I Level II/

Level III

Mail

order

discount Plan Name – Location

39
 
Health Maintenance Organization (HMO) and Point­of­Service (POS) Plans

See page 35 for an explanation of the columns on these pages.

Telephone

Enrollment

Code

Your Share of Premium

Monthly Biweekly

Self Self & Self Self & Self Self &

Guam

TakeCare ­high­ Guam/N.MarianaIslands/Belau(Palau)

Plan Name – Location

671­647­3526

Number

JK1

only

JK2

family

199.01

only

645.43

family

91.85

only

297.89

family

TakeCare ­std­ Guam/N.MarianaIslands/Belau(Palau)

Hawaii

HMSA­high­ Allof Hawaii

671­647­3526

808­948­6499

JK4

871

JK5

872

105.75

93.91

353.23

209.04

48.81

43.34

163.03

96.48

KaiserFoundation Health Plan of Hawaii ­high­ Hawaii/Kauai/Lanai/Maui/Molokai/Oahu 808­432­5955 631 632 100.86 216.85 46.55 100.08

KaiserFoundation Health Plan of Hawaii ­std­ Hawaii/Kauai/Lanai/Maui/Molokai/Oahu

Idaho

Altius Health Plans ­high­ Southern Region

808­432­5955

800­377­4161

634

9K1

635

9K2

46.95

158.86

100.94

327.67

21.67

73.32

46.59

151.23

Altius Health Plans ­std­ Southern Region 800­377­4161 DK4 DK5 105.79 232.73 48.82 107.41

Group Health Cooperative ­high­ KootenaiandLatah 888­901­4636 VR1 VR2 229.87 455.41 106.09 210.19

Group Health Cooperative ­std­ KootenaiandLatah

Illinois

Aetna Open Access ­high­ ChicagoArea

888­901­4636

877­459­6604

VR4

IK1

VR5

IK2

87.94

91.02

202.27

231.04

40.59

42.01

93.36

106.63

Blue Preferred HMO ­high­ Madison andSt. Clair counties 888­811­2092 9G1 9G2 149.24 289.45 68.88 133.59

Group Health Plan, Inc. ­high­ Southern/Central 800­755­3901 MM1 MM2 270.69 549.38 124.93 253.56

Group Health Plan, Inc. ­std­ Southern/Central 800­755­3901 MU4 MU5 241.28 485.75 111.36 224.19

Health Alliance HMO ­high­ Central/E.Central/N. Cent/South/West IL 800­851­3379 FX1 FX2 168.27 416.04 77.66 192.02

Health Alliance HMO ­std­ Central/E.Central/N. Cent/South/West IL 800­851­3379 FX4 FX5 93.39 236.20 43.10 109.02

Humana Health Plan Inc. ­high­ Chicagoarea 888­393­6765 751 752 157.54 374.16 72.71 172.69

Humana Health Plan Inc. ­std­ Chicagoarea 888­393­6765 754 755 79.62 183.13 36.75 84.52

OSF HealthPlans, Inc. ­high­ Cental/Central­Northwestern Illinois 800­673­5222 9F1 9F2 143.76 438.73 66.35 202.49

OSF HealthPlans, Inc. ­std­ Central/Central­Northwestern Illinois 800­673­5222 AB4 AB5 93.31 233.29 43.07 107.67

PersonalCare Insuranceof Illinois, Inc. ­high­ Central Illinois 800­431­1211 GE1 GE2 120.82 413.42 55.76 190.81

Unicare HMO ­high­ ChicagolandArea 888­234­8855 171 172 162.79 345.11 75.13 159.28

Unicare HMO ­std­ ChicagolandArea 888­234­8855 174 175 87.02 192.98 40.16 89.07

Union Health Service ­high­ Chicagoarea 312­829­4224 761 762 87.09 215.99 40.20 99.69

United Healthcareof the Midwest ­high­ Southwest llinois 877­835­9861 B91 B92 113.47 251.75 52.37 116.19

UnitedHealthcare Plan of the RiverValley Inc. ­high­ West Central Illinois 800­247­9110 YH1 YH2 89.22 218.59 41.18 100.89

40
Primary

care/

Specialist

office copay Plan Name – Location

Hospital

per stay

deductible

Prescription Member Survey Results

Drugs (with national averages for HMO/POS plans in each category)

Mail

Level II/ order

Level I Level III discount

Overall plan

satisfaction 62.8

Getting needed

care 84

Getting care

quickly 85.6

How well

doctors

communicate 92.6

Customerservice 82.1

Claimsprocessing 85.7

Shared decision

making 58.7

Guam

TakeCare­High $20/$40 $100/day for5days $10 $10/$50 No 64.7 74.1 73.3 88.4 75 77 57.7

TakeCare­Std $25/$40 $150/day for5days $20 $20/$80 No 64.7 74.1 73.3 88.4 75 77 57.7

Hawaii

HMSA­ In­Network $15/$15 None $5 $20/50% Yes 81.2 90.3 91.3 95 87.4 93.7 62.2

HMSA­ Out­Network 30%/30% 30% $5 + 20% +$20 + 20% +/50% +No 81.2 90.3 91.3 95 87.4 93.7 62.2

KaiserFoundation HP­Std $25/$25 10% $20 $20/$20 Yes 64.1 77 79.6 91.8 76.5 79.5 58.3

KaiserFoundation HP­High $15/$15 None $15 $15/$15 Yes 64.1 77 79.6 91.8 76.5 79.5

Idaho

Altius Health Plans­High $10/$15 $100 $5 $20/$50 Yes 62.1 81.9 86.6 94.4 84 88.3 53.5

Group Health Cooperative­High $20/$20 $350/dayx3 $15 $30/$60 Yes 64.4 83.6 87.3 93.3 85.8 88.6 57.3

Altius Health Plans­Std $20/$30 None $10 $25/$50 Yes

Group Health Cooperative­Std $20+20%/$20+20% $500/dayx3 $15 $30/$60 Yes 64.4 83.6 87.3 93.3 85.8 88.6 57.3

Illinois

Aetna Open Access­High

Group Health Plan, Inc.­High

Health Alliance HMO­High

Humana Health Plan Inc.­High

OSF HealthPlans, Inc.­High

$20/$30

$25/$25

$15/$25

$15/$25

$20/$20

$150/dayx5

$250/dayx3

$500

$200/dayx3

$500

$10

$10

$10

$10

$10

$25/$50

$30/$50

$20/$40

$25/$45

$30/$50

Yes

Yes

Yes

Yes

Yes

55.6

61.6

73.9

59.8

72.6

78.5

83.4

86.6

83.7

86.2

84.1 91.1 82.1 81.8 55.1

87.2 94.1 80.5 89.9 61.6

86.9 93.7 89.9 89.7 61.8

85.6 88.9 76.7 75.3 58.8

87.1 94.8 89.5 90.9 62.2

Blue Preferred HMO­High $25/$25 $500 $10 $20/$40 Yes 62.2 87.9 87.4 93.7 81.9 87.3 55.5

Group Health Plan, Inc.­Std $20/$40 20%after$500/dayx2 $12 $35/$60 Yes 61.6 83.4 87.2 94.1 80.5 89.9 61.6

Health Alliance HMO­Std $20/$35 20% $20 $35/$50 Yes 73.9 86.6 86.9 93.7 89.9 89.7 61.8

Humana Health Plan Inc.­Std $20/$30 $400/dayx3 $10 $25/$45 Yes 59.8 83.7 85.6 88.9 76.7 75.3 58.8

OSF HealthPlans, Inc.­Std $30/$30 $750 $10 $30/$50 Yes

PersonalCare Insurance­High $30/$35 $350/dayx4 $15 $35/$65 No 77.6 90.2 90.4 92.8 86.4 90 66.2

Unicare HMO­High $15/$15 $250 $10 $25/$50/20% Yes 58.1 78 78.3 88.5 69.1 74.3 69.6

Unicare HMO­Std $20/$35 10% $15 $30/$60/20% Yes 58.1 78 78.3 88.5 69.1 74.3 69.6

Union Health Service­High $10/$10 None $15 $15/$15 No

United Healthcare­High $20/$30 $150 adayx 3 $7 $30/$50 Yes 53.2 84.3 85 96.9 71.3 83.1 57.8

UnitedHealthcare RiverValley­High $15/$30 $100/5days $10 $30/$45 Yes 65.2 86.8 88.5 94.5 78.9 91.9 53.7

41

58.3
Health Maintenance Organization (HMO) and Point­of­Service (POS) Plans

See page 35 for an explanation of the columns on these pages.

Telephone

Enrollment

Code

Your Share of Premium

Monthly Biweekly

Self Self & Self Self & Self Self &

Indiana

Aetna Open Access ­high­ Northern IndianaArea

Plan Name – Location

877­459­6604

Number

IK1

only

IK2

family

91.02

only

231.04

family

42.01

only

106.63

family

Aetna Open Access ­high­ Southeastern IndianaArea 877­459­6604 RD1 RD2 309.19 834.41 142.70 385.11

Health Alliance HMO ­high­ Western Indiana 800­851­3379 FX1 FX2 168.27 416.04 77.66 192.02

Health Alliance HMO ­std­ Western Indiana 800­851­3379 FX4 FX5 93.39 236.20 43.10 109.02

Humana Health Plan Inc. ­high­ Lake/Porter/LaPorte Counties 888­393­6765 751 752 157.54 374.16 72.71 172.69

Humana Health Plan Inc. ­std­ Lake/Porter/LaPorte Counties 888­393­6765 754 755 79.62 183.13 36.75 84.52

Physicians Health Plan of Northern Indiana­high­ Northeast Indiana 260­432­6690 DQ1 DQ2 152.28 327.49 70.28 151.15

Unicare HMO ­high­ Lake/Porter Counties 888­234­8855 171 172 162.79 345.11 75.13 159.28

Unicare HMO ­std­ Lake/Porter Counties 888­234­8855 174 175 87.02 192.98 40.16 89.07

Welborn Health Plans ­high­ EvansvilleArea

Iowa

Coventry Health Careof Iowa­high­ Central/Eastern/Western Iowa

800­521­0265

800­257­4692

W11

SV1

W12

SV2

186.16

108.53

460.94

408.16

85.92

50.09

212.74

188.38

Coventry Health Careof Iowa­std­ Central/Eastern/Western Iowa 800­257­4692 SY4 SY5 86.01 202.12 39.70 93.29

Health Alliance HMO ­high­ Central Iowa 800­851­3379 FX1 FX2 168.27 416.04 77.66 192.02

Health Alliance HMO ­std­ Central Iowa 800­851­3379 FX4 FX5 93.39 236.20 43.10 109.02

HealthPartners Open Access Copay ­high­ Iowa 952­883­5000 V31 V32 195.29 460.98 90.13 212.76

HealthPartners Three forFree ­std­ Iowa 952­883­5000 V34 V35 70.16 161.37 32.38 74.48

Sanford Health Plan ­high­ Northwestern Iowa 800­752­5863 AU1 AU2 176.15 417.52 81.30 192.70

Sanford Health Plan ­std­ Northwestern Iowa 800­752­5863 AU4 AU5 151.67 360.53 70.00 166.40

UnitedHealthcare Plan of the RiverValley Inc. ­high­ Eastern Iowa; W. Central Illinois

Kansas

Coventry Health Careof Kansas ­high­ Kansas City/Wichita/Salinaareas

800­747­1446

800­969­3343

YH1

HA1

YH2

HA2

89.22

100.76

218.59

254.35

41.18

46.50

100.89

117.39

Coventry Health Careof Kansas ­std­ Kansas City/Wichita/Salinaareas 800­969­3343 HA4 HA5 79.46 186.68 36.67 86.16

Humana Health Plan, Inc. ­high­ Kansas Cityarea 888­393­6765 MS1 MS2 289.86 678.49 133.78 313.15

Humana Health Plan, Inc. ­std­ Kansas Cityarea 888­393­6765 MS4 MS5 91.26 209.90 42.12 96.88

United Healthcareof the Midwest ­high­ Kansas CityArea 877­835­9861 GX1 GX2 166.25 419.32 76.73 193.53

42
Indiana

Aetna Open Access­High $20/$30 $150/dayx5 $10 $25/$50 Yes 55.6 78.5 84.1 91.1 82.1 81.8 55.1

Aetna Open Access­High $20/$30 $150/dayx5 $10 $25/$50 Yes 59 84.4 85 91.9 82.3 84.8 51.6

Health Alliance HMO­High $15/$25 $500 $10 $20/$40 Yes 73.9 86.6 86.9 93.7 89.9 89.7 61.8

Health Alliance HMO­Std $20/$35 20% $20 $35/$50 Yes 73.9 86.6 86.9 93.7 89.9 89.7 61.8

Humana Health Plan Inc.­High $15/$25 $200/dayx3 $10 $25/$45 Yes 59.8 83.7 85.6 88.9 76.7 75.3 58.8

Humana Health Plan Inc.­Std $20/$30 $400/dayx3 $10 $25/$45 Yes 59.8 83.7 85.6 88.9 76.7 75.3 58.8

Physicians Health Plan­High $15/$15 20% $5 $20/25%/$45 Yes 56.7 89 90.2 92.8 88.7 94.1 59.3

Unicare HMO­High $15/$15 $250 $10 $25/$50/20% Yes 58.1 78 78.3 88.5 69.1 74.3 69.6

Unicare HMO­Std $20/$35 10% $15 $30/$60/20% Yes 58.1 78 78.3 88.5 69.1 74.3 69.6

Welborn Health Plans­High $20/$20 10% $10 $25/$40 Yes

Iowa

Coventry Health Careof Iowa­High $15/$30 $150/dayx5 $10 $30/$55 Yes 59.1 82.5 86.8 94.3 79.6 89.2 60

Coventry Health Careof Iowa­Std $20/$30 10% $10 $30/$55 No

Health Alliance HMO­High $15/$25 $500 $10 $20/$40 Yes 73.9 86.6 86.9 93.7 89.9 89.7 61.8

Health Alliance HMO­Std $20/$35 20% $20 $35/$50 Yes 73.9 86.6 86.9 93.7 89.9 89.7 61.8

HealthPartners OA Copay $20/$20 10% of charges $10 $25/$50 Yes

HealthPartners3forFree $0for3, then 20%/$0for3, then 20% 20% in/40% out $6 $30/$60 Yes

Sanford Health Plan­ In­Network $20/$30 $100/dayx5 $15 $30/$50 N/A 49.4 84.4 90 94 81.9 85.7 60.3

Sanford Health Plan­ Out­Network 40%/40% 40% N/A N/A/N/A N/A 49.4 84.4 90 94 81.9 85.7 60.3

Sanford Health Plan­ In­Network $25/$25 $100/dayx5 $15 $30/$50 No 49.4 84.4 90 94 81.9 85.7 60.3

Sanford Health Plan­ Out­Network 40%/40% 40% N/A N/A/N/A No 49.4 84.4 90 94 81.9 85.7 60.3

UnitedHealthcare RiverValley­High $15/$30 $100/5days $10 $30/$45 Yes 65.2 86.8 88.5 94.5 78.9 91.9 53.7

Kansas

Coventry Health Care­High $20/$30 $200/dayx5 $10 $35/$60 Yes 59.9 85.7 88.2 93.3 84.9 87.7 66

Coventry Health Care­Std $20/$40 20% $10 $40/$65 Yes 59.9 85.7 88.2 93.3 84.9 87.7 66

Humana Health Plan, Inc.­High $15/$25 $200/dayx3 $10 $30/$50 Yes 63.3 88 89.7 92.8 80.6 84.9 58.7

Humana Health Plan, Inc.­Std $20/$30 $400/dayx3 $10 $30/$50 Yes 63.3 88 89.7 92.8 80.6 84.9 58.7

United Healthcare­High $20/$30 $150adayx3 $7 $30/$50 Yes 53.2 84.3 85 96.9 71.3 83.1 57.8 Claims processing 85.7 Shared decision making 58.7 Overall plan satisfaction 62.8 Getting needed care 84 Getting care quickly 85.6 How well doctors communicate 92.6 Customer service 82.1

Prescription

Drugs

Member Survey Results

(with national averages for HMO/POS plans in each category)

Hospital

per stay

deductible

Primary

care/

Specialist

office copay Level I

Level II/

Level III

Mail

order

discount Plan Name – Location

43
 
Health Maintenance Organization (HMO) and Point­of­Service (POS) Plans

See page 35 for an explanation of the columns on these pages.

Telephone

Enrollment

Code

Your Share of Premium

Monthly Biweekly

Self Self & Self Self & Self Self &

Kentucky

Aetna Open Access ­high­ Northern KentuckyArea

Louisiana

Coventry Health CareofLouisiana­high­ New Orleansarea

Plan Name – Location

877­459­6604

800­­341­6613

Number

RD1

BJ1

only

RD2

BJ2

family

309.19

116.85

only

834.41

290.72

family

142.70

53.93

only

385.11

134.18

family

Coventry Health CareofLouisiana­std­ New Orleansarea 800­­341­6613 BJ4 BJ5 119.54 296.99 55.17 137.07

Vantage Health Plan, Inc. ­high­ Alexandria/Baton Rouge/Monroe/Shreveport 888­823­1910 MV1 MV2 123.24 295.27 56.88 136.28

Vantage Health Plan, Inc. ­std­ Alexandria/Baton Rouge/Monroe/Shreveport

Maryland

Aetna Open Access ­high­ Northern/Central/Southern MarylandAreas

888­823­1910

877­459­6604

MV4

JN1

MV5

JN2

100.90

230.06

232.10

506.85

46.57

106.18

107.12

233.93

Aetna Open Access ­basic­ Northern/Central/Southern MarylandAreas 877­459­6604 JN4 JN5 93.09 217.85 42.96 100.54

CareFirst BlueChoice ­high­ Allof Maryland 866­296­7363 2G1 2G2 112.82 253.13 52.07 116.83

Coventry Health Care ­high­ Allof Maryland 800­833­7423 IG1 IG2 101.29 254.18 46.75 117.31

Coventry Health Care ­std­ Allof Maryland 800­833­7423 IG4 IG5 79.70 199.25 36.78 91.96

KaiserFoundation Health Plan Mid­AtlanticStates ­high­ Baltimore/Washington, DC areas 1­877­574­3337 E31 E32 126.75 323.14 58.50 149.14

KaiserFoundation Health Plan Mid­AtlanticStates ­std­ Baltimore/Washington, DC areas 1­877­574­3337 E34 E35 66.13 157.36 30.52 72.63

M.D. IPA­high­ Allof Maryland

Massachusetts

Blue CHiP Coordinated Health Plan ­ BCBSof RI ­high­ Southeastern Massachusetts

877­835­9861

401­274­3500

JP1

DA1

JP2

DA2

111.20

252.31

261.82

798.42

51.32

116.45

120.84

368.50

ConnectiCare ­high­ Counties Hampden, Hampshire,Franklin 800­251­7722 TE1 TE2 148.14 340.56 68.37 157.18

ConnectiCare ­basic­ Counties Hampden, Hampshire,Franklin 800­251­7722 TE4 TE5 97.87 222.69 45.17 102.78

Fallon Community Health Plan ­std­ Central/Eastern/Western Massachusetts 800­868­5200 JV4 JV5 229.71 614.08 106.02 283.42

Fallon Community Health Plan ­basic­ Central/Eastern/Western Massachusetts 800­868­5200 JG1 JG2 184.21 503.43 85.02 232.35

44
Primary

care/

Specialist

office copay Plan Name – Location

Hospital

per stay

deductible

Prescription Member Survey Results

Drugs (with national averages for HMO/POS plans in each category)

Mail

Level II/ order

Level I Level III discount

Overall plan

satisfaction 62.8

Getting needed

care 84

Getting care

quickly 85.6

How well

doctors

communicate 92.6

Customerservice 82.1

Claimsprocessing 85.7

Shared decision

making 58.7

Kentucky

Aetna Open Access­High $20/$30 $150/dayx5 $10 $25/$50 Yes 59 84.4 85 91.9 82.3 84.8 51.6

Louisiana

Coventry Health Care­High $20/$40 $150/dayx3 $1 $35/$60 Yes 59.4 83.2 84.6 93.7 82 86.5 61.7

Vantage Health Plan, Inc.­High $15/$15 $250 $10 $20/$35 Yes

Coventry Health Care­Std $25/$50 30% $1 $35/$60 Yes 59.4 83.2 84.6 93.7 82 86.5

Vantage Health Plan, Inc.­Std $30/$50 $500 $15 $40/$60 Yes

Maryland

Aetna Open Access­High

CareFirst BlueChoice­High

Coventry Health Care­Std

KaiserFoundation HP­Std

$15/$25

$20/$30

$10/$20

$20/$30

$150/dayx3

$100

$200/dayx3

$250/dayx3

$5 $25/$50 No

$10 $25/$40 Yes

$10 $20/$45 Yes

$12/$22Net$35/$55/$50/$70 Yes

59.2

60.5

53.9

63.6

81.6

80.2

83.9

74.5

89.1 92.9 84.7 85.1 57.4

83.9 90.9 70.6 85.2 53

85.6 91.7 79.4 80.6 59.9

75.6 88.6 77 79.3 54

Aetna Open Access­Basic $20/$30 10% Plan Allow $10 $25/$50 No 59.2 81.6 89.1 92.9 84.7 85.1 57.4

Coventry Health Care­High $10/$20 $100 $10 $20/$45 Yes 53.9 83.9 85.6 91.7 79.4 80.6 59.9

KaiserFoundation HP­High $10/$20 $100 $7/$17 Net$30/$50/$45/$65 Yes 63.6 74.5 75.6 88.6 77 79.3 54

M.D. IPA­High $20/$30 $150/dayx3 $7 $25/$50 No 58 80.4 82.4 91 81.6 80.9 54.7

Massachusetts

BCBSof RI­ In­Network
 

BCBSof RI­ Out­Network
 

ConnectiCare­Basic

Fallon Health Plan­Basic

$15/$25

30%/30%

$25/$45

$20/$30

$500

None

Nothingafterded

$100to$500max

$7 $30/$50 Yes 57.9 89.6 88.7 94.9 85 92.2 65.1

$50+20%$50+20%/$50+20% No 57.9 89.6 88.7 94.9 85 92.2 65.1

$15 $30/50% or$60 max Yes 47.6 85.5 86.6 92.2 87.9 91.1 60.6

$10 $30/$60 Yes

ConnectiCare­High $20/$40 $250perday/$1250ma $15 $30/50% or$60 max Yes 47.6 85.5 86.6 92.2 87.9 91.1 60.6

Fallon Health Plan­Std $20/$20 Nothingafter $10 $30/$60 Yes 68.2 81.7 86 94.2 85.8 82.8 61.5

45

61.7
Health Maintenance Organization (HMO) and Point­of­Service (POS) Plans

See page 35 for an explanation of the columns on these pages.

Telephone

Enrollment

Code

Your Share of Premium

Monthly Biweekly

Self Self & Self Self & Self Self &

Michigan

Bluecare Networkof MI ­high­ Midland CountyArea

Plan Name – Location

800­662­6667

Number

K51

only

K52

family

185.45

only

427.98

family

85.59

only

197.53

family

Bluecare Networkof MI ­high­ Southeast MI 800­662­6667 LX1 LX2 94.51 245.58 43.62 113.34

GrandValley Health Plan ­high­ Grand Rapidsarea 616­949­2410 RL1 RL2 108.50 373.08 50.08 172.19

GrandValley Health Plan ­std­ Grand Rapidsarea 616­949­2410 RL4 RL5 95.95 249.48 44.28 115.14

Health Alliance Plan ­high­ Southeastern Michigan/Flintarea 800­556­9765 521 522 98.13 256.49 45.29 118.38

HealthPlus MI ­high­ East Central Michigan 800­332­9161 X51 X52 139.28 322.83 64.28 149.00

Physicians Health Plan of Mid­Michigan ­high­ Mid­Michigan 517­364­8400 9U1 9U2 169.72 457.93 78.33 211.35

Physicians Health Plan of Mid­Michigan ­std­ Mid­Michigan

Minnesota

HealthPartners Open Access Copay ­high­ Minnesota

517­364­8400

952­883­5000

9U4

V31

9U5

V32

105.99

195.29

257.79

460.98

48.92

90.13

118.98

212.76

HealthPartners Three forFree ­std­ Minnesota 952­883­5000 V34 V35 70.16 161.37 32.38 74.48

Medica Health Plan ­high­ Mostof Minnesota

Missouri

Blue Preferred HMO ­high­ StLouis/Central/SW areas

800­952­3455

888­811­2092

M21

9G1

M22

9G2

149.83

149.24

351.52

289.45

69.15

68.88

162.24

133.59

Coventry Health Careof Kansas ­high­ Kansas Cityarea 800­969­3343 HA1 HA2 100.76 254.35 46.50 117.39

Coventry Health Careof Kansas ­std­ Kansas Cityarea 800­969­3343 HA4 HA5 79.46 186.68 36.67 86.16

Group Health Plan, Inc. ­high­ St.LouisArea 800­755­3901 MM1 MM2 270.69 549.38 124.93 253.56

Group Health Plan, Inc. ­std­ St.LouisArea 800­755­3901 MU4 MU5 241.28 485.75 111.36 224.19

Humana Health Plan, Inc. ­high­ Kansas Cityarea 888­393­6765 MS1 MS2 289.86 678.49 133.78 313.15

Humana Health Plan, Inc. ­std­ Kansas Cityarea 888­393­6765 MS4 MS5 91.26 209.90 42.12 96.88

United Healthcareof the Midwest ­high­ St. LouisArea 877­835­9861 B91 B92 113.47 251.75 52.37 116.19

United Healthcareof the Midwest ­high­ Kansas CityArea

Montana

New West Health Services ­high­ Mostof Montana

877­835­9861

800­290­3657

GX1

NV1

GX2

NV2

166.25

159.99

419.32

298.31

76.73

73.84

193.53

137.68

New West Health Services ­POS­ Mostof Montana 800­290­3657 NV1 NV2 159.99 298.31 73.84 137.68

46
Primary

care/

Specialist

office copay Plan Name – Location

Hospital

per stay

deductible

Prescription Member Survey Results

Drugs (with national averages for HMO/POS plans in each category)

Mail

Level II/ order

Level I Level III discount

Overall plan

satisfaction 62.8

Getting needed

care 84

Getting care

quickly 85.6

How well

doctors

communicate 92.6

Customerservice 82.1

Claimsprocessing 85.7

Shared decision

making 58.7

Michigan

Bluecare Networkof MI­High

GrandValley Health Plan­High

Health Alliance Plan­High

Physicians Health Plan­High

$10/$25

$10/$10

$10/$20

$10/Nothing

$100

Nothing

None

Nothing

$5$30 or 50%/$30 or 50% Yes 65.2 86.7 87.3 92.6 84.2 91.1 60.9

$5 $15/$15 No 73.3 81.9 89.1 94.8 89.9 86.6 54.1

$10 $40/$40 Yes 76.9 83.8 88.2 92.9 84.4 91.2 59.4

$10 $25/$40 Yes

Bluecare Networkof MI­High $10/$25 $100 $5$30or50%/$30or50% Yes 65.2 86.7 87.3 92.6 84.2 91.1 60.9

GrandValley Health Plan­Std $20/$20 $500x3 $10 $40/$40 No

HealthPlus MI­High $10/$20 None $10 $20/N/A Yes 74.9 88.4 91 92.8 83.9 91.2 62.8

Physicians Health Plan­Std $20/Nothing 20% $15 $25/$50 Yes

Minnesota

HealthPartners OA Copay $20/$20 10% of charges $10 $25/$50 Yes

Medica Health Plan­ In­Network $15/$15 $300 $10 $25/$50/$50 Yes

Medica Health Plan­ Out­Network 40%/40% None 40%/$5040%/$50/40%/$50 No

HealthPartners3forFree $0for3, then 20%/$0for3, then 20% 20% in/40% out $6 $30/$60 Yes

Missouri

Blue Preferred HMO­High

Coventry Health Care­Std

Group Health Plan, Inc.­Std

Humana Health Plan, Inc.­Std

United Healthcare­High

$25/$25 $500 $10

$20/$40 20% $10

$20/$40 20%after$500/dayx2 $12

$20/$30 $400/dayx3 $10

$20/$30 $150 adayx3 $7

$20/$40

$40/$65

$35/$60

$30/$50

$30/$50

Yes

Yes

Yes

Yes

Yes

62.2

59.9

61.6

63.3

53.2

87.9

85.7

83.4

88

84.3

87.4 93.7 81.9 87.3 55.5

88.2 93.3 84.9 87.7 66

87.2 94.1 80.5 89.9 61.6

89.7 92.8 80.6 84.9 58.7

85 96.9 71.3 83.1 57.8

Coventry Health Care­High $20/$30 $200/dayx5 $10 $35/$60 Yes 59.9 85.7 88.2 93.3 84.9 87.7 66

Group Health Plan, Inc.­High $25/$25 $250/dayx3 $10 $30/$50 Yes 61.6 83.4 87.2 94.1 80.5 89.9 61.6

Humana Health Plan, Inc.­High $15/$25 $200/dayx3 $10 $30/$50 Yes 63.3 88 89.7 92.8 80.6 84.9 58.7

United Healthcare­High $20/$30 $150adayx3 $7 $30/$50 Yes 53.2 84.3 85 96.9 71.3 83.1 57.8

Montana

New West Health Services­ High $15/$15 $100 $10 $20/$40 Yes 46.1 82.4 87.1 94.9 85.8 83.9 58.1

New West Health Services­ POS 30%/30% 30% N/A N/A/N/A No 46.1 82.4 87.1 94.9 85.8 83.9 58.1

47
Health Maintenance Organization (HMO) and Point­of­Service (POS) Plans

See page 35 for an explanation of the columns on these pages.

Telephone

Enrollment

Code

Your Share of Premium

Monthly Biweekly

Self Self & Self Self & Self Self &

Nevada

Aetna Open Access ­high­ LasVegasand RenoAreas

Plan Name – Location

877­459­6604

Number

Y11

only

Y12

family

98.92

only

246.30

family

45.65

only

113.68

family

Health Plan of Nevada­high­ LasVegasarea 800­777­1840 NM1 NM2 70.63 180.87 32.60 83.48

PacifiCareof Nevada­high­ LasVegas/Clark County

New Jersey

Aetna Open Access ­high­ Northern New Jersey

866­546­0510

877­459­6604

K91

JR1

K92

JR2

104.35

222.56

236.87

523.88

48.16

102.72

109.32

241.79

Aetna Open Access ­basic­ Northern New Jersey 877­459­6604 JR4 JR5 109.89 253.67 50.72 117.08

Aetna Open Access ­high­ Southern NJ 877­459­6604 P31 P32 288.04 744.88 132.94 343.79

Aetna Open Access ­basic­ Southern NJ 877­459­6604 P34 P35 106.92 246.90 49.35 113.95

AmeriHealth HMO ­high­ Allof New Jersey 800­454­7651 FK1 FK2 195.00 495.26 90.00 228.58

AmeriHealth HMO ­std­ Allof New Jersey 800­454­7651 FK4 FK5 166.97 429.37 77.06 198.17

Coventry Health Care ­high­ Southern New Jersey 800­833­7423 2J1 2J2 213.33 612.54 98.46 282.71

Coventry Health Care ­std­ Southern New Jersey 800­833­7423 2J4 2J5 114.36 365.06 52.78 168.49

GHI Health Plan ­high­ Northern New Jersey 212­501­4444 801 802 204.26 589.98 94.27 272.30

GHI Health Plan ­std­ Northern New Jersey

New Mexico

Lovelace Health Plan ­high­ Allof New Mexico

212­501­4444

800­808­7363

804

Q11

805

Q12

96.55

117.46

225.37

350.22

44.56

54.21

104.02

161.64

Presbyterian Health Plan ­high­ All counties in New Mexico 800­356­2219 P21 P22 233.51 532.42 107.77 245.73

Presbyterian Health Plan ­std­ All counties in New Mexico 800­356­2219 P24 P25 177.13 404.30 81.75 186.60

48
Nevada

Aetna Open Access­High $20/$30 $150/dayx5 $10 $25/$50 Yes 56.7 78.6 80.5 89 76.6 82.5 57

Health Plan of Nevada­High $10/$10 $50 $5 $35/$55 Yes 50.6 72.4 73.2 85 79.8 82 53.3

PacifiCareof Nevada­High $15/$30 $150/dayx5 $10 $30/$50 Yes 51.1 75 75.3 85.8 68.2 78.3 53.3

New Jersey

Aetna Open Access­High $20/$30 $150/dayx5 $10 $25/$50 Yes 50.5 84.2 86.9 91.9 85.2 79.7 52.4

Aetna Open Access­Basic $15/$30 20% Plan Allow $5 $30/$50 Yes 50.5 84.2 86.9 91.9 85.2 79.7 52.4

Aetna Open Access­High $20/$30 $150/dayx5 $10 $25/$50 Yes 63.9 87.4 92 93.7 83 86.7 53.4

Aetna Open Access­Basic $15/$30 20% Plan Allow $5 $30/$50 Yes 63.9 87.4 92 93.7 83 86.7 53.4

AmeriHealth HMO­High $25/$40 $150/dayx5 $5 $40/50% Yes 61.2 86.6 86.3 94.1 83 80.8 65.3

AmeriHealth HMO­Std $30/$50 80% afterded $5 $40/50% Yes 61.2 86.6 86.3 94.1 83 80.8 65.3

Coventry Health Care­High $10/$20 $100 $10 $20/$45 Yes 53.9 83.9 85.6 91.7 79.4 80.6 59.9

Coventry Health Care­Std $10/$20 $200/dayx3 $10 $20/$45 Yes 53.9 83.9 85.6 91.7 79.4 80.6 59.9

GHI Health Plan­ In­Network $15/$15 $100 $15 $25/$50 Yes 69.6 87.1 86.8 92.1 76.2 86.8 65.3

GHI Health Plan­ Out­Network +50% of sch +50% of sch. N/A N/A/N/A No 69.6 87.1 86.8 92.1 76.2 86.8 65.3

GHI Health Plan­Std $25/$25 $250/dayx3 $10 $25/$50 Yes 69.6 87.1 86.8 92.1 76.2 86.8 65.3

New Mexico

Lovelace Health Plan­High $15/$25 $250 $7 $15/$35 Yes 60.4 80.4 76.3 92.9 82.5 85.2 53.5

Presbyterian Health Plan­High $15/$25 $200 $10 $20/$40 Yes

Presbyterian Health Plan­Std $30/$40 $500 $15 $35/$55 Yes 60.7 79.6 84.4 90.1 77.2 86.5 63.5 Claims processing 85.7 Shared decision making 58.7 Overall plan satisfaction 62.8 Getting needed care 84 Getting care quickly 85.6 How well doctors communicate 92.6 Customer service 82.1

Prescription

Drugs

Member Survey Results

(with national averages for HMO/POS plans in each category)

Hospital

per stay

deductible

Primary

care/

Specialist

office copay Level I

Level II/

Level III

Mail

order

discount Plan Name – Location

49
 
Health Maintenance Organization (HMO) and Point­of­Service (POS) Plans

See page 35 for an explanation of the columns on these pages.

Telephone

Enrollment

Code

Your Share of Premium

Monthly Biweekly

Self Self & Self Self & Self Self &

New York

Aetna Open Access ­high­ NYC Area/Upstate NY

Plan Name – Location

877­459­6604

Number

JC1

only

JC2

family

160.81

only

462.11

family

74.22

only

213.28

family

Aetna Open Access ­basic­ NYC Area/Upstate NY 877­459­6604 JC4 JC5 111.95 324.22 51.67 149.64

Blue Choice ­high­ Rochesterarea 800­462­0108 MK1 MK2 116.40 375.81 53.72 173.45

Blue Choice ­std­ Rochesterarea 800­462­0108 MK4 MK5 87.41 216.38 40.34 99.87

CDPHP Universal Benefits ­high­ Upstate, Hudson Valley, Cent New York 877­269­2134 SG1 SG2 145.99 460.05 67.38 212.33

CDPHP Universal Benefits ­std­ Upstate, Hudson Valley, Cent New York 877­269­2134 SG4 SG5 94.36 243.44 43.55 112.36

Community Blue ­high­ Northeastern NY­Clinton/Essex Counties 800­544­2583 BS1 BS2 306.26 962.87 141.35 444.40

Community Blue ­high­ Western New York 800­459­7587 BX1 BX2 137.31 549.60 63.37 253.66

Community Blue ­high­ Northeastern NY­Capital Region 800­544­2583 BZ1 BZ2 264.58 851.05 122.11 392.79

GHI HMO ­high­ Brnx/Brklyn/Manhat/Queen/Richmon/Westche 877­244­4466 6V1 6V2 129.85 423.15 59.93 195.30

GHI HMO ­high­ Capital/Hudson Valley Regions 877­244­4466 X41 X42 111.59 377.52 51.50 174.24

GHI Health Plan ­high­ Allof New York 212­501­4444 801 802 204.26 589.98 94.27 272.30

GHI Health Plan ­std­ New York City (the Boroughsof Manhattan, Brooklyn, Bronx,

Queens,andStaten Island), allof Nassau,Suffolk, Rockland,and Westchester Counties

212­501­4444 804 805 96.55 225.37 44.56 104.02

HIP of Greater New York­high­ New York Cityarea 800­HIP­TALK 511 512 124.59 529.27 57.50 244.28

HIP of Greater New York­std­ New York Cityarea 800­HIP­TALK 514 515 105.67 419.60 48.77 193.66

Independent Health Assoc ­high­ Western New York 800­501­3439 QA1 QA2 112.18 420.46 51.77 194.06

MVP Health Care ­high­ Eastern Region 888­687­6277 GA1 GA2 107.42 346.23 49.58 159.80

MVP Health Care ­std­ Eastern Region 888­687­6277 GA4 GA5 101.22 282.12 46.72 130.21

MVP Health Care ­high­ Central Region 888­687­6277 M91 M92 120.54 418.82 55.63 193.30

MVP Health Care ­std­ Central Region 888­687­6277 M94 M95 108.66 358.93 50.15 165.66

MVP Health Care ­high­ Northern Region 888­687­6277 MF1 MF2 169.89 546.39 78.41 252.18

MVP Health Care ­std­ Northern Region 888­687­6277 MF4 MF5 122.40 423.63 56.49 195.52

MVP Health Care ­high­ Mid­Hudson Region 888­687­6277 MX1 MX2 126.32 431.10 58.30 198.97

MVP Health Care ­std­ Mid­Hudson Region 888­687­6277 MX4 MX5 111.38 387.83 51.41 179.00

Preferred Care ­high­ Rochesterarea 800­950­3224 GV1 GV2 94.25 251.92 43.50 116.27

Preferred Care ­std­ Rochesterarea 800­950­3224 GV4 GV5 78.68 210.32 36.31 97.07

Univera Healthcare ­high­ Western New York(Southern Counties) 800­427­8490 KQ1 KQ2 320.02 973.55 147.70 449.33

Univera Healthcare ­high­ Western New York(Northern Counties) 800­427­8490 Q81 Q82 201.37 763.23 92.94 352.26

50
New York

Aetna Open Access­High $20/$30 $150/dayx5 $10 $25/$50 Yes 58.9 83.7 87.3 91.9 84.9 86.5 52.2

Aetna Open Access­Basic $15/$30 20% Plan Allow $5 $30/$50 Yes 58.9 83.7 87.3 91.9 84.9 86.5 52.2

Blue Choice­High $20/$20 $100 $10 $25/$40 No 64.3 88.9 88.6 91.5 84.7 92.4 59.3

Blue Choice­Std $25/$40 $500 $10 $30/$50 No

CDPHP Universal Benefits­High $20/$30 $100 X 5 25% 25%/25% No 76.8 90.6 91.4 94.1 90.1 90.6 58

CDPHP Universal Benefits­Std $25/$40 $500 + 10% 30% 30%/30% No 76.8 90.6 91.4 94.1 90.1 90.6 58

Community Blue­High $10/$10 $250 $5 $30/$50 Yes

Community Blue­High $10/$10 $250 $5 $30/$50 Yes

Community Blue­High $10/$10 $250 $5 $30/$50 Yes

GHI HMO­High $25/$40 $500 $10 $30/$50 Yes 60.6 82.4 86.2 91.9 81.9 75.5 67.7

GHI HMO­High $25/$40 $500 $10 $30/$50 Yes 60.6 82.4 86.2 91.9 81.9 75.5 67.7

GHI Health Plan­ In­Network $15/$15 $100 $15 $25/$50 Yes 69.6 87.1 86.8 92.1 76.2 86.8 65.3

GHI Health Plan­ Out­Network +50% of sch +50% of sch. N/A N/A/N/A No 69.6 87.1 86.8 92.1 76.2 86.8 65.3

GHI Health Plan­Std $25/$25 $250/dayx3 $10 $25/$50 Yes 69.6 87.1 86.8 92.1 76.2 86.8 65.3

HIP of Greater New York­High $10/$10 None $10 $20/$40 Yes 51.9 80.1 80.2 90.5 71.8 77 58.8

HIP of Greater New York­Std $10/$20 $500 $15 $30/$50 Yes 51.9 80.1 80.2 90.5 71.8 77 58.8

Independent Health ­ In­Network $20/$20 $250 $10 $20/$35 No 70.7 86.2 89.4 94.9 91.8 94.5 59

Independent Health ­ Out­Network 25%/25% 25% N/A N/A/N/A No 70.7 86.2 89.4 94.9 91.8 94.5 59

MVP Health Care­High $20/$20 $240 $10 $30/$50 Yes 68.6 87 87.4 93.9 88 88.6 61.8

MVP Health Care­Std $25/$40 $500 $10 $30/$50 Yes 68.6 87 87.4 93.9 88 88.6 61.8

MVP Health Care­High $20/$20 $240 $10 $30/$50 Yes 68.6 87 87.4 93.9 88 88.6 61.8

MVP Health Care­Std $25/$40 $500 $10 $30/$50 Yes 68.6 87 87.4 93.9 88 88.6 61.8

MVP Health Care­High $20/$20 $240 $10 $30/$50 Yes

MVP Health Care­Std $25/$40 $500 $10 $30/$50 Yes

MVP Health Care­High $20/$20 $240 $10 $30/$50 Yes 68.6 87 87.4 93.9 88 88.6 61.8

MVP Health Care­Std $25/$40 $500 $10 $30/$50 Yes 68.6 87 87.4 93.9 88 88.6 61.8

Preferred Care­High $20/$20 $250 $10 $30/$50 Yes 69.5 87.8 88.5 91.3 89.7 92.6 66.2

Preferred Care­Std $25/$40 $500 $10 $30/$50 Yes 69.5 87.8 88.5 91.3 89.7 92.6 66.2

Univera Healthcare­High $20/$20 $250 $10 $20/$45 No 64.3 88.9 88.6 91.5 84.7 92.4 59.3

Univera Healthcare­High $20/$20 $250 $10 $20/$45 No 60.1 88.2 91.3 94.5 80.5 86.8 67.9 Claims processing 85.7 Shared decision making 58.7 Overall plan satisfaction 62.8 Getting needed care 84 Getting care quickly 85.6 How well doctors communicate 92.6 Customer service 82.1

Prescription

Drugs

Member Survey Results

(with national averages for HMO/POS plans in each category)

Hospital

per stay

deductible

Primary

care/

Specialist

office copay Level I

Level II/

Level III

Mail

order

discount Plan Name – Location

51
 
Health Maintenance Organization (HMO) and Point­of­Service (POS) Plans

See page 35 for an explanation of the columns on these pages.

North Carolina

Aetna Open Access ­high­ Charlotte/Raleigh/Durham NC Areas

Aetna Open Access ­basic­ Charlotte/Raleigh/Durham NC Areas

North Dakota

HealthPartners Open Access Copay ­high­ North Dakota

HealthPartners Three forFree ­std­ North Dakota

HeartofAmerica Health Plan ­high­ Northcentral North Dakota

Ohio

Aetna Open Access ­high­ Clevelandand ToledoAreas

Aetna Open Access ­high­ ColumbusArea

Aetna Open Access ­high­ Greater CincinnatiArea

AultCare HMO ­high­ Stark/Carroll/Holmes/Tuscarawas/Wayne Co.

HMO Health Ohio­high­ Northeast Ohio

KaiserFoundation Health Plan of Ohio­high­ Cleveland/Akron areas

KaiserFoundation Health Plan of Ohio­std­ Cleveland/Akron areas

Paramount Health Care ­high­ Northwest/North Central Ohio

The Health Plan of the Upper OhioValley ­high­ Northeastand Eastern Ohio

United Healthcareof Ohio, Inc. ­high­ Cleveland

United Healthcareof Ohio, Inc. ­high­ Columbus

Oklahoma

Aetna Open Access ­high­ Oklahoma City/TulsaAreas

Aetna Open Access ­basic­ Oklahoma City/TulsaAreas

Globalhealth, Inc. ­high­ Oklahoma

PacifiCareof Oklahoma­high­ Central/Northeastern Oklahoma

Oregon

KaiserFoundation Health Plan of Northwest ­high­ Portland/Salem areas

KaiserFoundation Health Plan of Northwest ­std­ Portland/Salem areas

Plan Name – Location

877­459­6604

877­459­6604

952­883­5000

952­883­5000

800­525­5661

877­459­6604

877­459­6604

877­459­6604

330­363­6360

800­522­2066

800­686­7100

800­686­7100

800­462­3589

800­624­6961

877­835­9861

877­835­9861

877­459­6604

877­459­6604

877­280­2990

866­546­0510

800­813­2000

800­813­2000

Telephone

Number

Enrollment

Code

Your Share of Premium

Monthly Biweekly

JN1

JN4

V31

V34

RU1

7D1

ND1

RD1

3A1

L41

641

644

U21

U41

AK1

CA1

SL1

SL4

IM1

2N1

571

574

Self

only

JN2

JN5

V32

V35

RU2

7D2

ND2

RD2

3A2

L42

642

645

U22

U42

AK2

CA2

SL2

SL5

IM2

2N2

572

575

Self &

family

230.06

93.09

195.29

70.16

92.01

116.98

193.42

309.19

172.43

194.96

182.81

84.99

193.57

104.62

153.58

212.92

211.90

91.39

89.20

182.24

163.41

103.61

Self

only

506.85

217.85

460.98

161.37

236.48

317.31

517.16

834.41

487.37

597.52

432.27

195.48

510.06

240.63

374.86

505.64

510.06

228.62

214.99

451.86

386.32

238.03

Self &

family

106.18

42.96

90.13

32.38

42.47

53.99

89.27

142.70

79.58

89.98

84.37

39.22

89.34

48.29

70.88

98.27

97.80

42.18

41.17

84.11

75.42

47.82

Self

only

233.93

100.54

212.76

74.48

109.14

146.45

238.69

385.11

224.94

275.78

199.51

90.22

235.41

111.06

173.01

233.37

235.41

105.52

99.22

208.55

178.30

109.86

Self &

family

52
Primary

care/

Specialist

office copay Plan Name – Location

Hospital

per stay

deductible

Prescription Member Survey Results

Drugs (with national averages for HMO/POS plans in each category)

Mail

Level II/ order

Level I Level III discount

Overall plan

satisfaction 62.8

Getting needed

care 84

Getting care

quickly 85.6

How well

doctors

communicate 92.6

Customerservice 82.1

Claimsprocessing 85.7

Shared decision

making 58.7

North Carolina

Aetna Open Access­High $15/$25 $150/dayx3 $5 $25/$50 No

Aetna Open Access­Basic $20/$30 10% Plan Allow $10 $25/$50 No

North Dakota

HealthPartners OA Copay $20/$20 10% of charges $10 $25/$50 Yes

HeartofAmerica HP­High $15/$25 None 50% 50%/50% None

HealthPartners3forFree $0for3, then 20%/$0for3, then 20% 20% in/40% out $6 $30/$60 Yes

Ohio

Aetna Open Access­High

Aetna Open Access­High

HMO Health Ohio­High

KaiserFoundation HP­Std

HP of the Upper OhioValley­High

United Healthcare­High

$20/$30

$20/$30

$20/$20

$20/$40

$10/$20

$20/$30

$150/dayx5

$150/dayx5

$250

$500

$250

$150 adayx 3

$10

$10

$20

$15

$15

$7

$25/$50

$25/$50

$30/$40

$30/$30

$30/$50

$30/$50

Yes

Yes

Yes

No

Yes

Yes

59

59

63.5

65.1

73.7

52

84.4

84.4

90.4

83.1

90.8

87.2

85 91.9 82.3 84.8 51.6

85 91.9 82.3 84.8 51.6

87.7 94.4 85.4 87.6 59.2

85.8 91.9 79.3 80 54.2

90.7 95.5 90.3 95.1 62.3

86.9 93.3 80.1 83.5 51

Aetna Open Access­High $20/$30 $150/dayx5 $10 $25/$50 Yes 59 84.4 85 91.9 82.3 84.8 51.6

AultCare HMO­High $10/$10 None $10 $20/$35 No 80.7 94.4 93.8 94.1 91.7 97.1 61.2

KaiserFoundation HP­High $15/$15 $200 $10 $25/$25 No 65.1 83.1 85.8 91.9 79.3 80 54.2

Paramount Health Care­High $15/$25 $500 $10 $20/$45 Yes 69.4 81.8 86.9 93 83.9 88.1 57

United Healthcare­High $20/$30 $150adayx3 $7 $30/$50 Yes 52 87.2 86.9 93.3 80.1 83.5 51

Oklahoma

Aetna Open Access­High $20/$30 $150/dayx5 $10 $25/$50 Yes 60.9 86.6 88.2 94.6 84.4 90.3 60.5

Globalhealth, Inc.­High $15/$35 $150/dayx3 $10 $25/$40 Yes 58.5 77.1 82.1 91.8 75 77.5 55.2

Aetna Open Access­Basic $15/$30 20% Plan Allow $5 $30/$50 Yes 60.9 86.6 88.2 94.6 84.4 90.3 60.5

PacifiCareof Oklahoma­High $20/$40 $250/dayx5 $10 $30/$50 Yes 64.3 85.2 88.2 93.2 77.4 87.2 55.8

Oregon

KaiserFoundation HP­High $15/$15 $100 $15 $30/$30 Yes 61.7 75.5 77.4 92.7 81.3 85.1 53.9

KaiserFoundation HP­Std $20/$30 $250 $20 $40/$40 Yes 61.7 75.5 77.4 92.7 81.3 85.1 53.9

53
Health Maintenance Organization (HMO) and Point­of­Service (POS) Plans

See page 35 for an explanation of the columns on these pages.

Telephone

Enrollment

Code

Your Share of Premium

Monthly Biweekly

Self Self & Self Self & Self Self &

Pennsylvania

Aetna Open Access ­high­ Philadelphia/Central/Southeastern PA

Plan Name – Location

877­459­6604

Number

P31

only

P32

family

288.04

only

744.88

family

132.94

only

343.79

family

Aetna Open Access ­basic­ Philadelphia/Central/Southeastern PA 877­459­6604 P34 P35 106.92 246.90 49.35 113.95

Aetna Open Access ­high­ Pittsburgh and Western PAAreas 877­459­6604 YE1 YE2 76.80 211.76 35.44 97.73

Geisinger Health Plan ­high­ Northeastern/Central/South Centralareas 800­447­4000 GG1 GG2 167.83 397.82 77.46 183.61

Geisinger Health Plan ­std­ Northeastern/Central/South Centralareas 800­447­4000 GG4 GG5 110.80 255.54 51.14 117.94

HealthAmerica Pennsylvania­high­ Greater Pittsburgh area 866­351­5946 261 262 184.32 566.24 85.07 261.34

HealthAmerica Pennsylvania­std­ Greater Pittsburgh area 866­351­5946 264 265 106.75 325.04 49.27 150.02

HealthAmerica Pennsylvania­high­ Southeastern Pennsylvania 866­351­5946 PN1 PN2 232.94 547.67 107.51 252.77

HealthAmerica Pennsylvania­std­ Southeastern Pennsylvania 866­351­5946 PN4 PN5 158.82 375.14 73.30 173.14

HealthAmerica Pennsylvania­high­ Central Pennsylvania 866­351­5946 SW1 SW2 254.63 597.37 117.52 275.71

HealthAmerica Pennsylvania­std­ Central Pennsylvania 866­351­5946 SW4 SW5 118.33 283.92 54.61 131.04

Keystone Health Plan Central ­high­ Harrisburg/Northern Region/Lehigh Valley 800­622­2843 S41 S42 263.99 672.79 121.84 310.52

Keystone Health Plan Central ­std­ Harrisburg/Northern Region/Lehigh Valley 800­622­2843 S44 S45 215.07 553.56 99.26 255.49

Keystone Health Plan East ­high­ Philadelphiaarea 800­227­3115 ED1 ED2 224.54 717.99 103.63 331.38

Keystone Health Plan East ­std­ Philadelphiaarea 800­227­3115 ED4 ED5 160.23 549.14 73.95 253.45

UPMC Health Plan ­high­ Western Pennsylvania 888­876­2756 8W1 8W2 186.79 441.44 86.21 203.74

UPMC Health Plan ­std­ Western Pennsylvania

Puerto Rico

Humana Health Plansof Puerto Rico, Inc. ­high­ Puerto Rico

1­888­876­2756

800­314­3121

UW4

ZJ1

UW5

ZJ2

154.42

69.53

366.93

159.90

71.27

32.09

169.35

73.80

Triple­S­high­ Allof Puerto Rico

Rhode Island

Blue CHiP Coordinated Health Plan ­ BCBSof RI ­high­ Allof Rhode Island

787­774­6060

401­459­5500

891

DA1

892

DA2

71.03

252.31

163.38

798.42

32.78

116.45

75.40

368.50

54
Pennsylvania

Aetna Open Access­High $20/$30 $150/dayx5 $10 $25/$50 Yes 53.6 86.2 89.9 92.6 79 88.4 45.4

Aetna Open Access­Basic $15/$30 20% Plan Allow $5 $30/$50 Yes 53.6 86.2 89.9 92.6 79 88.4 45.4

Aetna Open Access­High $20/$30 $150/dayx5 $10 $25/$50 Yes 53.6 86.2 89.9 92.6 79 88.4 45.4

Geisinger Health Plan­High $20/$35 NothingaftrDed $5 $35/$60 Yes 60.7 86.9 86.3 95.2 90.2 93.7 68.8

Geisinger Health Plan­Std $20/$35 20%aftrDeduct $5 $35/$60 Yes 60.7 86.9 86.3 95.2 90.2 93.7 68.8

HealthAmerica­High $15/$25 10% $5 $25/$40 Yes 68.1 86.7 88.6 93.4 88.1 93.2 63.4

HealthAmerica­Std $20/$30 20% $5 $35/$50 Yes 68.1 86.7 88.6 93.4 88.1 93.2 63.4

HealthAmerica­High $15/$25 10% $5 $25/$40 Yes 68.1 86.7 88.6 93.4 88.1 93.2 63.4

HealthAmerica­Std $20/$30 20% $5 $35/$50 Yes 68.1 86.7 88.6 93.4 88.1 93.2 63.4

HealthAmerica­High $15/$25 10% $5 $25/$40 Yes 68.1 86.7 88.6 93.4 88.1 93.2 63.4

HealthAmerica­Std $20/$30 20% $5 $35/$50 Yes 68.1 86.7 88.6 93.4 88.1 93.2 63.4

Keystone HP Central­High $15/$20 $200copay $10 $25/$40 Yes 72.9 87.5 87.8 94 87.6 93.1 62.9

Keystone HP Central­Std $15/$35 $100x5 $5 $35/$60 Yes 72.9 87.5 87.8 94 87.6 93.1 62.9

Keystone HP East­High $20/$25 $125perday/$625max $5 $20/$50 Yes 63 85 87.3 94 86.1 90 61.9

Keystone HP East­Std $20/$40 20% afterded $20 $40/$60 Yes 63 85 87.3 94 86.1 90 61.9

UPMC Health Plan­High $20/$20 $250 $10 $30/$50 Yes 66.6 86.6 87.6 93.2 91 90.5 63.8

UPMC Health Plan­Std $20/$35 $300 $10 $40/$60 Yes 66.6 86.6 87.6 93.2 91 90.5 63.8

Puerto Rico

Humana­ In­Network $5/$5 None $2.50 $10/$15/$15 No 76.4 82.9 79.8 94.7 81.1 72.8 69.5

Humana­ Out­Network $8/$8 $50 N/A N/A/N/A No 76.4 82.9 79.8 94.7 81.1 72.8 69.5

Triple­S­ In­Network $7.50/$10 None $7.50 $12/$15 Yes 81.4 88.8 84.3 95.6 76.1 72 68.3

Triple­S­ Out­Network $7.50 +/$10 + None 25% 25%/25% No 81.4 88.8 84.3 95.6 76.1 72 68.3

Rhode Island

BCBSof RI ­ In­Network $15/$25 $500 $7 $30/$50 Yes 57.9 89.6 88.7 94.9 85 92.2 65.1

BCBSof RI ­ Out­Network 30%/30% None $50+20%$50+20%/$50+20% No 57.9 89.6 88.7 94.9 85 92.2 65.1 Claims processing 85.7 Shared decision making 58.7 Overall plan satisfaction 62.8 Getting needed care 84 Getting care quickly 85.6 How well doctors communicate 92.6 Customer service 82.1

Prescription

Drugs

Member Survey Results

(with national averages for HMO/POS plans in each category)

Hospital

per stay

deductible

Primary

care/

Specialist

office copay Level I

Level II/

Level III

Mail

order

discount Plan Name – Location

55
 
Health Maintenance Organization (HMO) and Point­of­Service (POS) Plans

See page 35 for an explanation of the columns on these pages.

South Dakota

HealthPartners Open Access Copay ­high­ South Dakota

HealthPartners Three forFree ­std­ South Dakota

Sanford Health Plan ­high­ Eastern/Central/Rapid CityAreas

Sanford Health Plan ­std­ Eastern/Central/Rapid CityAreas

Tennessee

Aetna Open Access ­high­ NashvilleArea

Aetna Open Access ­high­ MemphisArea

Texas

Aetna Open Access ­high­ Houston Area

Aetna Open Access ­high­ Austin andSan AntonioAreas

Firstcare ­high­ Wacoarea

Firstcare ­high­ West Texas

Humana Health Plan of Texas ­high­ San Antonioarea

Humana Health Plan of Texas ­std­ San Antonioarea

Humana Health Plan of Texas ­high­ Austin Area

Humana Health Plan of Texas ­std­ Austin Area

Pacificareof Texas ­high­ San Antonio, Dallas/Ft. Worth

Utah

Altius Health Plans ­high­ Wasatch Front

Altius Health Plans ­std­ Wasatch Front

Virgin Islands

Triple­S­high­ USVirgin Islands

Plan Name – Location

952­883­5000

952­883­5000

800­752­5863

800­752­5863

877­459­6604

877­459­6604

877­459­6604

877­459­6604

800­884­4901

800­884­4901

888­393­6765

888­393­6765

888­393­6765

888­393­6765

866­546­0510

800­377­4161

800­377­4161

800­981­3241

Telephone

Number

Enrollment

Code

Your Share of Premium

Monthly Biweekly

V31

V34

AU1

AU4

6J1

UB1

8G1

P11

6U1

CK1

UR1

UR4

UU1

UU4

GF1

9K1

DK4

851

Self

only

V32

V35

AU2

AU5

6J2

UB2

8G2

P12

6U2

CK2

UR2

UR5

UU2

UU5

GF2

9K2

DK5

852

Self &

family

195.29

70.16

176.15

151.67

255.93

94.36

178.39

146.75

96.74

192.66

344.61

93.07

110.39

100.35

199.21

158.86

105.79

103.05

Self

only

460.98

161.37

417.52

360.53

588.55

240.62

523.51

455.41

207.98

375.42

804.44

214.06

253.90

230.81

469.60

327.67

232.73

234.02

Self &

family

90.13

32.38

81.30

70.00

118.12

43.55

82.33

67.73

44.65

88.92

159.05

42.95

50.95

46.32

91.94

73.32

48.82

47.56

Self

only

212.76

74.48

192.70

166.40

271.64

111.05

241.62

210.19

95.99

173.27

371.28

98.80

117.18

106.53

216.74

151.23

107.41

108.01

Self &

family

56
South Dakota

HealthPartners OA Copay $20/$20 10% of charges $10 $25/$50 Yes

HealthPartners3forFree $0for3, then 20%/$0for3, then 20% 20% in/40% out $6 $30/$60 Yes

Sanford HP­ In­Network $20/$30 $100/dayx5 $15 $30/$50 N/A 49.4 84.4 90 94 81.9 85.7 60.3

Sanford HP­ Out­Network 40%/40% 40% N/A N/A/N/A N/A 49.4 84.4 90 94 81.9 85.7 60.3

Sanford HP­ In­Network $25/$25 $100/dayx5 $15 $30/$50 No 49.4 84.4 90 94 81.9 85.7 60.3

Sanford HP­ Out­Network 40%/40% 40% N/A N/A/N/A No 49.4 84.4 90 94 81.9 85.7 60.3

Tennessee

Aetna Open Access­High $20/$30 $150/dayx5 $10 $25/$50 Yes 63.4 85.7 86.6 92.2 86.8 90.7 57.1

Aetna Open Access­High $20/$30 $150/dayx5 $10 $25/$50 Yes 63.4 85.7 86.6 92.2 86.8 90.7 57.1

Texas

Aetna Open Access­High $20/$30 $150/dayx5 $10 $25/$50 Yes 60.2 83.3 86.6 92.9 85.7 86.2 56.5

Aetna Open Access­High $20/$30 $150/dayx5 $10 $25/$50 Yes 63.5 85.3 87 93.9 80.5 82.4 54

Firstcare­High $20/$55 $150/dayX5 $15 $35/$65 No 64.5 88.6 89.2 92.7 77.1 84.8 70.5

Firstcare­High $20/$55 $150/dayX5 $15 $35/$65 No 64.6 88.3 87.1 93.7 84.6 91.5 62.8

Humana Health Plan­High $15/$25 $200/dayx3 $10 $30/$50 Yes 69.3 89.1 84.3 89.9 83.3 84.7 61.5

Humana Health Plan­Std $20/$30 $400/dayx3 $10 $30/$50 Yes 69.3 89.1 84.3 89.9 83.3 84.7 61.5

Humana Health Plan­High $15/$25 $200/dayx3 $10 $30/$50 Yes

Humana Health Plan­Std $20/$30 $400/dayx3 $10 $30/$50 Yes

Pacificareof Texas­High $20/$40 $250/dayx5 $10 $30/$50 Yes 57.6 83.8 85.7 93.4 75.9 83.7 52.6

Utah

Altius Health Plans­High $10/$15 $100 $5 $20/$50 Yes 62.1 81.9 86.6 94.4 84 88.3 53.5

Altius Health Plans­Std $20/$30 None $10 $25/$50 Yes

Virgin Islands

Triple­S­ In­Network $7.50/$10 None $7.50 $12/$15 Yes

Triple­S­ Out­Network $7.50 +/$10 + None 25% 25%/25% No

Claimsprocessing 85.7

Shared decision

making 58.7

Overall plan

satisfaction 62.8

Getting needed

care 84

Getting care

quickly 85.6

How well

doctors

communicate 92.6

Customerservice 82.1

Prescription

Drugs

Member Survey Results

(with national averages for HMO/POS plans in each category)

Hospital

per stay

deductible

Primary

care/

Specialist

office copay Level I

Level II/

Level III

Mail

order

discount Plan Name – Location

57
 
Health Maintenance Organization (HMO) and Point­of­Service (POS) Plans

See page 35 for an explanation of the columns on these pages.

Virginia

Aetna Open Access ­high­ Northern/Central/RichmondVirginiaAreas

Aetna Open Access ­basic­ Northern/Central/RichmondVirginiaAreas

CareFirst BlueChoice ­high­ Northern Virginia

KaiserFoundation Health Plan Mid­AtlanticStates ­high­ Northern Virginia/Fredericksbur

KaiserFoundation Health Plan Mid­AtlanticStates ­std­ Northern Virginia/Fredericksburga

M.D. IPA­high­ N.VA/CntrlVA/Richmond/Tidewater/Roanoke

Optima Health Plan ­high­ Hampton Roadsand Richmondareas

Optima Health Plan ­std­ Hampton Roadsand Richmondareas

Piedmont Community Healthcare ­high­ Lynchburgarea

Washington

Group Health Cooperative ­high­ Mostof Western Washington

Group Health Cooperative ­std­ Mostof Western Washington

Group Health Cooperative ­high­ Central WA/Spokane/Pullman

Group Health Cooperative ­std­ Central WA/Spokane/Pullman

KPS Health Plans ­std­ Allof Washington

KPS Health Plans ­high­ Allof Washington

KaiserFoundation Health Plan of Northwest ­high­ Vancouver/Longview

KaiserFoundation Health Plan of Northwest ­std­ Vancouver/Longview

West Virginia

The Health Plan of the Upper OhioValley ­high­ Northern/Central WestVirginia

Wisconsin

Dean Health Plan ­high­ South Central Wisconsin

Group Health Cooperative ­high­ South Central Wisconsin

HealthPartners Open Access Copay ­high­ Wisconsin

HealthPartners Three forFree ­std­ Wisconsin

Wyoming

Altius Health Plans ­high­ Uinta County

Altius Health Plans ­std­ Uinta County

Plan Name – Location

877­459­6604

877­459­6604

866­296­7363

garea1­877­574­3337

rea1­877­574­3337

877­835­9861

800­206­1060

800­206­1060

888­674­3368

888­901­4636

888­901­4636

888­901­4636

888­901­4636

800­552­7114

800­552­7114

800­813­2000

800­813­2000

800­624­6961

800­279­1301

608­828­4827

952­883­5000

952­883­5000

800­377­4161

800­377­4161

Telephone

Number

Enrollment

Code

Your Share of Premium

Monthly Biweekly

JN1

JN4

2G1

E31

E34

JP1

9R1

9R4

2C1

541

544

VR1

VR4

L11

VT1

571

574

U41

WD1

WJ1

V31

V34

9K1

DK4

Self

only

JN2

JN5

2G2

E32

E35

JP2

9R2

9R5

2C2

542

545

VR2

VR5

L12

VT2

572

575

U42

WD2

WJ2

V32

V35

9K2

DK5

Self &

family

230.06

93.09

112.82

126.75

66.13

111.20

156.68

88.68

108.27

201.61

85.24

229.87

87.94

96.30

179.12

163.41

103.61

104.62

106.20

104.92

195.29

70.16

158.86

105.79

Self

only

506.85

217.85

253.13

323.14

157.36

261.82

404.84

209.84

247.83

394.68

192.44

455.41

202.27

207.86

364.48

386.32

238.03

240.63

298.18

338.87

460.98

161.37

327.67

232.73

Self &

family

106.18

42.96

52.07

58.50

30.52

51.32

72.31

40.93

49.97

93.05

39.34

106.09

40.59

44.45

82.67

75.42

47.82

48.29

49.02

48.42

90.13

32.38

73.32

48.82

Self

only

233.93

100.54

116.83

149.14

72.63

120.84

186.85

96.85

114.38

182.16

88.82

210.19

93.36

95.93

168.22

178.30

109.86

111.06

137.62

156.40

212.76

74.48

151.23

107.41

Self &

family

58
Virginia

Aetna Open Access­High $15/$25 $150/dayx3 $5 $25/$50 No 59.2 81.6 89.1 92.9 84.7 85.1 57.4

Aetna Open Access­Basic $20/$30 10% Plan Allow $10 $25/$50 No 59.2 81.6 89.1 92.9 84.7 85.1 57.4

CareFirst BlueChoice­High $20/$30 $100 $10 $25/$40 Yes 60.5 80.2 83.9 90.9 70.6 85.2 53

KaiserFoundation HP­High $10/$20 $100 $7/$17 Net$30/$50/$45/$65 Yes 63.6 74.5 75.6 88.6 77 79.3 54

KaiserFoundation HP­Std $20/$30 $250/dayx3 $12/$22Net$35/$55/$50/$70 Yes 63.6 74.5 75.6 88.6 77 79.3 54

M.D. IPA­High $20/$30 $150/dayx3 $7 $25/$50 No 58 80.4 82.4 91 81.6 80.9 54.7

Optima Health Plan­High $5/$0child<13/$30 $200 $5 $25/$45/$45 Yes 67.5 90.7 87.6 91.9 84.5 88.5 59.4

Optima Health Plan­Std $20/$30 None $5 $25/50% upto$3,000 No

Piedmont ­ In­Network $35/$35 20% $15 $30/$55 Yes

Piedmont ­ Out­Network 30%/30% 30% $15 $30/$55 Yes

Washington

Group Health Cooperative­High $20/$20 $350/dayx3 $15 $30/$60 Yes 64.4 83.6 87.3 93.3 85.8 88.6 57.3

Group Health Cooperative­Std $20+20%/$20+20% $500/dayx3 $15 $30/$60 Yes 64.4 83.6 87.3 93.3 85.8 88.6 57.3

Group Health Cooperative­High $20/$20 $350/dayx3 $15 $30/$60 Yes 64.4 83.6 87.3 93.3 85.8 88.6 57.3

Group Health Cooperative­Std $20+20%/$20+20% $500/dayx3 $15 $30/$60 Yes 64.4 83.6 87.3 93.3 85.8 88.6 57.3

KPS Health Plans­ In­Network$15/3or20%/20% $100/dayx5 $10 $30/50% or$40 Yes 68.4 90.7 89.2 92 90.1 91.5 58

KPS Health Plans­ Out­Network$15/3or45%/45% $100/dayx5 Not Covered Not Covered No 68.4 90.7 89.2 92 90.1 91.5 58

KPS Health Plans­ In­Network $30/$30 None $5 $20/50% or$100 Yes 78.9 91.5 91 92.6 88.2 91.7 61.7

KPS Health Plans­ Out­Network$20+45%/$20+45% None Not covered N/A/N/A No 78.9 91.5 91 92.6 88.2 91.7 61.7

KaiserFoundation HP­High $15/$15 $100 $15 $30/$30 Yes 61.7 75.5 77.4 92.7 81.3 85.1 53.9

KaiserFoundation HP­Std $20/$30 $250 $20 $40/$40 Yes 61.7 75.5 77.4 92.7 81.3 85.1 53.9

West Virginia

HP of the Upper OhioValley­High $10/$20 $250 $15 $30/$50 Yes 73.7 90.8 90.7 95.5 90.3 95.1 62.3

Wisconsin

Dean Health Plan­High $10/$10 None $10 30%/$75max/30% No 70.7 85 88.7 94 84.9 91.1 61.5

Group Health Cooperative­High $10/$10 None $5 $20/$20 No 74.7 80.9 86.9 94.7 88.2 89.4 56.3

HealthPartners OA Copay $20/$20 10% of charges $10 $25/$50 Yes

HealthPartners3forFree $0for3, then 20%/$0for3, then 20% 20% in/40% out $6 $30/$60 Yes

Wyoming

Altius Health Plans­High $10/$15 $100 $5 $20/$50 Yes

Altius Health Plans­Std $20/$30 None $10 $25/$50 Yes

Claimsprocessing 85.7

Shared decision

making 58.7

Overall plan

satisfaction 62.8

Getting needed

care 84

Getting care

quickly 85.6

How well

doctors

communicate 92.6

Customerservice 82.1

Prescription

Drugs

Member Survey Results

(with national averages for HMO/POS plans in each category)

Hospital

per stay

deductible

Primary

care/

Specialist

office copay Level I

Level II/

Level III

Mail

order

discount Plan Name – Location

59
 
Appendix E
 

FEHB Plan Comparison Charts
 

High Deductible and Consumer­Driven Health Plans

With a Health Savings Account or Health Reimbursement Arrangement
 

(Pages 64 through 97)
 

A High Deductible Health Plan (HDHP) provides comprehensive coverage for high­cost medical

events and a tax­advantaged way to help you build savings for future medical expenses. The

HDHP gives you greater flexibility and discretion over how you use your health care benefits.

When you enroll, your health plan establishes for you either a Health Savings Account (HSA) or

a Health Reimbursement Arrangement (HRA). The plan automatically deposits the monthly

“premium pass through” into your HSA. The plan credits an amount into the HRA. (This is the

“Premium Contribution to HSA/HRA” column in the following charts.)

Preventive care is often covered in full, usually with no or only a small deductible or copayment.

Preventive care expenses may also be payable up to an annual maximum dollar amount

(up to $300 for instance). As you receive other non­preventive medical care, you must meet the

plan deductible before the health plan pays benefits. You can choose to pay your deductible

with funds from your HSA or you can choose instead to pay for your deductible out­of­pocket,

allowing your savings to continue to grow.

The HDHP features higher annual deductibles (a minimum of $1,150 for Self and $2,300 for

Family coverage) and annual out­of­pocket limits (not to exceed $5,800 for Self and $11,600 for

Family coverage) than other insurance plans. Depending on the HDHP you choose, you may

have the choice of using In­Network and out­of­network providers. There may be higher

deductibles and out­of­pocket limits when you use out­of­network providers. Using In­Network

providers will save you money.

Health Savings Account (HSA)

A health savings account allows individuals to pay for current health expenses and save for

future qualified medical expenses on a pre­tax basis. Funds deposited into an HSA are not taxed,

the balance in the HSA grows tax free, and that amount is available on a tax free basis to pay

medical costs. You are eligible for an HSA if you are enrolled in an HDHP, not covered by any

other health plan that is not an HDHP (including a spouse’s health plan, but does not include

specific injury insurance and accident, disability, dental care, vision care, or long­term coverage),

not enrolled in Medicare, not received VA benefits within the last three months, not covered by

your own or your spouse’s flexible spending account (FSA), and are not claimed as a dependent

on someone else’s tax return. If you are enrolled in a High Deductible Health Plan with an HSA

you may not participate in a Health Care Flexible Spending Account (HCFSA), but you are

permitted to participate in a Limited Expense (LEX) HCFSA. HSA’s are subject to a number of

rules and limitations established by the Department of the Treasury.

Visit www.ustreas.gov/offices/public­affairs/hsa for more information. The 2009 maximum

contribution limits are $3,000 for Self Only coverage and $5,950 for Self and Family coverage. If

you are over 55, you can make an additional “catch up” contribution. You can use funds in your

account to help pay your health plan deductible.

60
Appendix E
 

FEHB Plan Comparison Charts
 

High Deductible and Consumer­Driven Health Plans

With a Health Savings Account or Health Reimbursement Arrangement

Starting in 2007, Federal employees who are enrolled in HDHPs became eligible to make

pre­tax allotments to their HSAs through The Federal Flexible Benefits Plan (FEDFLEX). By

January 1, 2008, eligible employees will be able to make these allotments to their HSAs.

OPM has worked with payroll providers and employee self service systems to provide

this service.

Features of an HSA include:

• Tax­deductible deposits you make to the HSA. Your own HSA contributions are either taxdeductible or pre­tax (if made by payroll deduction). See IRS Publication 969.

• Tax­deferred interest earned on the account.

• Tax­free withdrawals for qualified medical expenses.

• Carryover of unused funds and interest from year to year.

• Portability; the account is owned by you and is yours to keep – even when you retire,

leave government service, or change plans.

Health Reimbursement Arrangement (HRA)

Health Reimbursement Arrangements are a common feature of Consumer­Driven Health Plans.

They may be referred to by the health plan under a different name, such as personal care

account. They are also available to enrollees in High Deductible Health Plans who are not

eligible for an HSA. HRAs are similar to HSAs except:

• an enrollee cannot make deposits into an HRA;

• a health plan may impose a ceiling on the value of an HRA;

• interest is not earned on an HRA;

• and the amount in an HRA is not transferable if the enrollee leaves the health plan.

If you are enrolled in a High Deductible Health Plan with an HRA you may participate in a
 

Health Care Flexible Spending Account (HCFSA).
 

The plan will credit the HRA different amounts depending on whether you have a Self Only or a
 

Self and Family enrollment. You can use funds in your account to help pay your health plan
 

deductible.
 

Features of an HRA include:
 

• Tax­free withdrawals for qualified medical expenses.

• Carryover of unused credits from year to year.

• Credits in an HRA do not earn interest.

• Credits in the HRA are forfeited if you leave federal employment or switch health
 

insurance plans
 

61
Appendix E
 

FEHB Plan Comparison Charts
 

High Deductible and Consumer­Driven Health Plans
 

With a Health Savings Account or Health Reimbursement Arrangement
 

Health Savings Account (HSA) Health Reimbursement Arrangement

(HRA)

ELIGIBILITY You must enroll in a High Deductible

Health Plan (HDHP). No other general

medical insurance coverage is permitted.

You cannot be enrolled in Medicare Part A

or Part B. You cannot be claimed as a

dependent on someone else’s tax returns.

You must enroll in a High Deductible

Health Plan (HDHP).

FUNDING The plan deposits a monthly “premium

pass through” into your account.

The plan deposits the credit amount directly

into your account.

CONTRIBUTIONS

DISTRIBUTIONS

PORTABLE

ANNUAL ROLLOVER
 

The maximum allowed is a combination

of the health plan “premium pass through”

and the member contribution up to the

maximum contribution amount set by the

IRS each year.

May be used to pay the out­of­pocket

medical expenses for yourself, your

spouse, or your dependents (even if they

are not covered by the HDHP), or to pay

the plan’s deductible.

See IRS Publication 502 for a complete list

of eligible expenses, including over­thecounter drugs.

Yes, you can take this account with you

when you change plans, separate from

service, or retire.

Yes, funds accumulate without a

maximum cap.

Only that portion of the premium specified

by the health plan will be contributed. You

cannot add your own money to an HRA.

May be used to pay the out­of­pocket

expenses for qualified medical expenses for

individuals covered under the HDHP, or to

pay the plan’s deductible.

See IRS Publication 502 for a complete list of

eligible expenses.

If you retire and remain in your HDHP you

may continue to use and accumulate credits

in your HRA.

If you terminate employment or change

health plans, only eligible expenses incurred

while covered under that HDHP will be

eligible for reimbursement, subject to timely

filing requirements. Unused credits are

forfeited.

Yes, credits accumulate without a

maximum cap.

IMPORTANT REMINDER: This is only a summary of the features of the HDHP/HSA or HRA. Refer to the specific

Plan brochure for the complete details covering Plan design, operation, and administration as each Plan will

have differences.

62
Appendix E
 

FEHB Plan Comparison Charts
 

High Deductible and Consumer­Driven Health Plans

With a Health Savings Account or Health Reimbursement Arrangement

A Consumer­Driven plan provides you with freedom in spending health care dollars the

way you want. The typical plan has common features: member responsibility for certain up­front

medical costs, an employer­funded account that you may use to pay these up­front costs,

and catastrophic coverage with a high deductible. You and your family receive full coverage for

In­Network preventive care.

63
Appendix E
 

FEHB Plan Comparison Charts
 

High Deductible and Consumer­Driven Health Plans
 

With a Health Savings Account or Health Reimbursement Arrangement
 

The tables on the following pages highlight what you are expected to pay for selected features under each plan. The

charts are not a complete statement of your out­of­pocket obligations in every individual circumstance. Unlike many

regular medical plans, the covered out­of­pocket expenses under a High Deductible Health Plan, including office visit

copayments and prescription drug copayments, count toward the calendar year deductible and the catastrophic limit.

You must read the plan’s brochure for details.

Premium Contribution (pass through) to HSA/HRA (or personal care account) shows the amount your health plan

automatically deposits or credits into your account on a monthly basis for Self Only/Self and Family enrollments.

(Consumer­Driven Health Plans credit accounts annually.) The amount credited under “Premium Contribution” is

shown as a monthly amount for comparison purposes only.

Calendar Year (CY) Deductible Self/Family is the maximum amount of covered expenses an individual or family must

pay out­of­pocket, including deductibles, coinsurance and copayments, before the plan pays catastrophic benefits.

Catastrophic (Cat.) Limit Self/Family is the maximum amount of covered expenses an individual or family must pay

out­of­pocket, including deductibles and coinsurance and copays, before the Plan pays catastrophic benefits.

Office Visit shows what you pay for a visit to a primary care physician after the deductible is met for other than

preventive care.

Inpatient Hospital shows what you pay after the deductible is met for hospital services when an inpatient. The amount

could be a daily copayment up to a specified amount (e.g., $50 a day up to three days), a coinsurance amount such as

Your Share of Premium

Plan Name Telephone

Number

Enrollment Code Monthly Biweekly

Self

only

Self &

family

Self

only

Self &

family

Self

only

Self &

family

APWU Health Plan ­CDHP

GEHA High Deductible Health Plan ­HDHP

Mail Handlers Benefit Plan Consumer Option ­HDHP

866­833­3463

800­821­6136

800­694­9901

474

341

481

475

342

482

84.17

95.20

75.44

189.37

217.45

170.95

38.85

43.94

34.82

87.40

100.36

78.90

64
Appendix E
 

FEHB Plan Comparison Charts
 

High Deductible and Consumer­Driven Health Plans
 

With a Health Savings Account or Health Reimbursement Arrangement
 

20%, or a flat deductible amount (e.g., $200 per admission). This amount does not include charges from physicians or

for services that may not be charged by the hospital such as laboratory or radiology.

Outpatient Surgery shows what you pay the doctor for surgery performed on an outpatient basis.

Preventive Services are often covered in full, usually with no or only a small deductible or copayment. Preventive

services may also be payable up to an annual maximum dollar amount (e.g., up to $300 per person per year).

Prescription Drugs are catagorized using a variety of terms to define what you pay such as generic, brand, Level I,

Level II, Tier I, Tier II, etc. In capturing these differences we use the following: Level I includes most generic drugs,

but may include some preferred brands. Level II may include generics and preferred brands not included in Level I.

Level III includes all other covered drugs with some exceptions for specialty drugs. The level in which a medication is

placed and what you pay for prescription drugs is often based on what the plan is charged.

High Deductible Health Plans and Consumer Driven Health Plans are much different from the other types of plans

shown in this Guide. You can use in­network providers to save money. If you use out­of­network providers, however, you

not only pay more of the costs but you are also usually responsible for any difference between the amount billed for a

service and what the plan actually allows. (For example, you receive a bill from an out­of­network provider for $100 but

the plan allows $85 for the service. You pay the higher copayment for out­of­network care plus the $15 difference between

$100 – the billed amount – and the plan’s allowance of $85.) In addition, the difference you pay between the billed

amount and the plan’s allowance does not count toward satisfying the catastrophic limit.

Plan Name Benefit Premium CY Ded. Cat. Limit Office Inpatient Outpatient Preventive Prescription

Type Contribution Self/Family Self/Family Visit Hospital Surgery Services Drugs

to HSA/HRA Levels I, II, III

APWU Health Plan­ In­Network N/A $600/$1,200 $3,000/$4,500 15% None 15% Nothing 25%/25%/25%

APWU Health Plan­ Out­Network N/A $600/$1,200 $9,000/$9,000 40%+diff. None 40%+diff. Nothing upto $1200 Not Covered

GEHA HDHP­ In­Network $60/$120 $1,500/$3,000 $5,000/$10,000 5% 5% 5% Nothing 25%/25%/25%

GEHA HDHP­ Out­Network $60/$120 $1,500/$3,000 $5,000/$10,000 25% 25% 25% Ded/25% 25%+/25%+/25%+

Mail Handlers Benefit Plan

Consumer Option­ In­Network $70/$140 $2,000/$4,000 $5,000/$10,000 $15 $75day­$750 Nothing Nothing $10/$25/$40

Mail Handlers Benefit Plan

Consumer Option­ Out­Network $70/$140 $2,000/$4,000 $7,500/$15,000 40% 40% 40% Not Covered Not Covered

65
High Deductible Health Plans and Consumer­Driven Health Plan Member Survey Results

Member Survey results are collected, scored, and reported by an independent organization – not by the health plans.

See Appendix D for a fuller explanation of each survey category.

Overall Plan Satisfaction • How wouldyou rate youroverall experience with your health plan?

Getting Needed Care • Was it easy togetan appointment with specialists?

• Was it easy toget the care, tests,or treatment you thought you needed?

Getting Care Quickly • Didyou get theadviceor helpyou needed when you calledyourdoctorduringregularoffice hours?

• Couldyou getan appointment for regularor routine careas soon as you thought you needed?

How Well Doctors

Communicate

• Didyourdoctor listen carefully toyou andexplain things in a way you could understand?

• Didyourdoctor spendenough time with you?

CustomerService • Was yourplan helpful when you calledits customer service?

• Didtheplan’s written materialsor the Internetprovide you with the information you neededabout how theplan works?

Claims Processing • Didyourplan pay your claimsquicklyandcorrectly?

Shared Decision Making • Didyourdoctor talk with you about theprosandconsof each choice for your treatmentor health care?

• When there was more than one choice for your treatmentor health care,didyourdoctorask which choice wasbest for you?

High Deductible Health Plans

Plan Name

Member Survey Results

(with national averages for High Deductible Health Plans

and Consumer­Driven Health Plans in each category)

Plan

Code

Overall plan

satisfaction

58.2

Getting

needed care

85.1

Getting

care quickly

87.3

How well

doctors

communicate

93.8

Customer

service

83.3

Claims

processing

87.5

Shared

decision

making

53.8

Aetna Health Fund­ Nationwide 22 58.6 85.3 87.5 95.3 82.8 88.1 47.8

AultCare HMO ­ OH 3A 67.9 90.5 88 94 90.3 93.5 59.5

BluegrassFamily Health ­ IN, KY, TN KV 62.7 87.8 89.2 94.5 82.1 91.2 61.2

GEHA High Deductible Health Plan ­ Nationwide 34 58.1 84 85.3 92.9 85.6 90.4 48.2

Mail Handlers Benefit Plan Consumer Option 48 49.8 83.5 89.2 94.7 82.4 80.4 52

UnitedHealthcare Insurance Company, Inc. ­ 23Statesand D.C. E9 52.1 79.7 84.8 91.4 76.6 81.3 54.4

Consumer­Driven Health Plans

Plan Name

Plan

Code

Overall plan

satisfaction

54

Getting

needed care

85.5

Getting

care quickly

86.1

How well

doctors

communicate

92.9

Customer

service

80.1

Claims

processing

85.4

Shared

decision

making

55.9

Aetna Health Fund­ Nationwide 22 58.6 85.3 87.5 95.3 82.8 88.1 47.8

APWU Health Fund­ Nationwide 47 64.3 87.9 88.8 94.1 78.9 83.2 50.5

Humana CoverageFirst ­ IN, KY, OH L8 42.5 85.9 84.3 93.3 76.4 85.8 63.3

Humana CoverageFirst ­ FL MJ 50.6 82.7 84 88.9 82.4 84.6 62.1

66
This page intentionally left blank

67
 
High Deductible and Consumer­Driven Health Plans

See page 64­65 for an explanation of the columns on these pages.

Your Share of Premium

Alabama

Aetna HealthFund­CDHP­ MostofAlabama

Aetna HealthFund­HDHP­ MostofAlabama

Alaska

Aetna HealthFund­CDHP­ MostofAlaska

Aetna HealthFund­HDHP­ MostofAlaska

Arizona

Aetna HealthFund­CDHP­ AllofArizona

Aetna HealthFund­HDHP­ AllofArizona

Humana CoverageFirst ­CDHP­ Phoenix/Tucson Area

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Arizona

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Arizona

Arkansas

Aetna HealthFund­CDHP­ MostofArkansas

Aetna HealthFund­HDHP­ MostofArkansas

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Arkansas

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Arkansas

Plan Name

877­459­6604

877­459­6604

877­459­6604

877­459­6604

877­459­6604

877­459­6604

888­393­6765

877­835­9861

877­835­9861

877­459­6604

877­459­6604

877­835­9861

877­835­9861

Telephone

Number

Enrollment Code Monthly Biweekly

221

224

221

224

221

224

DB1

E91

E94

221

224

E91

E94

Self

only

222

225

222

225

222

225

DB2

E92

E95

222

225

E92

E95

Self &

family

87.71

67.01

87.71

67.01

87.71

67.01

75.97

76.33

89.26

87.71

67.01

76.33

89.26

Self

only

201.72

146.75

201.72

146.75

201.72

146.75

174.74

170.52

197.59

201.72

146.75

170.52

197.59

Self &

family

40.48

30.93

40.48

30.93

40.48

30.93

35.06

35.23

41.20

40.48

30.93

35.23

41.20

Self

only

93.10

67.73

93.10

67.73

93.10

67.73

80.65

78.70

91.19

93.10

67.73

78.70

91.19

Self &

family

68
Alabama

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

Alaska

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

Arizona

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

UnitedHealthcare­ In­Network $62.50/125 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$30/$50

UnitedHealthcare­ Out­Network $62.50/125 $3000/$6000 $6000/$12000 35% 35% 35% 35% $10/$30/$50

UnitedHealthcare­ In­Network $104.17/208.33 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$25/$40

UnitedHealthcare­ Out­Network $104.17/208.33 $2000/$4000 $4000/$8000 40% 40% 40% 40% $10/$25/$40

Arkansas

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

UnitedHealthcare­ In­Network $62.50/125 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$30/$50

UnitedHealthcare­ Out­Network $62.50/125 $3000/$6000 $6000/$12000 35% 35% 35% 35% $10/$30/$50

UnitedHealthcare­ In­Network $104.17/208.33 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$25/$40

UnitedHealthcare­ Out­Network $104.17/208.33 $2000/$4000 $4000/$8000 40% 40% 40% 40% $10/$25/$40

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Prescription

Drugs

Levels I, II, III

Benefit

Type

69
 
High Deductible and Consumer­Driven Health Plans

See page 64­65 for an explanation of the columns on these pages.

Your Share of Premium

California

Aetna HealthFund­CDHP­ Mostof California

Aetna HealthFund­HDHP­ Mostof California

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Mostof Califo

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Mostof Califo

Colorado

Aetna HealthFund­CDHP­ Allof Colorado

Aetna HealthFund­HDHP­ Allof Colorado

Humana CoverageFirst ­CDHP­ DenverArea

Humana CoverageFirst ­CDHP­ ColoradoSpringsArea

UnitedHealthcare Insurance Company, Inc. ­HDHP­ DenverArea

UnitedHealthcare Insurance Company, Inc. ­CDHP­ DenverArea

Connecticut

Aetna HealthFund­CDHP­ Allof Connecticut

Aetna HealthFund­HDHP­ Allof Connecticut

Delaware

Aetna HealthFund­CDHP­ Allof Delaware

Aetna HealthFund­HDHP­ Allof Delaware

Coventry Health Care HDHP ­HDHP­ Allof Delaware

Plan Name

877­459­6604

877­459­6604

rnia877­835­9861

rnia877­835­9861

877­459­6604

877­459­6604

888­393­6765

888­393­6765

877­835­9861

877­835­9861

877­459­6604

877­459­6604

877­459­6604

877­459­6604

800/833­7423

Telephone

Number

Enrollment Code Monthly Biweekly

221

224

E91

E94

221

224

7T1

FC1

E91

E94

221

224

221

224

LK1

Self

only

222

225

E92

E95

222

225

7T2

FC2

E92

E95

222

225

222

225

LK2

Self &

family

87.71

67.01

76.33

89.26

87.71

67.01

79.14

79.14

76.33

89.26

87.71

67.01

87.71

67.01

88.29

Self

only

201.72

146.75

170.52

197.59

201.72

146.75

182.02

182.02

170.52

197.59

201.72

146.75

201.72

146.75

213.90

Self &

family

40.48

30.93

35.23

41.20

40.48

30.93

36.52

36.52

35.23

41.20

40.48

30.93

40.48

30.93

40.75

Self

only

93.10

67.73

78.70

91.19

93.10

67.73

84.01

84.01

78.70

91.19

93.10

67.73

93.10

67.73

98.72

Self &

family

70
California

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

UnitedHealthcare­ In­Network $62.50/125 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$30/$50

UnitedHealthcare­ Out­Network $62.50/125 $3000/$6000 $6000/$12000 35% 35% 35% 35% $10/$30/$50

UnitedHealthcare­ In­Network $104.17/208.33 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$25/$40

UnitedHealthcare­ Out­Network $104.17/208.33 $2000/$4000 $4000/$8000 40% 40% 40% 40% $10/$25/$40

Colorado

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

UnitedHealthcare­ In­Network $62.50/125 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$30/$50

UnitedHealthcare­ Out­Network $62.50/125 $3000/$6000 $6000/$12000 35% 35% 35% 35% $10/$30/$50

UnitedHealthcare­ In­Network $104.17/208.33 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$25/$40

UnitedHealthcare­ Out­Network $104.17/208.33 $2000/$4000 $4000/$8000 40% 40% 40% 40% $10/$25/$40

Connecticut

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

Delaware

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

Coventry Health Care­ In­Network $41.66/$83.33 $1,500/$3,000 $4,000/$8,000 $15 Nothing Nothing $15/$25 Nocopay/$25/$50

Coventry Health Care­ Out­Network $41.66/$83.33 $1,500/$3,000 $4,000/$8,000 30% 30% 30% 30% N/A/N/A/ N/A

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Prescription

Drugs

Levels I, II, III

Benefit

Type

71
 
High Deductible and Consumer­Driven Health Plans

See page 64­65 for an explanation of the columns on these pages.

Your Share of Premium

District of Columbia

Aetna HealthFund­CDHP­ Allof Washington DC

Aetna HealthFund­HDHP­ Allof Washington DC

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Washington D

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Washington D

Florida

Aetna HealthFund­CDHP­ MostofFlorida

Aetna HealthFund­HDHP­ MostofFlorida

Humana CoverageFirst ­CDHP­ PensacolaArea

Humana CoverageFirst ­CDHP­ DaytonaArea

Humana CoverageFirst ­CDHP­ TampaArea

Humana CoverageFirst ­CDHP­ JacksonvilleArea

Humana CoverageFirst ­CDHP­ South FloridaArea

Humana CoverageFirst ­CDHP­ OrlandoArea

UnitedHealthcare Insurance Company, Inc. ­HDHPCentralandSouthwestFlorida

UnitedHealthcare Insurance Company, Inc. ­CDHPCentralandSouthwestFlorida

Plan Name

877­459­6604

877­459­6604

C 877­835­9861

C 877­835­9861

877­459­6604

877­459­6604

888­393­6765

888­393­6765

888­393­6765

888­393­6765

888­393­6765

888­393­6765

877­835­9861

877­835­9861

Telephone

Number

Enrollment Code Monthly Biweekly

221

224

E91

E94

221

224

BP1

DL1

MJ1

MQ1

QP1

YG1

E91

E94

Self

only

222

225

E92

E95

222

225

BP2

DL2

MJ2

MQ2

QP2

YG2

E92

E95

Self &

family

87.71

67.01

76.33

89.26

87.71

67.01

96.74

105.53

92.85

97.08

75.97

87.93

76.33

89.26

Self

only

201.72

146.75

170.52

197.59

201.72

146.75

222.52

242.74

213.57

223.28

174.74

202.24

170.52

197.59

Self &

family

40.48

30.93

35.23

41.20

40.48

30.93

44.65

48.71

42.85

44.80

35.06

40.58

35.23

41.20

Self

only

93.10

67.73

78.70

91.19

93.10

67.73

102.70

112.03

98.57

103.05

80.65

93.34

78.70

91.19

Self &

family

72
District of Columbia

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

UnitedHealthcare­ In­Network $62.50/125 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$30/$50

UnitedHealthcare­ Out­Network $62.50/125 $3000/$6000 $6000/$12000 35% 35% 35% 35% $10/$30/$50

UnitedHealthcare­ In­Network $104.17/208.33 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$25/$40

UnitedHealthcare­ Out­Network $104.17/208.33 $2000/$4000 $4000/$8000 40% 40% 40% 40% $10/$25/$40

Florida

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

UnitedHealthcare­ In­Network $62.50/125 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$30/$50

UnitedHealthcare­ Out­Network $62.50/125 $3000/$6000 $6000/$12000 35% 35% 35% 35% $10/$30/$50

UnitedHealthcare­ In­Network $104.17/208.33 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$25/$40

UnitedHealthcare­ Out­Network $104.17/208.33 $2000/$4000 $4000/$8000 40% 40% 40% 40% $10/$25/$40

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Prescription

Drugs

Levels I, II, III

Benefit

Type

73
 
High Deductible and Consumer­Driven Health Plans

See page 64­65 for an explanation of the columns on these pages.

Your Share of Premium

Georgia

Aetna HealthFund­CDHP­ Mostof Georgia

Aetna HealthFund­HDHP­ Mostof Georgia

Humana CoverageFirst ­CDHP­ AtlantaArea

Humana CoverageFirst ­CDHP­ Macon Area

KaiserFoundation Health Plan of GeorgiaInc. HDHP ­

Atlanta,Athens,Columbus,Macon,Savannah

UnitedHealthcare Insurance Company, Inc. ­HDHPAtlanta,Athens, Macon Areas

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Atlanta,

Athens, Macon Areas

Guam

TakeCare ­HDHP­ Guam/N. MarianaIslands/Belau (Palau)

Idaho

Aetna HealthFund­CDHP­ Mostof Idaho

Aetna HealthFund­HDHP­ Mostof Idaho

Altius Health Plans ­HDHP­ Southern Region

Plan Name

877­459­6604

877­459­6604

888­393­6765

888­393­6765

888/865­5813

877­835­9861

877­835­9861

671­647­3526

877­459­6604

877­459­6604

800­377­4161

Telephone

Number

Enrollment Code Monthly Biweekly

221

224

AD1

LM1

GW1

E91

E94

KX1

221

224

9K4

Self

only

222

225

AD2

LM2

GW2

E92

E95

KX2

222

225

9K5

Self &

family

87.71

67.01

74.75

92.34

82.25

76.33

89.26

95.10

87.71

67.01

99.71

Self

only

201.72

146.75

171.93

212.39

184.90

170.52

197.59

239.91

201.72

146.75

206.57

Self &

family

40.48

30.93

34.50

42.62

37.96

35.23

41.20

43.89

40.48

30.93

46.02

Self

only

93.10

67.73

79.35

98.02

85.34

78.70

91.19

110.73

93.10

67.73

95.34

Self &

family

74
Georgia

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

KaiserFoundation HP­ HDHP $62.50/$125.00 $1,500/$3,000 $3,000/$6,000 20% 20% 20% $15 20%/20%/20%

UnitedHealthcare­ In­Network $62.50/125 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$30/$50

UnitedHealthcare­ Out­Network $62.50/125 $3000/$6000 $6000/$12000 35% 35% 35% 35% $10/$30/$50

UnitedHealthcare­ In­Network $104.17/208.33 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$25/$40

UnitedHealthcare­ Out­Network $104.17/208.33 $2000/$4000 $4000/$8000 40% 40% 40% 40% $10/$25/$40

Guam

TakeCare­ In­Network $86.66/$222.08 $3,000/$6,000 $5,000/$10,000 20% after DED20@ after DED 20% after DED 1st$300/ded $20/$40/$150

TakeCare­ Out­Network $86.66/$222.08 $3,000/$6,000 $10,000/$20,00030% after DED30% after DED 30% after DED 1st$300/ded 30% after DED

Idaho

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

Altius Health Plans $45.83/$91.66 $1,200/$2,400 $5,000/$10,000 $20 10% 10% Nothing $10/$25/$50

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Prescription

Drugs

Levels I, II, III

Benefit

Type

75
 
High Deductible and Consumer­Driven Health Plans

See page 64­65 for an explanation of the columns on these pages.

Your Share of Premium

Illinois

Aetna HealthFund­CDHP­ Mostof Illinois

Aetna HealthFund­HDHP­ Mostof Illinois

Group Health Plan, Inc. ­HDHP­ Southern/Central

Health Alliance HMO ­HDHP­ Central, E cent.,N. cent.So, W. Illino

Humana CoverageFirst ­CDHP­ ChicagoArea

Unicare HMO ­HDHP­ ChicagolandArea

UnitedHealthcare Insurance Company, Inc. ­HDHP­ St.LouisArea

UnitedHealthcare Insurance Company, Inc. ­CDHP­ St.LouisArea

Indiana

Aetna HealthFund­CDHP­ Allof Indiana

Aetna HealthFund­HDHP­ Allof Indiana

BluegrassFamily Health ­HDHP­ Southern Indiana

Health Alliance HMO ­HDHP­ Western Indiana

Humana CoverageFirst ­CDHP­ Eastern IndianaArea

Humana CoverageFirst ­CDHP­ Lake/Porter/LaPorte Counties

Unicare HMO ­HDHP­ Lake/Porter Counties

Plan Name

877­459­6604

877­459­6604

800­755­3901

is 800­851­3379

888­393­6765

888­234­8855

877­835­9861

877­835­9861

877­459­6604

877­459­6604

800­787­2680

800­851­3379

888­393­6765

888­393­6765

888­234­8855

Telephone

Number

Enrollment Code Monthly Biweekly

221

224

MM4

FM1

MW1

721

E91

E94

221

224

KV1

FM1

L81

MW1

721

Self

only

222

225

MM5

FM2

MW2

722

E92

E95

222

225

KV2

FM2

L82

MW2

722

Self &

family

87.71

67.01

148.66

100.79

71.83

72.84

76.33

89.26

87.71

67.01

108.33

100.79

87.93

71.83

72.84

Self

only

201.72

146.75

288.84

225.91

165.20

159.28

170.52

197.59

201.72

146.75

216.66

225.91

202.24

165.20

159.28

Self &

family

40.48

30.93

68.61

46.52

33.15

33.62

35.23

41.20

40.48

30.93

50.00

46.52

40.58

33.15

33.62

Self

only

93.10

67.73

133.31

104.27

76.25

73.51

78.70

91.19

93.10

67.73

100.00

104.27

93.34

76.25

73.51

Self &

family

76
Illinois

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

Group Health Plan, Inc.­ In­Network $62.50/$125.00 $1,500/$3,000 $5,000/$10,000 $15 10% 10% $15/$25 $15/$25/$50

Group Health Plan, Inc.­ Out­Network $62.50/$125.00 $2,500/$5,000 $10,000/$20,000 30% 30% 30% 30%+Ded N/A/N/A/N/A

Health Alliance HMO­ In­Network $83.34/$166.67 $2000/$4000 $2000/$4000 $0 None 0% N/A 0%/0% coinsurance/0%

Health Alliance HMO­ Out­Network $83.34/$166.67 $4000/$8000 $10000/$20000 50% None 50% N/A 50%/50%/50%

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

Unicare HMO­ In­Network $60/$120 $1,500/$3,000 $3,000/$6,000 10% 10% 10% Nothing $10/$20/$40

Unicare HMO­ Out­Network $60/$120 $3,000/$6,000 $6,000/$12,000 30% 30% 30% Ded. + 30% $10 + 30%/$20 + 30%/$40 + 30%

UnitedHealthcare­ In­Network $62.50/125 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$30/$50

UnitedHealthcare­ Out­Network $62.50/125 $3000/$6000 $6000/$12000 35% 35% 35% 35% $10/$30/$50

UnitedHealthcare­ In­Network $104.17/208.33 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$25/$40

UnitedHealthcare­ Out­Network $104.17/208.33 $2000/$4000 $4000/$8000 40% 40% 40% 40% $10/$25/$40

Indiana

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

BluegrassFamily Health­ In­Network $104.17/$208.33 $2,500/$5,000 $5,000/$7,500 0% 0% 0% Nothing $10/$20/$30/$30

BluegrassFamily Health­ Out­Network $104.17/$208.33 $5,000/$10,000 $10,000/$15,000 30% 30% 30% Ded/30% N/A/N/A/N/A

Health Alliance HMO­ In­Network $83.34/$166.67 $2000/$4000 $2000/$4000 $0 None 0% N/A 0%/0% coinsurance/0%

Health Alliance HMO­ Out­Network $83.34/$166.67 $4000/$8000 $10000/$20000 50% None 50% N/A 50%/50%/50%

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

Unicare HMO­ In­Network $60/$120 $1,500/$3,000 $3,000/$6,000 10% 10% 10% Nothing $10/$20/$40

Unicare HMO­ Out­Network $60/$120 $3,000/$6,000 $6,000/$12,000 30% 30% 30% Ded. + 30% $10 + 30%/$20 + 30%/$40 + 30%

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Prescription

Drugs

Levels I, II, III

Benefit

Type

77
 
High Deductible and Consumer­Driven Health Plans

See page 64­65 for an explanation of the columns on these pages.

Your Share of Premium

Iowa

Aetna HealthFund­CDHP­ Allof Iowa

Aetna HealthFund­HDHP­ Allof Iowa

Coventry Health Careof Iowa­HDHP­ Central/Eastern/Western Io

Health Alliance HMO ­HDHP­ Central Iowa

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Central Iowa

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Central Iowa

Kansas

Aetna HealthFund­CDHP­ Mostof Kansas

Aetna HealthFund­HDHP­ Mostof Kansas

Blue Crossand BlueShieldService Benefit Plan ­HDHPCertain Counties in Kansas City

Coventry Health Careof Kansas (Kansas City)­HDHP ­HDHPKansas City/Wichita/SalinaAreas

Humana CoverageFirst ­CDHP­ Kansas CityArea

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Kansas CityArea

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Kansas CityArea

Kentucky

Aetna HealthFund­CDHP­ Mostof Kentucky

Aetna HealthFund­HDHP­ Mostof Kentucky

BluegrassFamily Health ­HDHP­ Kentucky

Humana CoverageFirst ­CDHP­ Lexington Area

Humana CoverageFirst ­CDHP­ Northern Kentucky

Plan Name

877­459­6604

877­459­6604

wa 800­257­4692

800­851­3379

877­835­9861

877­835­9861

877­459­6604

877­459­6604

Localphone#

800­969­3343

888­393­6765

877­835­9861

877­835­9861

877­459­6604

877­459­6604

800­787­2680

888­393­6765

888­393­6765

Telephone

Number

Enrollment Code Monthly Biweekly

221

224

SV4

FM1

E91

E94

221

224

114

9H1

PH1

E91

E94

221

224

KV1

6N1

L81

Self

only

222

225

SV5

FM2

E92

E95

222

225

115

9H2

PH2

E92

E95

222

225

KV2

6N2

L82

Self &

family

87.71

67.01

82.08

100.79

76.33

89.26

87.71

67.01

92.44

72.89

67.80

76.33

89.26

87.71

67.01

108.33

87.93

87.93

Self

only

201.72

146.75

195.89

225.91

170.52

197.59

201.72

146.75

216.48

171.28

155.97

170.52

197.59

201.72

146.75

216.66

202.24

202.24

Self &

family

40.48

30.93

37.88

46.52

35.23

41.20

40.48

30.93

42.66

33.64

31.29

35.23

41.20

40.48

30.93

50.00

40.58

40.58

Self

only

93.10

67.73

90.41

104.27

78.70

91.19

93.10

67.73

99.91

79.05

71.98

78.70

91.19

93.10

67.73

100.00

93.34

93.34

Self &

family

78
Iowa

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

Coventry Health Careof Iowa $66.66/$133.33 $1,800/$3,600 $5,000/$10,000 $20 10% 10% $20/$30/10% $10/$30/$55

Health Alliance HMO­ In­Network $83.34/$166.67 $2000/$4000 $2000/$4000 $0 None 0% N/A 0%/0% coinsurance/0%

Health Alliance HMO­ Out­Network $83.34/$166.67 $4000/$8000 $10000/$20000 50% None 50% N/A 50%/50%/50%

UnitedHealthcare­ In­Network $62.50/125 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$30/$50

UnitedHealthcare­ Out­Network $62.50/125 $3000/$6000 $6000/$12000 35% 35% 35% 35% $10/$30/$50

UnitedHealthcare­ In­Network $104.17/208.33 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$25/$40

UnitedHealthcare­ Out­Network $104.17/208.33 $2000/$4000 $4000/$8000 40% 40% 40% 40% $10/$25/$40

Kansas

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

BCBSService Benefit Plan $75/$150 $2,900/$5,800 $2,900/$5,800 Nothing Nothing Nothing Nothing Nothing

Coventry Health Care ­HDHP $50.00/$100.00 $2,500/$5,000 $2,500/$5,000 $20 None Nothing $20/$35/20% Nothing

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

UnitedHealthcare­ In­Network $62.50/125 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$30/$50

UnitedHealthcare­ Out­Network $62.50/125 $3000/$6000 $6000/$12000 35% 35% 35% 35% $10/$30/$50

UnitedHealthcare­ In­Network $104.17/208.33 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$25/$40

UnitedHealthcare­ Out­Network $104.17/208.33 $2000/$4000 $4000/$8000 40% 40% 40% 40% $10/$25/$40

Kentucky

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

BluegrassFamily Health­ In­Network $104.17/$208.33 $2,500/$5,000 $5,000/$7,500 0% 0% 0% Nothing $10/$20/$30/$30

BluegrassFamily Health­ Out­Network $104.17/$208.33 $5,000/$10,000 $10,000/$15,000 30% 30% 30% Ded/30% N/A/N/A/N/A

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Prescription

Drugs

Levels I, II, III

Benefit

Type

79
 
High Deductible and Consumer­Driven Health Plans

See page 64­65 for an explanation of the columns on these pages.

Your Share of Premium

Louisiana

Aetna HealthFund­CDHP­ MostofLouisiana

Aetna HealthFund­HDHP­ MostofLouisiana

Coventry Health CareofLouisiana HDHP ­HDHP­ New Orleansare

Humana CoverageFirst ­CDHP­ New OrleansArea

Humana CoverageFirst ­CDHP­ Baton RougeArea

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Louisiana

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Louisiana

Maine

Aetna HealthFund­CDHP­ Allof Maine

Aetna HealthFund­HDHP­ Allof Maine

Maryland

Aetna HealthFund­CDHP­ Allof Maryland

Aetna HealthFund­HDHP­ Allof Maryland

Coventry Health Care HDHP ­HDHP­ Allof Maryland

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Maryland

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Maryland

Massachusetts

Aetna HealthFund­CDHP­ Mostof Massachusetts

Aetna HealthFund­HDHP­ Mostof Massachusetts

Plan Name

877­459­6604

877­459­6604

a 800/341­6613

888­393­6765

888­393­6765

877­835­9861

877­835­9861

877­459­6604

877­459­6604

877­459­6604

877­459­6604

800/833­7423

877­835­9861

877­835­9861

877­459­6604

877­459­6604

Telephone

Number

Enrollment Code Monthly Biweekly

221

224

HB1

9J1

9L1

E91

E94

221

224

221

224

GZ1

E91

E94

221

224

Self

only

222

225

HB2

9J2

9L2

E92

E95

222

225

222

225

GZ2

E92

E95

222

225

Self &

family

87.71

67.01

94.66

83.55

92.34

76.33

89.26

87.71

67.01

87.71

67.01

69.02

76.33

89.26

87.71

67.01

Self

only

201.72

146.75

219.86

192.18

212.39

170.52

197.59

201.72

146.75

201.72

146.75

166.86

170.52

197.59

201.72

146.75

Self &

family

40.48

30.93

43.69

38.56

42.62

35.23

41.20

40.48

30.93

40.48

30.93

31.86

35.23

41.20

40.48

30.93

Self

only

93.10

67.73

101.47

88.70

98.02

78.70

91.19

93.10

67.73

93.10

67.73

77.01

78.70

91.19

93.10

67.73

Self &

family

80
Louisiana

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

Coventry Health Care­ In­Network $41.67/$83.34 $1,150/$2,300 $4,000/$8,000 20% 20% 20% 20% $10/$35/$60

Coventry Health Care­ Out­Network $41.67/$83.34 $2,000/$4,000 $6,000/$12,000 30% 30% 30% 30% N/A/N/A/N/A

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

UnitedHealthcare­ In­Network $62.50/125 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$30/$50

UnitedHealthcare­ Out­Network $62.50/125 $3000/$6000 $6000/$12000 35% 35% 35% 35% $10/$30/$50

UnitedHealthcare­ In­Network $104.17/208.33 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$25/$40

UnitedHealthcare­ Out­Network $104.17/208.33 $2000/$4000 $4000/$8000 40% 40% 40% 40% $10/$25/$40

Maine

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

Maryland

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

Coventry Health Care­ In­Network $41.67/$83.34 $1,500/$3,000 $4,000/$8,000 $15 Nothing Nothing $15/$25 Nocopay/$25/$50

Coventry Health Care­ Out­Network $41.67/$83.34 $1,500/$3,000 $4,000/$8,000 30% 30% 30% 30% N/A/N/A/ N/A

UnitedHealthcare­ In­Network $62.50/125 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$30/$50

UnitedHealthcare­ Out­Network $62.50/125 $3000/$6000 $6000/$12000 35% 35% 35% 35% $10/$30/$50

UnitedHealthcare­ In­Network $104.17/208.33 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$25/$40

UnitedHealthcare­ Out­Network $104.17/208.33 $2000/$4000 $4000/$8000 40% 40% 40% 40% $10/$25/$40

Massachusetts

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Prescription

Drugs

Levels I, II, III

Benefit

Type

81
 
High Deductible and Consumer­Driven Health Plans

See page 64­65 for an explanation of the columns on these pages.

Your Share of Premium

Michigan

Aetna HealthFund­CDHP­ Allof Michigan

Aetna HealthFund­HDHP­ Allof Michigan

Health Alliance Plan ­HDHP­ Southeastern Michigan/Flintarea

Minnesota

Aetna HealthFund­CDHP­ Mostof Minnesota

Aetna HealthFund­HDHP­ Mostof Minnesota

Blue Crossand BlueShieldService Benefit Plan ­HDHP­ Minnesota

Mississippi

Aetna HealthFund­CDHP­ Mostof Mississippi

Aetna HealthFund­HDHP­ Mostof Mississippi

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Mississippi

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Mississippi

Missouri

Aetna HealthFund­CDHP­ Mostof Missouri

Aetna HealthFund­HDHP­ Mostof Missouri

Blue Crossand BlueShieldService Benefit Plan ­HDHPCertain Counties in Kansas City

Coventry Health Careof Kansas (Kansas City)­HDHP ­HDHPKansas CityArea

Group Health Plan, Inc. ­HDHP­ St.LouisArea

Humana CoverageFirst ­CDHP­ Kansas CityArea

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Kansas City,

Springfield,St.LouisArea

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Kansas City,

Springfield,St.LouisArea

Plan Name

877­459­6604

877­459­6604

800­556­9765

877­459­6604

877­459­6604

Localphone#

877­459­6604

877­459­6604

877­835­9861

877­835­9861

877­459­6604

877­459­6604

Localphone#

800/969­3343

800­755­3901

888­393­6765

877­835­9861

877­835­9861

Telephone

Number

Enrollment Code Monthly Biweekly

221

224

524

221

224

114

221

224

E91

E94

221

224

114

9H1

MM4

PH1

E91

E94

Self

only

222

225

525

222

225

115

222

225

E92

E95

222

225

115

9H2

MM5

PH2

E92

E95

Self &

family

87.71

67.01

101.44

87.71

67.01

92.44

87.71

67.01

76.33

89.26

87.71

67.01

92.44

72.89

148.66

67.80

76.33

89.26

Self

only

201.72

146.75

254.00

201.72

146.75

216.48

201.72

146.75

170.52

197.59

201.72

146.75

216.48

171.28

288.84

155.97

170.52

197.59

Self &

family

40.48

30.93

46.82

40.48

30.93

42.66

40.48

30.93

35.23

41.20

40.48

30.93

42.66

33.64

68.61

31.29

35.23

41.20

Self

only

93.10

67.73

117.23

93.10

67.73

99.91

93.10

67.73

78.70

91.19

93.10

67.73

99.91

79.05

133.31

71.98

78.70

91.19

Self &

family

82
Michigan

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

Health Alliance Plan $62.50/$125 $1,500/$3,000 $5,000/$10,000 $15 None $0afterded $15/$25 $10/$20/$50

Minnesota

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

BCBSService Benefit Plan $75/$150 $2,900/$5,800 $2,900/$5,800 Nothing Nothing Nothing Nothing Nothing

Mississippi

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

UnitedHealthcare­ In­Network $62.50/125 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$30/$50

UnitedHealthcare­ Out­Network $62.50/125 $3000/$6000 $6000/$12000 35% 35% 35% 35% $10/$30/$50

UnitedHealthcare­ In­Network $104.17/208.33 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$25/$40

UnitedHealthcare­ Out­Network $104.17/208.33 $2000/$4000 $4000/$8000 40% 40% 40% 40% $10/$25/$40

Missouri

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

BCBSService Benefit Plan $75/$150 $2,900/$5,800 $2,900/$5,800 Nothing Nothing Nothing Nothing Nothing

Coventry Health Care­HDHP $50.00/$100.00 $2,500/$5,000 $2,500/$5,000 $20 None Nothing $20/$35/20% Nothing

Group Health Plan, Inc.­ In­Network $62.50/$125.00 $1,500/$3,000 $5,000/$10,000 $15 10% 10% $15/$25 $15/$25/$50

Group Health Plan, Inc.­ Out­Network $62.50/$125.00 $2,500/$5,000 $10,000/$20,000 30% 30% 30% 30%+Ded N/A/N/A/N/A

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

UnitedHealthcare­ In­Network $62.50/125 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$30/$50

UnitedHealthcare­ Out­Network $62.50/125 $3000/$6000 $6000/$12000 35% 35% 35% 35% $10/$30/$50

UnitedHealthcare­ In­Network $104.17/208.33 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$25/$40

UnitedHealthcare­ Out­Network $104.17/208.33 $2000/$4000 $4000/$8000 40% 40% 40% 40% $10/$25/$40

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Prescription

Drugs

Levels I, II, III

Benefit

Type

83
 
High Deductible and Consumer­Driven Health Plans

See page 64­65 for an explanation of the columns on these pages.

Your Share of Premium

Montana

Aetna HealthFund­CDHP­ South/Southeast/Western Montana

Aetna HealthFund­HDHP­ South/Southeast/Western Montana

Nebraska

Aetna HealthFund­CDHP­ Mostof Nebraska

Aetna HealthFund­HDHP­ Mostof Nebraska

Nevada

Aetna HealthFund­CDHP­ LasVegas/Clarkand Nye Counties

Aetna HealthFund­HDHP­ LasVegas/Clarkand Nye Counties

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Nevada

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Nevada

New Hampshire

Aetna HealthFund­CDHP­ Allof New Hampshire

Aetna HealthFund­HDHP­ Allof New Hampshire

New Jersey

Aetna HealthFund­CDHP­ Allof New Jersey

Aetna HealthFund­HDHP­ Allof New Jersey

Coventry Health Care HDHP ­HDHP­ Southern New Jersey

Plan Name

877­459­6604

877­459­6604

877­459­6604

877­459­6604

877­459­6604

877­459­6604

877­835­9861

877­835­9861

877­459­6604

877­459­6604

877­459­6604

877­459­6604

800/833­7423

Telephone

Number

Enrollment Code Monthly Biweekly

221

224

221

224

221

224

E91

E94

221

224

221

224

LK1

Self

only

222

225

222

225

222

225

E92

E95

222

225

222

225

LK2

Self &

family

87.71

67.01

87.71

67.01

87.71

67.01

76.33

89.26

87.71

67.01

87.71

67.01

88.29

Self

only

201.72

146.75

201.72

146.75

201.72

146.75

170.52

197.59

201.72

146.75

201.72

146.75

213.90

Self &

family

40.48

30.93

40.48

30.93

40.48

30.93

35.23

41.20

40.48

30.93

40.48

30.93

40.75

Self

only

93.10

67.73

93.10

67.73

93.10

67.73

78.70

91.19

93.10

67.73

93.10

67.73

98.72

Self &

family

84
Montana

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

Nebraska

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

Nevada

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

UnitedHealthcare­ In­Network $62.50/125 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$30/$50

UnitedHealthcare­ Out­Network $62.50/125 $3000/$6000 $6000/$12000 35% 35% 35% 35% $10/$30/$50

UnitedHealthcare­ In­Network $104.17/208.33 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$25/$40

UnitedHealthcare­ Out­Network $104.17/208.33 $2000/$4000 $4000/$8000 40% 40% 40% 40% $10/$25/$40

New Hampshire

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

New Jersey

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

Coventry Health Care­ In­Network $41.67/$83.34 $1,500/$3,000 $4,000/$8,000 $15 Nothing Nothing $15/$25 Nocopay/$25/$50

Coventry Health Care­ Out­Network $41.67/$83.34 $1,500/$3,000 $4,000/$8,000 30% 30% 30% 30% N/A/N/A/ N/A

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Prescription

Drugs

Levels I, II, III

Benefit

Type

85
 
High Deductible and Consumer­Driven Health Plans

See page 64­65 for an explanation of the columns on these pages.

Your Share of Premium

New Mexico

Aetna HealthFund­CDHP­ Albuquerque/DonaAna/HobbsAreas

Aetna HealthFund­HDHP­ Albuquerque/DonaAna/HobbsAreas

UnitedHealthcare Insurance Company, Inc. ­HDHP­ New Mexico

UnitedHealthcare Insurance Company, Inc. ­CDHP­ New Mexico

New York

Aetna HealthFund­CDHP­ Mostof New York

Aetna HealthFund­HDHP­ Mostof New York

CDPHP Universal Benefits ­ HDHP ­HDHP­ Upstate,

Hudson Valley, Cent New York

Independent Health Assoc ­HDHP­ Western New York

North Carolina

Aetna HealthFund­CDHP­ Allof North Carolina

Aetna HealthFund­HDHP­ Allof North Carolina

UnitedHealthcare Insurance Company, Inc. ­HDHPMostof North Carolina

UnitedHealthcare Insurance Company, Inc. ­CDHPMostof North Carolina

North Dakota

Aetna HealthFund­CDHP­ Mostof North Dakota

Aetna HealthFund­HDHP­ Mostof North Dakota

Plan Name

877­459­6604

877­459­6604

877­835­9861

877­835­9861

877­459­6604

877­459­6604

877/269­2134

800/501­3439

877­459­6604

877­459­6604

877­835­9861

877­835­9861

877­459­6604

877­459­6604

Telephone

Number

Enrollment Code Monthly Biweekly

221

224

E91

E94

221

224

SX1

QA4

221

224

E91

E94

221

224

Self

only

222

225

E92

E95

222

225

SX2

QA5

222

225

E92

E95

222

225

Self &

family

87.71

67.01

76.33

89.26

87.71

67.01

71.18

92.90

87.71

67.01

76.33

89.26

87.71

67.01

Self

only

201.72

146.75

170.52

197.59

201.72

146.75

183.65

232.62

201.72

146.75

170.52

197.59

201.72

146.75

Self &

family

40.48

30.93

35.23

41.20

40.48

30.93

32.85

42.88

40.48

30.93

35.23

41.20

40.48

30.93

Self

only

93.10

67.73

78.70

91.19

93.10

67.73

84.76

107.36

93.10

67.73

78.70

91.19

93.10

67.73

Self &

family

86
New Mexico

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

UnitedHealthcare­ In­Network $62.50/125 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$30/$50

UnitedHealthcare­ Out­Network $62.50/125 $3000/$6000 $6000/$12000 35% 35% 35% 35% $10/$30/$50

UnitedHealthcare­ In­Network $104.17/208.33 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$25/$40

UnitedHealthcare­ Out­Network $104.17/208.33 $2000/$4000 $4000/$8000 40% 40% 40% 40% $10/$25/$40

New York

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

CDPHP Universal­HDHP­ In­Network $62.50/$125 $1,500/$3,000 $5,100/$10,200 10% ofAllow 10% ofAllow 10% ofAllow Nothing $15/$40/$60for each

CDPHP Universal­HDHP­ Out­Network $62.50/$125 $5,000/$10,000 $10,000/$20,000 30% ofAllow 30% ofAllow 30% ofAllow 30% + Ded N/A/N/A/N/A

Independent Health­ In­Network $66.42/$166.67 $2000/$4000 $5000/$10000 $15 Nothing 20% $15 $7/$25/$40

Independent Health­ Out­Network $66.42/$166.67 $2000/$4000 $5000/$10000 40% 40% 40% Ded/40% N/A/N/A/N/A

North Carolina

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

UnitedHealthcare­ In­Network $62.50/125 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$30/$50

UnitedHealthcare­ Out­Network $62.50/125 $3000/$6000 $6000/$12000 35% 35% 35% 35% $10/$30/$50

UnitedHealthcare­ In­Network $104.17/208.33 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$25/$40

UnitedHealthcare­ Out­Network $104.17/208.33 $2000/$4000 $4000/$8000 40% 40% 40% 40% $10/$25/$40

North Dakota

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Prescription

Drugs

Levels I, II, III

Benefit

Type

87
 
High Deductible and Consumer­Driven Health Plans

See page 64­65 for an explanation of the columns on these pages.

Your Share of Premium

Ohio

Aetna HealthFund­CDHP­ Allof Ohio

Aetna HealthFund­HDHP­ Allof Ohio

AultCare HMO ­HDHP­ Stark/Carroll/Holmes/Tuscarawas/Wayne Co.

Blue Crossand BlueShieldService Benefit Plan ­HDHP­ Ohio

Humana CoverageFirst ­CDHP­ Cincinnati/Dayton Area

Paramount Health Care ­HDHP­ Northwest/North Central Ohio

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Cleveland

and ColumbusAreas

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Cleveland

and ColumbusAreas

Oklahoma

Aetna HealthFund­CDHP­ Mostof Oklahoma

Aetna HealthFund­HDHP­ Mostof Oklahoma

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Central

and North East Oklahoma

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Central

and North East Oklahoma

Oregon

Aetna HealthFund­CDHP­ Mostof Oregon

Aetna HealthFund­HDHP­ Mostof Oregon

UnitedHealthcare Insurance Company, Inc. ­HDHPMetro Portland/Salem/Corvalis/Eugene

UnitedHealthcare Insurance Company, Inc. ­CDHPMetro Portland/Salem/Corvalis/Eugene

Plan Name

877­459­6604

877­459­6604

330­363­6360

Localphone#

888­393­6765

800/462­3589

877­835­9861

877­835­9861

877­459­6604

877­459­6604

877­835­9861

877­835­9861

877­459­6604

877­459­6604

877­835­9861

877­835­9861

Telephone

Number

Enrollment Code Monthly Biweekly

221

224

3A4

114

L81

U24

E91

E94

221

224

E91

E94

221

224

E91

E94

Self

only

222

225

3A5

115

L82

U25

E92

E95

222

225

E92

E95

222

225

E92

E95

Self &

family

87.71

67.01

91.29

92.44

87.93

97.31

76.33

89.26

87.71

67.01

76.33

89.26

87.71

67.01

76.33

89.26

Self

only

201.72

146.75

182.91

216.48

202.24

227.00

170.52

197.59

201.72

146.75

170.52

197.59

201.72

146.75

170.52

197.59

Self &

family

40.48

30.93

42.13

42.66

40.58

44.91

35.23

41.20

40.48

30.93

35.23

41.20

40.48

30.93

35.23

41.20

Self

only

93.10

67.73

84.42

99.91

93.34

104.77

78.70

91.19

93.10

67.73

78.70

91.19

93.10

67.73

78.70

91.19

Self &

family

88
Ohio

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

AultCare HMO­ In­Network 83.34/166.67 $2,000/$4,000 $4,000/$8,000 20% 20% 20% Nothing 20%/20%/20%

AultCare HMO­ Out­Network 83.34/166.67 $4,000/$8,000 $8,000/$16,000 40% UCR 40% UCR 40% UCR 50% UCR 40%/40%/40%

BCBSService Benefit Plan $75/$150 $2,900/$5,800 $2,900/$5,800 Nothing Nothing Nothing Nothing Nothing

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

Paramount Health Care $41.67/$83.34 $1,500/$3,000 $1,500/$3,000Ded/Ded. + Coins.$0after DEDDed. /Ded + Coins. Nothing $0after DED

UnitedHealthcare­ In­Network $62.50/125 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$30/$50

UnitedHealthcare­ Out­Network $62.50/125 $3000/$6000 $6000/$12000 35% 35% 35% 35% $10/$30/$50

UnitedHealthcare­ In­Network $104.17/208.33 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$25/$40

UnitedHealthcare­ Out­Network $104.17/208.33 $2000/$4000 $4000/$8000 40% 40% 40% 40% $10/$25/$40

Oklahoma

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

UnitedHealthcare­ In­Network $62.50/125 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$30/$50

UnitedHealthcare­ Out­Network $62.50/125 $3000/$6000 $6000/$12000 35% 35% 35% 35% $10/$30/$50

UnitedHealthcare­ In­Network $104.17/208.33 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$25/$40

UnitedHealthcare­ Out­Network $104.17/208.33 $2000/$4000 $4000/$8000 40% 40% 40% 40% $10/$25/$40

Oregon

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

UnitedHealthcare­ In­Network $62.50/125 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$30/$50

UnitedHealthcare­ Out­Network $62.50/125 $3000/$6000 $6000/$12000 35% 35% 35% 35% $10/$30/$50

UnitedHealthcare­ In­Network $104.17/208.33 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$25/$40

UnitedHealthcare­ Out­Network $104.17/208.33 $2000/$4000 $4000/$8000 40% 40% 40% 40% $10/$25/$40

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Prescription

Drugs

Levels I, II, III

Benefit

Type

89
 
High Deductible and Consumer­Driven Health Plans

See page 64­65 for an explanation of the columns on these pages.

Your Share of Premium

Pennsylvania

Aetna HealthFund­CDHP­ Allof Pennsylvania

Aetna HealthFund­HDHP­ Allof Pennsylvania

HealthAmerica Pennsylvania­HDHP ­HDHP­ Southeastern PA

HealthAmerica Pennsylvania­HDHP ­HDHP­ Greater Pittsburgh Area

HealthAmerica Pennsylvania­HDHP ­HDHP­ Central PA

UPMC Health Plan ­HDHP­ Western Pennsylvania

Rhode Island

Aetna HealthFund­CDHP­ Allof Rhode Island

Aetna HealthFund­HDHP­ Allof Rhode Island

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Rhode Island

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Rhode Island

South Carolina

Aetna HealthFund­CDHP­ MostofSouth Carolina

Aetna HealthFund­HDHP­ MostofSouth Carolina

South Dakota

Aetna HealthFund­CDHP­ Rapid City/SiouxFallsAreas

Aetna HealthFund­HDHP­ Rapid City/SiouxFallsAreas

Plan Name

877­459­6604

877­459­6604

866­351­5946

866­351­5946

866­351­5946

888­876­2756

877­459­6604

877­459­6604

877­835­9861

877­835­9861

877­459­6604

877­459­6604

877­459­6604

877­459­6604

Telephone

Number

Enrollment Code Monthly Biweekly

221

224

9N1

Y61

YW1

8W4

221

224

E91

E94

221

224

221

224

Self

only

222

225

9N2

Y62

YW2

8W5

222

225

E92

E95

222

225

222

225

Self &

family

87.71

67.01

108.77

93.72

111.71

117.59

87.71

67.01

76.33

89.26

87.71

67.01

87.71

67.01

Self

only

201.72

146.75

245.71

231.45

252.89

252.44

201.72

146.75

170.52

197.59

201.72

146.75

201.72

146.75

Self &

family

40.48

30.93

50.20

43.25

51.56

54.27

40.48

30.93

35.23

41.20

40.48

30.93

40.48

30.93

Self

only

93.10

67.73

113.40

106.82

116.72

116.51

93.10

67.73

78.70

91.19

93.10

67.73

93.10

67.73

Self &

family

90
Pennsylvania

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

HealthAmerica­HDHP $52.09/$104.17 $1,250/$2,500 $4,000/$8,000 $15 None Nothing $15/$25 $5/$35/$50

HealthAmerica­HDHP $52.09/$104.17 $1,250/$2,500 $4,000/$8,000 $15 None Nothing $15/$25 $5/$35/$50

HealthAmerica­HDHP $52.09/$104.17 $1,250/$2,500 $4,000/$8,000 $15 None Nothing $15/$25 $5/$35/$50

UPMC Health Plan­ In­Network $104.17/$208.34 $2,500/$5,000 $4,000/$8,000 Nothing None Nothing Nothing $15/$30/$50

UPMC Health Plan­ Out­Network $104.17/$208.34 $2,500/$5,000 $5,500/$11,000 20% None 20% 20% N/A/N/A/N/A

Rhode Island

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

UnitedHealthcare­ In­Network $62.50/125 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$30/$50

UnitedHealthcare­ Out­Network $62.50/125 $3000/$6000 $6000/$12000 35% 35% 35% 35% $10/$30/$50

UnitedHealthcare­ In­Network $104.17/208.33 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$25/$40

UnitedHealthcare­ Out­Network $104.17/208.33 $2000/$4000 $4000/$8000 40% 40% 40% 40% $10/$25/$40

South Carolina

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

South Dakota

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Prescription

Drugs

Levels I, II, III

Benefit

Type

91
 
High Deductible and Consumer­Driven Health Plans

See page 64­65 for an explanation of the columns on these pages.

Your Share of Premium

Tennessee

Aetna HealthFund­CDHP­ Mostof Tennessee

Aetna HealthFund­HDHP­ Mostof Tennessee

Blue Crossand BlueShieldService Benefit Plan ­HDHP­ Tennesee

BluegrassFamily Health ­HDHP­ Knoxville/NashvilleAreas

Humana CoverageFirst ­CDHP­ NashvilleArea

Humana CoverageFirst ­CDHP­ MemphisArea

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Tennessee

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Tennessee

Texas

Aetna HealthFund­CDHP­ Mostof Texas

Aetna HealthFund­HDHP­ Mostof Texas

Humana CoverageFirst ­CDHP­ Houston Area

Humana CoverageFirst ­CDHP­ Dallas/Ft. Worth Area

Humana CoverageFirst ­CDHP­ Corpus ChristiArea

Humana CoverageFirst ­CDHP­ San AntonioArea

Humana CoverageFirst ­CDHP­ Austin Area

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Mostof Texas

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Mostof Texas

Plan Name

877­459­6604

877­459­6604

Localphone#

800­787­2680

888­393­6765

888­393­6765

877­835­9861

877­835­9861

877­459­6604

877­459­6604

888­393­6765

888­393­6765

888­393­6765

888­393­6765

888­393­6765

877­835­9861

877­835­9861

Telephone

Number

Enrollment Code Monthly Biweekly

221

224

114

KV1

BT1

L61

E91

E94

221

224

T21

T81

TP1

TU1

TV1

E91

E94

Self

only

222

225

115

KV2

BT2

L62

E92

E95

222

225

T22

T82

TP2

TU2

TV2

E92

E95

Self &

family

87.71

67.01

92.44

108.33

87.93

88.63

76.33

89.26

87.71

67.01

88.54

109.73

88.55

84.23

88.63

76.33

89.26

Self

only

201.72

146.75

216.48

216.66

202.24

203.87

170.52

197.59

201.72

146.75

203.65

252.41

203.68

193.75

203.86

170.52

197.59

Self &

family

40.48

30.93

42.66

50.00

40.58

40.90

35.23

41.20

40.48

30.93

40.86

50.64

40.87

38.88

40.90

35.23

41.20

Self

only

93.10

67.73

99.91

100.00

93.34

94.09

78.70

91.19

93.10

67.73

93.99

116.50

94.00

89.42

94.09

78.70

91.19

Self &

family

92
Tennessee

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

BCBSService Benefit Plan $75/$150 $2,900/$5,800 $2,900/$5,800 Nothing Nothing Nothing Nothing Nothing

BluegrassFamily Health­ In­Network $104.17/$208.34 $2,500/$5,000 $5,000/$7,500 Nothing Nothing Nothing Nothing $10/$20/$30/$30

BluegrassFamily Health­ Out­Network $104.17/$208.34 $5,000/$10,000 $10,000/$15,000 30% 30% 30% Ded/30% N/A/N/A/N/A

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

UnitedHealthcare­ In­Network $62.50/125 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$30/$50

UnitedHealthcare­ Out­Network $62.50/125 $3000/$6000 $6000/$12000 35% 35% 35% 35% $10/$30/$50

UnitedHealthcare­ In­Network $104.17/208.33 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$25/$40

UnitedHealthcare­ Out­Network $104.17/208.33 $2000/$4000 $4000/$8000 40% 40% 40% 40% $10/$25/$40

Texas

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

UnitedHealthcare­ In­Network $62.50/125 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$30/$50

UnitedHealthcare­ Out­Network $62.50/125 $3000/$6000 $6000/$12000 35% 35% 35% 35% $10/$30/$50

UnitedHealthcare­ In­Network $104.17/208.33 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$25/$40

UnitedHealthcare­ Out­Network $104.17/208.33 $2000/$4000 $4000/$8000 40% 40% 40% 40% $10/$25/$40

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Prescription

Drugs

Levels I, II, III

Benefit

Type

93
 
High Deductible and Consumer­Driven Health Plans

See page 64­65 for an explanation of the columns on these pages.

Your Share of Premium

Utah

Aetna HealthFund­CDHP­ Mostof Utah

Aetna HealthFund­HDHP­ Mostof Utah

Altius Health Plans ­HDHP­ Wasatch Front

Humana CoverageFirst ­CDHP­ SaltLake CityArea

Vermont

Aetna HealthFund­CDHP­ AllofVermont

Aetna HealthFund­HDHP­ AllofVermont

Virginia

Aetna HealthFund­CDHP­ MostofVirginia

Aetna HealthFund­HDHP­ MostofVirginia

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Virginia

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Virginia

Washington

Aetna HealthFund­CDHP­ Mostof Washington

Aetna HealthFund­HDHP­ Mostof Washington

KPS Health Plans ­HDHP­ Allof Washington

UnitedHealthcare Insurance Company, Inc. ­HDHPMostof Washington

UnitedHealthcare Insurance Company, Inc. ­CDHPMostof Washington

Plan Name

877­459­6604

877­459­6604

800­377­4161

888­393­6765

877­459­6604

877­459­6604

877­459­6604

877­459­6604

877­­835­9861

877­­835­9861

877­459­6604

877­459­6604

800/552­7114

877­835­9861

877­835­9861

Telephone

Number

Enrollment Code Monthly Biweekly

221

224

9K4

IA1

221

224

221

224

E91

E94

221

224

L14

E91

E94

Self

only

222

225

9K5

IA2

222

225

222

225

E92

E95

222

225

L15

E92

E95

Self &

family

87.71

67.01

99.71

87.93

87.71

67.01

87.71

67.01

76.33

89.26

87.71

67.01

79.78

76.33

89.26

Self

only

201.72

146.75

206.57

202.24

201.72

146.75

201.72

146.75

170.52

197.59

201.72

146.75

174.32

170.52

197.59

Self &

family

40.48

30.93

46.02

40.58

40.48

30.93

40.48

30.93

35.23

41.20

40.48

30.93

36.82

35.23

41.20

Self

only

93.10

67.73

95.34

93.34

93.10

67.73

93.10

67.73

78.70

91.19

93.10

67.73

80.46

78.70

91.19

Self &

family

94
Utah

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

Altius Health Plans $45.83/$91.66 $1,200/$2,400 $5,000/$10,000 $20 10% 10% Nothing $10/$25/$50

Humana CoverageFirst­ In­Network $83.33 $1,000/$2,000 Stated Copays $20 $250/dayx5 $150 $20/$35 $10/$30/$50

Humana CoverageFirst­ Out­Network N/A $3,000/$6,000 $4,000/$8,000 30% 30% 30% 30% $10+/$30+/$50+

Vermont

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

Virginia

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

UnitedHealthcare­ In­Network $62.50/125 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$30/$50

UnitedHealthcare­ Out­Network $62.50/125 $3000/$6000 $6000/$12000 35% 35% 35% 35% $10/$30/$50

UnitedHealthcare­ In­Network $104.17/208.33 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$25/$40

UnitedHealthcare­ Out­Network $104.17/208.33 $2000/$4000 $4000/$8000 40% 40% 40% 40% $10/$25/$40

Washington

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

KPS Health Plans­ In­Network $50/$100 $1,500/$3,000 $5,000/$10,000 20% None 20% Nothing upto$400 $10/$30/50%

KPS Health Plans­ Out­Network $50/$100 $1,500/$3,000 $5,000/$10,000 40% None 40% Not Covered Not Covered

UnitedHealthcare­ In­Network $62.50/125 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$30/$50

UnitedHealthcare­ Out­Network $62.50/125 $3000/$6000 $6000/$12000 35% 35% 35% 35% $10/$30/$50

UnitedHealthcare­ In­Network $104.17/208.33 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$25/$40

UnitedHealthcare­ Out­Network $104.17/208.33 $2000/$4000 $4000/$8000 40% 40% 40% 40% $10/$25/$40

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Prescription

Drugs

Levels I, II, III

Benefit

Type

95
 
High Deductible and Consumer­Driven Health Plans

See page 64­65 for an explanation of the columns on these pages.

Your Share of Premium

West Virginia

Aetna HealthFund­CDHP­ Mostof WestVirginia

Aetna HealthFund­HDHP­ Mostof WestVirginia

Wisconsin

Aetna HealthFund­CDHP­ Allof Wisconsin

Aetna HealthFund­HDHP­ Allof Wisconsin

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Wisconsin

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Wisconsin

Wyoming

Aetna HealthFund­CDHP­ Allof Wyoming

Aetna HealthFund­HDHP­ Allof Wyoming

Altius Health Plans ­HDHP­ Uinta County

Plan Name

877­459­6604

877­459­6604

877­459­6604

877­459­6604

877­835­9861

877­835­9861

877­459­6604

877­459­6604

800­377­4161

Telephone

Number

Enrollment Code Monthly Biweekly

221

224

221

224

E91

E94

221

224

9K4

Self

only

222

225

222

225

E92

E95

222

225

9K5

Self &

family

87.71

67.01

87.71

67.01

76.33

89.26

87.71

67.01

99.71

Self

only

201.72

146.75

201.72

146.75

170.52

197.59

201.72

146.75

206.57

Self &

family

40.48

30.93

40.48

30.93

35.23

41.20

40.48

30.93

46.02

Self

only

93.10

67.73

93.10

67.73

78.70

91.19

93.10

67.73

95.34

Self &

family

96
West Virginia

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

Wisconsin

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

UnitedHealthcare­ In­Network $62.50/125 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$30/$50

UnitedHealthcare­ Out­Network $62.50/125 $3000/$6000 $6000/$12000 35% 35% 35% 35% $10/$30/$50

UnitedHealthcare­ In­Network $104.17/208.33 $2000/$4000 $3000/$6000 $0 PV/10% SIC 10% 10% Nothing $10/$25/$40

UnitedHealthcare­ Out­Network $104.17/208.33 $2000/$4000 $4000/$8000 40% 40% 40% 40% $10/$25/$40

Wyoming

Aetna HealthFund­ In­Network $104.16/$208.33 $750/$1,500 $3,000/$6,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $104.16/208.33 $750/$1,500 $4,000/$8,000 40% 40% 40% Fund/Ded/40% 40%/40%/40%

Aetna HealthFund­ In­Network $62.50/$125 $1,500/$3,000 $4,000/$8,000 10% 10% 10% Nothing $10/$25/$40

Aetna HealthFund­ Out­Network $62.50/$125 $2,500/$5,000 $5,000/$10,000 30% 30% 30% Ded/30% 30%/30%/30%

Altius Health Plans $45.83/$91.66 $1,200/$2,400 $5,000/$10,000 $20 10% 10% Nothing $10/$25/$50

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Prescription

Drugs

Levels I, II, III

Benefit

Type

97
 
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98
 
Appendix F
 

FEDVIP Program Features
 

Waiting Periods

Dental ­ limited only to orthodontic services on most plans; for all other service, you may use

your benefits as soon as your coverage becomes effective. There are very few pre­existing

condition limitations.

Vision ­ no waiting period, you may use your benefits as soon as your coverage becomes

effective. There are no pre­existing condition limitations.

A Choice of Coverage

Choose between Self Only, Self Plus One or Self and Family.

Contributions

There are no Government contributions. The enrollee pays 100% of the premium.

Salary Deduction

You automatically pay your premium through a payroll deduction using pre­tax dollars;

employees cannot elect to waive this pre­tax option and annuitants are not eligible for this

option. When premium contributions are withheld on a pre­tax basis, Internal Revenue Service

(IRS) guidelines affect your ability to change coverage, i.e., you may cancel or change coverage

levels only during a FEDVIP Open Season. You may also make changes throughout the plan

year if a qualified life event occurs.

Annual Enrollment Opportunity

Each year, you may enroll or change your dental and/or vision plan enrollment. The Open

Season runs from the Monday of the second full work week in November through the Monday

of the second full work week in December. Other events allow for certain types of changes

throughout the year.

Continued Coverage

Eligibility for you or your family member may continue following your retirement or changes in

employment status.

Claim Dispute Resolution

The claim review process will differ among plans. Upon written request from the enrollee and

as a final option, the carrier will submit a dispute for resolution through a binding arbitration

process. OPM will not review nor resolve disputes regarding FEDVIP. Please see your plan

brochure for details.

99
Appendix G
 

FEDVIP Definitions
 

Coordination of Benefits (COB) – Under this rule, the FEHB plan is considered the primary payer and

pays first, while the FEDVIP plan is considered the secondary payer. Payment is coordinated under the

COB rule to ensure that no more than 100% of any claim is paid by both plans.

Eligible Dependents – Your spouse and unmarried dependent children under age 22. Under certain

circumstances, you may also continue coverage for a disabled child 22 years of age or older who is

incapable of self­support.

In­Network Services – Services provided by members of the plan’s provider network.

Nationwide Plan – A plan which provides services throughout the United States and around the world.

Out­of­Network Services – Services provided by health care professionals who are not a member of the

plan’s provider network.

Plan – The insurance company which participates in the FEDVIP program. Also called carrier.

Precertification – Also called predetermination. This is the procedure used by dental offices to

determine what services a plan will cover and how much will be paid before the service is rendered.

Provider – A licensed health care professional; for example: dentists, oral surgeons, optometrists and

ophthalmologists.

Provider Network – A group of health care providers who have a contract with a specific plan to

provide services at an agreed upon cost.

Qualifying Life Event (QLE) – An event that allows you to enroll, or if you are already enrolled, allows

you to change your enrollment outside of an Open Season. There is no QLE under FEDVIP which

allows for cancellation, except upon deployment to active military duty or transitions to certain agencies.

Regional Plan – A plan which provides services only in specified geographic regions.

Usual, Customary and Reasonable – A widely used method, which may vary from company to

company, for determining benefit reimbursement levels. The initials simply mean:

Usual. The fee that an individual dentist most frequently charges for a given dental service.

Customary. A fee determined by the insurance company based on the range of usual fees charged by

dentists in the same geographic area.

Reasonable. A fee which is justifiable considering special circumstances of the particular care rendered.

Waiting Period – The length of time a person must be covered under the plan before they are eligible

for certain benefits. For example, most plans have a 24 month waiting period for orthodontic benefits.

This means that you must be covered continuously by the same plan for 24 months before you are

eligible for orthodontic coverage.

100
Appendix H
 

FEDVIP Qualifying Life Events for Enrollment Changes
 

A qualifying life event (QLE) is an event that allows you to enroll, or if you are already enrolled, allows you to
 

change your enrollment outside of an Open Season.
 

The following chart lists the QLEs and the enrollment actions you may take.
 

Qualifying

Life Event

From

Not Enrolled

to

Enrolled

Increase

Enrollment

Type

Decrease

Enrollment

Type

Cancel Change

from

One Plan

to

Another

Acquiring an

eligible family

member

No Yes No No No

Losing a covered

family member No No Yes No No

Losing other

dental/vision

coverage (eligible

or covered person)

Yes Yes No No No

Moving out of

regional plan’s

service area

No No No No Yes

Going on active

military duty, nonpay status (you or

your spouse)

No No No Yes No

Return to pay

status from active

military duty

Yes No No No No

Annuity/

compensation

restored

Yes Yes Yes No No

The time frame for requestinga QLE change is from 31daysbefore to60daysafter the event. Thereare twoexceptions:

• There is notime limit forachangebasedon movingfrom aregionalplans servicearea;and

• You cannot requesta new enrollmentbasedon a QLE before the QLE occurs. you must make the change nolater than 60daysafter

the event.

Generally, enrollmentsandenrollment changes madebasedon a QLE are effectiveon the firstdayof thepayperiodfollowingtheone in

which BENEFEDSreceivesandconfirms the enrollmentor change. BENEFEDS will sendyou confirmation of your new coverage effectivedate.

BENEFEDSisasecure enrollment website sponsoredby OPM.

Cancelling an enrollment

You can cancel your enrollmentonlyduringtheannual Open Season, upon deployment toactive militaryduty,or transfers tocertain

agencies.An eligible family members coveragealsoends upon the effectivedateof the cancellation.

101
Appendix I
 

FEDVIP Plan Comparison Charts
 

This is a brief summary of the features of the dental and vision plans. Before making a final decision,

please read the plan brochures and provider directories thoroughly. All plans are not the same. All

benefits are subject to the definitions, limitations, copayments, annual maximums and exclusions set

forth in the individual plan brochures. Go to our website at www.opm.gov/insure/dentalvision to find the

rating region assigned to the area where you live and the related premium cost you will pay.

Reading the Chart:

The table on the following pages highlights the selected features/classes of dental and/or vision

services. Always consult plan brochures before making a decision. The chart does not show all of your

possible out­of­pocket costs.

Dental Insurance

The deductibles shown for the dental plans are the amount of covered expenses that you pay before

the plan begins to pay. Service Class refers to the level of benefits for each plan. The Service Classes

are listed below. Calendar year maximum refers to the annual amount of benefits that you can receive

per person.

Please Note: Most plans require that you be continuously enrolled in the same dental plan for the full

waiting period before accessing orthodontia services. There are no other waiting periods for services.

Dental plans provide a comprehensive range of services, including but not limited to the following:

• Class A (Basic) services, which include oral examinations, prophylaxis, diagnostic evaluations,

sealants and x­rays.

• Class B (Intermediate) services, which include restorative procedures such as fillings, prefabricated

stainless steel crowns, periodontal scaling, tooth extractions, and denture adjustments.

• Class C (Major) services, which include endodontic services such as root canals, periodontal

services such as gingivectomy, major restorative services such as crowns, oral surgery, bridges and

prosthodontic services such as complete dentures.

• Class D (Orthodontic) services with up to a 24­month waiting period for dependents up to age 19.

Please review the dental plans’ benefits material for detailed information on the benefits covered, costsharing requirements and provider directories.

Vision Insurance

Vision plans provide comprehensive eye examinations and coverage for lenses, frames and contact

lenses (in lieu of eye glasses). Other benefits, such as discounts on lasik surgery, may also be available.

Please review the vision plans’ benefits material for detailed information on the benefits covered, costsharing requirements and provider directories.

102
Appendix I

Federal Employees Dental and Vision Insurance Program (FEDVIP)

Nationwide and International Dental Plans Open to All

Plan Name

Telephone

&

Website

You pay: Calendar Year Maximum

Class

A

Class

B

Class

C

Class

D

Deductible

Aetna High 1­800­537­9384 0% 40% 60% 70% $0 $3,000per year (standardand high option)perperson in­network

(In­Network www.aetnafeds.com $2,000per year (standardand high option)perperson out­of­network

Benefits) $1,500lifetime maxperperson (orthodontic servicesonly)

24­month waitingperiodfororthodontiaservices

Aetna High 0% 40% 60% 70% $0

(Out­of­Network

Benefits)

GEHAStandard 1­877­434­2336 0% 45% 65% 50% $0 $3,500per year (high option)or

(In­Network www.gehadental.com $1,200per year (standard)perperson

Benefits) $1,500lifetime maxperperson (orthodontic servicesonly)

24­month waitingperiodfororthodontiaservices

GEHAStandard 0% 45% 65% 50% $0

(Out­of­Network

Benefits)

GEHA High 0% 20% 50% 50% $0

(In­Network

Benefits)

GEHA High 0% 20% 50% 50% $0

(Out­of­Network

Benefits)

MetLifeStandard 1­888­865­6854 0% 45% 65% 50% $0 $1,200standardoption in­networkannual non­orthodontic

(In­Network www.federaldental.metlife.com maximum perperson

Benefits) $600standardoption out­of­networkannual non­orthodontic

maximum perperson

MetLifeStandard 40% 60% 80% 50% $100/person $3,000 high option non­orthodontic maximum perperson $1,500

(Out­of­Network standardoption in­networklifetime maxperperson for

Benefits) orthodontics

$1,000standardoption out­of­networklifetime maxper

MetLife High 0% 30% 50% 50% $0 person fororthodontics

(In­Network There is nocalendar yeardeductible for Class D services

Benefits) 24­month waitingperiodfororthodontiaservices

MetLife High 10% 40% 60% 50% $50/person

(Out­of­Network

Benefits)

United Concordia 1­877­438­8224(Open Season) 0% 20% 50% 50% $0 $1,200per yearperperson

High 1­877­394­8224(General) $1,500lifetime maxperperson (orthodontic servicesonly)

www.uccifedvip.com Out­of­networkbenefits NOT provided

24­month waitingperiodfororthodontiaservices

Please Note: Out­of­Network Benefits – membersare responsible forpayingthedifferencebetween theplan’spaymentandthe non­networkprovider’sbilledcharges.

103
Appendix I

Federal Employees Dental and Vision Insurance Program (FEDVIP)

Regional Dental Plans Only Open to Persons Living in Specific Geographic Areas

You pay: Calendar Year Maximum

Plan Name

Telephone

&

Website

Class

A

Class

B

Class

C

Class

D Deductible

Humana/CompBenefits 1­877­692­2468 0% Flat Flat Flat $0 $10,000per yearperperson

High (Open toresidentsof www.MyCBFed.com Rate Rate Rate Unlimitedlifetimeorthodontic coverage

theSouthwestern, Out­of­networkbenefits NOT provided

Southeastern, Midwestern, Approx Approx Approx No waitingperiodfororthodontiaservices

and Mid­Atlantic states) 40% 54% 70%

(formerly CompBenefits)

GHI High 212­501­4444 0% 0% 0% 0% $50self/$150self & $1,200per yearperperson

(In­networkbenefits) www.ghi.com family/selfplusone $2,000lifetime maxperperson

Class B and Class C (orthodontic servicesonly)

(Open to NYand Northern There is nocalendar yeardeductible for

NJ residentsandpartsof ClassAand D services

CT and PA) Out­of­networkbenefitsavailable – paidat

the same in­network rate

GHI High

(Out­of­networkbenefits)

0% 0% 0% 0% 12­month waitingperiodfororthodontia

services

TripleS High 787­774­6060 0% 30% 60% / 50% 0% No maximum

(Open to Puerto Rico

residents)

787­749­4777

1­800­981­3241

TTY787­792­1370

30% $1,500lifetime maxperperson

(orthodontic servicesonly)

Out­of­networkbenefits NOT provided

TTY1­866­215­1999

www.ssspr.com

24­month waitingperiodfor

orthodontiaservices

Please Note: Out­of­Network Benefits – membersare responsible forpayingthedifferencebetween theplan’spaymentandthe non­networkprovider’sbilledcharges.

104
Appendix I
 

Federal Employees Dental and Vision Insurance Program (FEDVIP)
 

Nationwide and International Vision Plans Open to All

The table below highlights the selected features of available vision plans. Always consult plan brochures

before making a decision. The chart does not show all of your possible out­of­pocket costs.

Vision plans provide comprehensive eye examinations and coverage for lenses, frames and contact lenses (in

lieu of eye glasses). There are no deductibles or waiting periods. Other benefits such as discounts on lasik

surgery may also be available.

Plan Name

Frames Lenses Exams Copayments

Lens

Options Covered

Additional Features

FEP BlueVisiion

Standard

Every24

months

Every12

months

Every12

months

$0 Single

Conventional Bifocal

Conventional Trifocal

Breakage warranty;Laser vision correction discount; low vision

coverage.$130plus20% of remainingcost frameallowance.

Additional lensoptions covered with aco­pay.

Lenticular Out­of­networkbenefits NOT provided.

Flat rate reimbursement in limitedaccessareasand

internationally.

FEP BlueVision

High

Every12

months

Every12

months

Every12

months

$0 Single

Lined Bifocal

Lined Trifocal

Lenticular

Breakage warranty;Laser vision correction discount; low vision

coverage.$130plus20% of remainingcost frameallowance.

Additional lensoptions covered with aco­pay.

Out­of­networkbenefitsavailableatalower rate.

Flat rate reimbursement in limitedaccessareasand

internationally.

UnitedHealthcareVision

Plan (formerlySpectera)

Standard

Every12

months

Every12

months

Every12

months

$10exam/

$25 material

Single

Lined Bifocal

Lined Trifocal

Lenticular

Polycarbonate

Scratch­resistant coating

Low vision;prosthetic eye; vision therapy;Laser vision

correction discount.$130frameallowance.

Additional lensoption discounts.

Out­of­networkbenefitsavailable– paidatalower rate.

Flat rate reimbursement for international,out­of­networkand

limitedaccess services.

UnitedHealthcareVision

Plan (formerlySpectera)

High

Every12

months

Every12

months

Every12

months

$10exam/

$10 material

Single

Lined Bifocal

Lined Trifocal

Lenticular

Polycarbonate

Scratch­resistant coating

Tintedlenses

UVcoating

Low vision;prosthetic eye; vision therapy;Laser vision

correction discount.$130frameallowance.

Additional lensoption discounts.

Out­of­networkbenefitsavailable– paidatalower rate.

Flat rate reimbursement for international,out­of­networkand

limitedaccess services.

VSP (Vision Service

Plan)

Standard

Every12

months

Every12

months

Every12

months

$10exam/

$20 material

Single

Lined Bifocal

Lined Trifocal

Lenticular

Polycarbonate

Scratch­resistant coating

Laser vision correction discount. $120frameallowance.

Additional lensesoptions coveredatadiscount.

Out­of­networkbenefitsavailable – paidatalower rate.

Additional lensoption andcontact lens exam discounts.

Additionalprescription glassesandsunglassesdiscounts.

FSAFEDSpaperless reimbursementavailable.

VSP (Vision Service

Plan)

High

Every12

months

Every12

months

Every12

months

$10exam and

glasses

Single

Lined Bifocal

Lined Trifocal

Lenticular

Laser vision correction discount. $150frameallowance.

Out­of­networkbenefitsavailable – paidatalower rate.

Additional lensoption andcontact lens exam discounts.

Additionalprescription glassesandsunglassesdiscounts.

Polycarbonate FSAFEDSpaperless reimbursementavailable

Scratch­resistant coating

Anti­reflective coating

Lenses that transition tolight

UVcoating

Select tints

105
Appendix J
 

Federal Employees Dental and Vision Insurance Program (FEDVIP)
 

Dental Rating Regional Chart
 

Rating Areas

State State/ZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Comp Benefits GHI Triple­S

AK entire state 5 5 5 5 5 5 #N/A #N/A #N/A

AL 356­358 1 1 1 1 1 1 1 #N/A #N/A

AL restof state 2 1 1 1 1 1 1 #N/A #N/A

AR entire state 2 1 1 1 1 1 5 #N/A #N/A

AZ entire state 3 3 3 1 1 1 2 #N/A #N/A

CA 900­918,922­935 3 4 4 5 5 3 4 #N/A #N/A

CA 919­921 3 4 4 4 4 4 4 #N/A #N/A

CA 939­941,943­954 4 5 5 5 5 5 4 #N/A #N/A

CA restof state 4 4 4 5 5 4 4 #N/A #N/A

CA 942,956­958 4 4 4 4 4 4 4 #N/A #N/A

CO entire state 3 4 4 4 4 3 4 #N/A #N/A

CT 060­063 5 4 4 5 5 5 #N/A #N/A #N/A

CT 064­069 3 5 5 5 5 5 #N/A 1 #N/A

DC entire state 2 4 4 4 4 4 2 #N/A #N/A

DE entire state 2 3 3 3 3 2 #N/A #N/A #N/A

FL 327­328,347 2 2 2 1 1 1 2 #N/A #N/A

FL 330­334 2 4 4 3 3 3 2 #N/A #N/A

FL restof state 3 2 2 1 1 1 2 #N/A #N/A

GA 300­303,311 3 3 3 2 2 1 3 #N/A #N/A

GA restof state 4 2 2 1 1 1 5 #N/A #N/A

GU entire state 5 1 1 5 5 5 #N/A #N/A #N/A

HI entire state 4 3 3 4 4 5 #N/A #N/A #N/A

IA entire state 3 1 1 1 1 2 #N/A #N/A #N/A

ID entire state 4 2 2 1 1 2 #N/A #N/A #N/A

IL 600­608 2 3 3 4 4 3 1 #N/A #N/A

IL 620­622 2 2 2 1 1 1 1 #N/A #N/A

IL restof state 3 1 1 1 1 1 1 #N/A #N/A

IN 460­462 2 2 2 1 1 1 1 #N/A #N/A

IN 463­464 2 3 3 4 4 3 1 #N/A #N/A

IN restof state 3 1 1 1 1 2 1 #N/A #N/A

KS 660­662 1 2 2 1 1 2 1 #N/A #N/A

KS restof state 3 1 1 1 1 2 1 #N/A #N/A

KY 410 2 2 2 1 1 1 1 #N/A #N/A

KY restof state 1 1 1 1 1 1 1 #N/A #N/A

106
Appendix J
 

Federal Employees Dental and Vision Insurance Program (FEDVIP)
 

Dental Rating Regional Chart
 

Rating Areas

State State/ZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Comp Benefits GHI Triple­S

LA entire state 2 2 2 1 1 1 5 #N/A #N/A

MA 101­013 5 4 4 5 5 5 #N/A #N/A #N/A

MA restof state 5 4 4 5 5 5 #N/A #N/A #N/A

MD 206­218 2 4 4 4 4 4 2 #N/A #N/A

MD 219 2 3 3 3 3 2 #N/A #N/A #N/A

MD restof state 2 2 2 2 2 4 #N/A #N/A #N/A

ME entire state 5 3 3 2 2 3 #N/A #N/A #N/A

MI 480­485 3 3 3 3 3 2 #N/A #N/A #N/A

MI restof state 3 2 2 2 2 3 #N/A #N/A #N/A

MN 550­555 2 3 3 4 4 3 #N/A #N/A #N/A

MN restof state 3 2 2 2 2 2 #N/A #N/A #N/A

MO 630­633 2 2 2 1 1 1 1 #N/A #N/A

MO 640­641 1 2 2 1 1 2 1 #N/A #N/A

MO restof state 3 1 1 1 1 1 1 #N/A #N/A

MS entire state 2 1 1 1 1 1 5 #N/A #N/A

MT entire state 4 2 2 1 1 1 #N/A #N/A #N/A

NC entire state 4 2 2 1 1 1 5 #N/A #N/A

ND entire state 3 1 1 1 1 2 #N/A #N/A #N/A

NE entire state 1 1 1 1 1 2 #N/A #N/A #N/A

NH entire state 5 4 4 5 5 5 #N/A #N/A #N/A

NJ 080­084 2 3 3 3 3 2 #N/A #N/A #N/A

NJ restof state 3 5 5 5 5 5 #N/A 1 #N/A

NM entire state 3 3 3 1 1 1 #N/A #N/A #N/A

NV 897 4 4 4 4 4 4 #N/A #N/A #N/A

NV restof state 2 3 3 2 2 2 #N/A #N/A #N/A

NY 004,005 3 5 5 5 5 5 #N/A 1 #N/A

NY 100­119,124­126 3 5 5 5 5 5 #N/A 1 #N/A

NY restof state 4 2 2 2 2 3 #N/A 1 #N/A

OH 430­432 2 2 2 1 1 2 3 #N/A #N/A

OH 440­443 2 2 2 1 1 3 1 #N/A #N/A

OH 450­452 2 2 2 1 1 1 1 #N/A #N/A

OH 453­455 2 2 2 1 1 2 1 #N/A #N/A

OH restof state 3 1 1 1 1 1 1 #N/A #N/A

OK entire state 2 2 2 1 1 1 3 #N/A #N/A

OR 970­973 4 3 3 4 4 5 #N/A #N/A #N/A

OR restof state 5 3 3 3 3 4 #N/A #N/A #N/A

107
Appendix J
 

Federal Employees Dental and Vision Insurance Program (FEDVIP)
 

Dental Rating Regional Chart
 

Rating Areas

State State/ZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Comp Benefits GHI Triple­S

PA 150­154,156,160 1 1 1 1 1 1 #N/A #N/A #N/A

PA 183 3 5 5 5 5 5 #N/A 1 #N/A

PA 189­194 2 3 3 3 3 2 #N/A #N/A #N/A

PA restof state 3 1 1 1 1 1 #N/A #N/A #N/A

PR entire state 3 1 1 1 1 1 #N/A #N/A 1

RI entire state 5 4 4 5 5 5 #N/A #N/A #N/A

SC entire state 4 2 2 1 1 1 5 #N/A #N/A

SD entire state 3 1 1 1 1 2 #N/A #N/A #N/A

TN entire state 1 2 2 1 1 1 1 #N/A #N/A

TX 750­753,760­762 2 3 3 1 1 1 3 #N/A #N/A

TX 770­775 2 3 3 1 1 1 3 #N/A #N/A

TX restof state 2 2 2 1 1 1 3 #N/A #N/A

UT entire state 2 1 1 1 1 2 1 #N/A #N/A

VA 201,220­226 2 4 4 4 4 4 2 #N/A #N/A

VA 230­232,238 3 2 2 1 1 2 5 #N/A #N/A

VA restof state 3 2 2 1 1 1 4 #N/A #N/A

VI entire state overseas 1 1 5 5 5 #N/A #N/A #N/A

VT entire state 5 2 2 2 2 3 #N/A #N/A #N/A

WA 980­985 5 5 5 5 5 5 #N/A #N/A #N/A

WA 986 4 3 3 4 4 5 #N/A #N/A #N/A

WA restof state 5 4 4 4 4 4 #N/A #N/A #N/A

WI 530­534 3 2 2 2 2 3 #N/A #N/A #N/A

WI 540 2 3 3 4 4 3 #N/A #N/A #N/A

WI restof state 3 2 2 2 2 2 #N/A #N/A #N/A

WV entire state 4 2 2 1 1 1 3 #N/A #N/A

WY entire state 4 1 1 1 1 2 #N/A #N/A #N/A

108
Appendix K
 

Federal Employees Dental and Vision Insurance Program (FEDVIP)
 

Premium Rate Charts
 

Nationwide Dental Rates

Please note: Rating areas for each carrier are not the same for all plans. Please refer to Appendix J to determine your

specific region.

Biweekly Premium Monthly Premium

Plan Name Option Rating

Region Self Only Self

Plus One

Self & Family Self Only Self

Plus One

Self & Family

Aetna PPO High 1 $12.85 $25.70 $38.55 $27.84 $55.68 $83.53

(In and Out­of­Networkbenefits) 2 $14.11 $28.24 $42.35 $30.57 $61.19 $91.76

3 $15.00 $30.02 $45.02 $32.50 $65.04 $97.54

4 $16.53 $33.06 $49.59 $35.82 $71.63 $107.45

5 $17.92 $35.85 $53.77 $38.83 $77.68 $116.50

GEHA PPO Standard 1 $9.37 $18.75 $28.12 $20.30 $40.63 $60.93

(In and Out­of­Networkbenefits) 2 $10.27 $20.53 $30.80 $22.25 $44.48 $66.73

3 $11.62 $23.23 $34.85 $25.18 $50.33 $75.51

4 $12.52 $25.04 $37.56 $27.13 $54.25 $81.38

5 $13.87 $27.74 $41.61 $30.05 $60.10 $90.16

GEHA PPO High 1 $13.06 $26.12 $39.18 $28.30 $56.59 $84.89

(In and Out­of­Networkbenefits) 2 $14.34 $28.66 $43.00 $31.07 $62.10 $93.17

3 $16.22 $32.45 $48.67 $35.14 $70.31 $105.45

4 $17.49 $34.99 $52.48 $37.90 $75.81 $113.71

5 $19.40 $38.79 $58.19 $42.03 $84.05 $126.08

MetLife PPO Standard 1 $8.41 $16.84 $25.26 $18.22 $36.49 $54.73

(In and Out­of­Networkbenefits) 2 $9.08 $18.16 $27.24 $19.67 $39.35 $59.02

3 $10.02 $20.04 $30.06 $21.71 $43.42 $65.13

4 $11.11 $22.21 $33.32 $24.07 $48.12 $72.19

5 $12.17 $24.35 $36.53 $26.37 $52.76 $79.15

MetLife PPO High 1 $14.05 $28.11 $42.15 $30.44 $60.91 $91.33

(In and Out­of­Networkbenefits) 2 $15.70 $31.41 $47.11 $34.02 $68.06 $102.07

3 $17.07 $34.14 $51.21 $36.99 $73.97 $110.96

4 $18.45 $36.90 $55.34 $39.98 $79.95 $119.90

5 $20.64 $41.27 $61.91 $44.72 $89.42 $134.14

United Concordia PPO High 1 $12.60 $25.18 $37.78 $27.30 $54.56 $81.86

(In­Networkbenefitsonly except 2 $14.41 $28.82 $43.22 $31.22 $62.44 $93.64

for emergency services) 3 $15.63 $31.23 $46.86 $33.87 $67.67 $101.53

4 $16.84 $33.65 $50.50 $36.49 $72.91 $109.42

5 $18.65 $37.29 $55.93 $40.41 $80.80 $121.18

109
Appendix K
 

Federal Employees Dental and Vision Insurance Program (FEDVIP)
 

Premium Rate Charts
 

Regional Dental Rates

Please note: Rating areas for each carrier are not the same for all plans. Please refer to Appendix J to determine

your specific region.

Plan Name Option Rating

Region

Biweekly Premium Monthly Premium

Self Only Self

Plus One

Self & Family Self Only Self

Plus One

Self & Family

Humana/CompBenefits

GHI PPO

TripleS PPO

High

High

High

1

2

3

4

5

1

1

$10.00

$10.26

$10.82

$14.05

$14.80

$17.35

$4.51

$20.00

$20.51

$21.65

$28.10

$29.60

$34.69

$9.02

$30.00

$30.77

$32.47

$42.14

$44.40

$52.04

$11.93

$21.67

$22.23

$23.44

$30.44

$32.07

$37.59

$9.77

$43.33

$44.44

$46.91

$60.88

$64.13

$75.16

$19.54

$65.00

$66.67

$70.35

$91.30

$96.20

$112.75

$25.85

International Dental Rates

Please note: International premium rates are not regionally based.

Plan Name

Biweekly Premium Monthly Premium

Self Only Self

Plus One

Self & Family Self Only Self

Plus One

Self & Family

Aetna

GEHAStandard

GEHA High

MetLifeStandard

MetLife High

United Concordia

$19.13

$9.37

$13.06

$12.17

$20.64

$18.65

$38.28

$18.75

$26.12

$24.35

$41.27

$37.29

$57.41

$28.12

$39.18

$36.53

$61.91

$55.93

$41.45

$20.30

$28.30

$26.37

$44.72

$40.41

$82.94

$40.63

$56.59

$52.76

$89.42

$80.80

$124.39

$60.93

$84.89

$79.15

$134.14

$121.18

110
Appendix K
 

Federal Employees Dental and Vision Insurance Program (FEDVIP)
 

Premium Rate Charts
 

Nationwide Vision Rates

Plan Name Telephone &

Website

Plan

Option

Biweekly Premium Monthly Premium

Self Only Self

Plus One

Self & Family Self Only Self

Plus One

Self & Family

FEP BlueVision

UnitedHealthcareVision

Plan (formerlySpectera)

VSP (Vision Service Plan)

1­888­550­2583

fepblue.org

1­866­249­1999

unitedhealthcarevisionplan.com

1­800­807­0764

choosevsp.com

Standard

High

Standard

High

Standard

High

$4.00

$5.00

$2.94

$3.93

$3.84

$5.39

$8.00

$10.00

$5.76

$7.67

$7.68

$10.78

$12.00

$15.00

$8.56

$11.43

$11.52

$16.17

$8.67

$10.83

$6.37

$8.52

$8.32

$11.68

$17.33

$21.67

$12.48

$16.62

$16.64

$23.36

$26.00

$32.50

$18.55

$24.77

$24.96

$35.04

International Vision Rates
 

Plan Name Telephone &

Website

Plan

Option

Biweekly Premium Monthly Premium

Self Only Self

Plus One

Self & Family Self Only Self

Plus One

Self & Family

FEP BlueVision

UnitedHealthcareVision

Plan (formerlySpectera)

VSP (Vision Service Plan)

1­888­550­2583

fepblue.org

1­866­249­1999

unitedhealthcarevisionplan.com

1­800­807­0764

choosevsp.com

Standard

High

Standard

High

Standard

High

$4.00

$5.00

$2.94

$3.93

$3.84

$5.39

$8.00

$10.00

$5.76

$7.67

$7.68

$10.78

$12.00

$15.00

$8.56

$11.43

$11.52

$16.17

$8.67

$10.83

$6.37

$8.52

$8.32

$11.68

$17.33

$21.67

$12.48

$16.62

$16.64

$23.36

$26.00

$32.50

$18.55

$24.77

$24.96

$35.04

111
Summary Information
 

New Hires

Can Enroll

Federal Benefits Open

Season

How to Enroll OPM’s Program Website

FEHB Within 60 days

from new hire

date

Annual –

November 10 to

December 8, 2008

Varies by agency;

automated enrollment

or via SF 2809

www.opm.gov/insure/health

FEDVIP Within 60 days

from new hire

date

Annual –

November 10 to

December 8, 2008

Go to

www.BENEFEDS.com

or call 1­877­888­3337

www.opm.gov/insure/dental

www.opm.gov/insure/vision

FSAFEDS Within 60 days

from new hire

date

Annual –

November 10 to

December 8, 2008

Go to

www.FSAFEDS.com or

call 1­877­372­3337

www.opm.gov/insure/pretax/fsa

FEGLI Within 31 days

from new hire

date for optional

insurance;

automatically

enrolled in Basic

insurance

until you take

action to cancel

No annual

Open Season

Varies by agency;

automated enrollment

or via SF 2817 for new

hires

Others provide

medical information

on SF 2822

www.opm.gov/insure/life

FLTCIP Apply (not

necessarily enroll)

within 60 days

from new hire

date with

abbreviated

underwriting

No annual

Open Season

Go to

www.LTCFEDS.com or

call 1­800­582­3337 www.opm.gov/insure/ltc

112