Introducing the 2009
 Guide to

Federal Benefits

For TCC and Former Spouse Enrollees/

Individuals Eligible To Enroll For:

• Temporary Continuation of Coverage (TCC);

• Coverage under the Spouse Equity Provisions of

FEHB Law or similar statutes providing coverage

to former spouses.

Center for RI 70 ­5

Retirement Revised November 2008 and

Insurance Services
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c2
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

i
Introduction to Federal Benefits and This Guide

Enrollment in the Federal Employees Health Benefits (FEHB) Program can provide

important insurance coverage to protect you and your family and/or, in some cases, offer

tax advantages that reduce the burden of paying for some health products and services,

or dependent or elder care services.

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

to you as a Temporary Continuation of Coverage (TCC) or Former Spouse enrollee under

the Federal Employees Health Benefits Program, and assist you in making informed choices

about benefits.

Additional Information

You will find references to websites or other locations to obtain more detailed information.

We encourage you to access these sites to become a more educated decision­maker and

consumer of this Federal benefit program.

ii
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.

iii
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

iv
Table of Contents

Page:
 

Eligibility Requirements ........................................................................................................................................................ 1
 

Federal Employees Health Benefits (FEHB) Program .......................................................................................................... 2
 

Appendix A: FEHB Program Features ................................................................................................................................ 4
 

Appendix B: Choosing an FEHB Plan ................................................................................................................................ 5
 

Appendix C: Qualifying Life Events that May Permit a Change in Your FEHB Enrollment .......................................... 10
 

Appendix D: Member Survey Results ................................................................................................................................ 12
 

Appendix E: FEHB Plan Comparison Charts .................................................................................................................... 13
 

• Fee­for­Service .......................................................................................................................................................... 14
 

• Health Maintenance Organization Plans and Plans Offering a Point­of­Service Product ................................ 19
 

• High Deductible and Consumer­Driven ................................................................................................................ 44
 

v
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vi
 
Eligibility Requirements

These individuals are eligible to enroll in the FEHB Program but do not receive a Government contribution

toward the cost of their enrollment.

Individuals eligible for temporary continuation of

coverage (TCC), including:

• former employees whose FEHB coverage ended

because they separated from service, unless they were

separated for gross misconduct, including employees

who are not eligible to continue FEHB into retirement;

• children who lose FEHB coverage

under a family enrollment; and

• former (divorced) spouses who are not

eligible for FEHB coverage under the

Spouse Equity provisions of FEHB law

because they have remarried before

age 55 or are not entitled to a portion

of the Federal employee’s annuity or a

former spouse survivor annuity.

You may voluntarily cancel your

enrollment at any time. However, once

your cancellation takes effect, you cannot reenroll. You

will not be entitled to a 31­day extension of coverage for

conversion to a non­group (private) policy. Family

members who lose coverage upon your cancellation

may enroll only if they are eligible in their own right as

Federal employees or annuitants.

If your TCC enrollment terminates because you acquire

other FEHB coverage, and that coverage ends before

your original TCC eligibility period ends, you may

reenroll for the time remaining until your original TCC

ending date.

Note: The office that maintained the other FEHB

enrollment can advise you on your eligibility for a new

TCC enrollment period.

Strict time limits for electing TCC apply. As early

as possible before (or after) the qualifying event for TCC

occurs, contact the employee’s human resources office

or the annuitant’s retirement system to get more facts

about the requirements for electing coverage.

Former (divorced) spouses eligible to enroll under

the Spouse Equity Provisions of FEHB Law or similar

statutes. If you are the spouse of a Federal employee

Do not cancel

your enrollment

before reading

this section.

or annuitant and lose FEHB coverage because of

divorce, you may elect FEHB coverage – under certain

circumstances. Contact the employee’s human resources

office or the annuitant’s retirement system for the

requirements for electing coverage.

Former spouses enrolled under the Spouse Equity

Provisions of FEHB Law or similar statute

who cancel their enrollment cannot

reenroll as a former spouse unless they

cancel because they acquire other

coverage under the FEHB Program and

that coverage ends.

You may suspend your FEHB enrollment

because you are enrolling in one of the

following programs:

•	 A Medicare Advantage health plan;

•	 Medicaid or similar State­sponsored program of

medical assistance for the needy;

•	 TRICARE (including Uniformed Services Family

Health Plan or TRICARE for Life);

•	 CHAMPVA; or

•	 Coverage as a Peace Corps volunteer.

For more information on how to suspend your FEHB

enrollment, contact the human resources office or

retirement system that handles your account.

Time limitations and other restrictions apply. For

instance, you must submit documentation that you are

suspending FEHB for one of the reasons stated above

in case you wish to reenroll in the FEHB Program at a

later time.

If you had suspended FEHB coverage for one of these

reasons (and had submitted the required documentation)

but now want to enroll in the FEHB Program again, you

may enroll during Open Season. You may reenroll

outside of Open Season only if you involuntarily lose

coverage under one of these programs. For more

information on enrolling in the FEHB Program, contact

your human resources office or retirement system.

1
•

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 eligible employees, retirees and their dependents. Temporary

Continuation of Coverage (TCC) is available to eligible former employees and former dependents of

employees or retirees for a limited period. Spouse Equity coverage is available to certain former

spouses of employees or retirees as long as they remain eligible. You can choose from among fee­forservice, health maintenance organizations, point­of­service products, high deductible, and consumer

driven health plans.

Key FEHB Program 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.

• Enrollment changes can only be made during Open Season or if you experience a qualifying
 

life event.
 

• 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 enrollee;

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

Note: A former spouse’s eligible family members are limited to children of both the employee or

annuitant and the former spouse.

How much does it cost?

Under Spouse Equity coverage, you pay the total monthly premium, that is, both the enrollee and

Government shares. Under TCC, you pay the total monthly premium plus a 2 percent administrative charge.

The charts in Appendix E provide cost information for all plans in the FEHB Program.

Am I eligible to enroll?

Individuals eligible for TCC include:

• former employees whose FEHB coverage ended because they separated from service, unless they

were separated for gross misconduct. This includes employees who are not eligible to continue

FEHB into retirement;

• children who lose FEHB coverage under a self and family enrollment because they are no longer

considered eligible family members; and

2
Federal Employees Health Benefits (FEHB) Program

• former (divorced) spouses who are not eligible for FEHB coverage under the Spouse Equity
 

provisions of FEHB law because they have remarried before age 55 or are not entitled to a
 

portion of the Federal employee’s annuity or a former spouse survivor annuity.
 

Former (divorced) spouses eligible to enroll under the Spouse Equity provisions of FEHB law

or similar statutes. If you are the spouse of a Federal employee or annuitant and lose FEHB

coverage because of divorce, you may elect FEHB coverage – under certain circumstances. Contact

the employee’s human resources office or the annuitant’s retirement system for the requirements

for electing coverage.

When can I enroll?

Individuals eligible for TCC generally must enroll within 60 days after the qualifying event

permitting enrollment, or after receiving notice of eligibility, whichever is later. However, the

opportunity to elect TCC ends 60 days after the qualifying event if: (1) you do not notify your human

resources office or retirement system within 60 days of your child’s loss of coverage, or (2) you or

your former spouse do not notify your human resources office or retirement system within 60 days of

your divorce.

Former spouses under the Spouse Equity provisions generally must apply within 60 days after the

dissolution of the marriage. However, if a retiring employee elects to provide a former spouse annuity

or insurable interest annuity for the former spouse, the former spouse must apply within 60 days after

OPM’s notice of eligibility for FEHB. Former spouses may enroll any time after an employee’s or

retiree’s employing office establishes eligibility.

How do I enroll?

You must contact the employee’s human resources office or the retiree’s retirement system to enroll.

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

• In the case of a former employee, TCC ends on the date that is 18 months after the date of

separation.

• Children who lose coverage because they are no longer dependent, and former spouses not

eligible for coverage under the Spouse Equity provisions, may carry the enrollment for 36

months from the time they cease being an eligible family member for FEHB purposes.

• A TCC enrollee may cancel the enrollment at any time. However, once the cancellation takes

effect, the enrollee cannot reenroll – the cancellation is final.

• Former spouses enrolled under the Spouse Equity provisions may suspend their FEHB

enrollment because they are enrolling in one of these programs: A Medicare Advantage health

plan; Medicaid or similar State­sponsored program of medical assistance for the needy; TRICARE

(including Uniformed Services Family Health Plan or TRICARE for Life); CHAMPVA; or coverage

as a Peace Corps volunteer. For more information on how to suspend your FEHB enrollment,

contact the human resources office or retirement system that handles your account.

How do I get more information about this Program?

Visit FEHB on­line at www.opm.gov/insure/health for more information about Temporary

Continuation of Coverage and the Spouse Equity provisions.

3
Appendix A
 

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. Choose between Self Only or Self and Family.

• Group Benefits.	 Under Spouse Equity coverage, you pay the total monthly premium. Under

TCC, you pay the total monthly premium plus a 2 percent administrative charge.

• A Choice of Plans and Options.	 Select from Fee­for­Service (with the option of a Preferred

Provider Organization), Health Maintenance Organization, Point­of­Service plans, ConsumerDriven Plans, or High Deductible Health Plans.

• Annual Enrollment Opportunity.	 Each year you can enroll or change your health 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.

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

following your retirement, divorce or death. See your human resources office or retirement

system for more information.

• Coverage after FEHB Ends.	 You or your family members may be eligible for conversion to

non­group (private) coverage when FEHB coverage ends. See your human resources office for

more information.

• Consumer Protections.	 Go to www.opm.gov/insure/health/consumers to: see your appeal

rights to OPM if you and your plan have a dispute over a claim; read the Patients’ Bill of Rights

and the FEHB Program; and learn about your privacy protections when it comes to your medical

information.

4
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)

5
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

Prescription drugs

Maximum out­ofpocket limit for year

Durable medical

equipment

Preventive care

Maternity care

Well child care

Routine physicals

TOTAL COST

6
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

7
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

8
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, hospitals, and medical practitioners 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.

9
Appendix C
 

Qualifying Life Events (QLEs)
 

that May Permit a Change in Your FEHB Enrollment
 

(for Former Spouses under Spouse Equity provisions)
 

Qualifying Life Events are those events that permit individuals to change their health benefits

enrollment outside of the annual Open Season period. Below is a brief list of the more common

qualifying life events for Former Spouses under the Spouse Equity provisions. (Note: Former

spouses may change to Self and Family only if family members are also eligible family members of

the employee or annuitant.) Be aware that time limits apply for requesting changes. A complete

listing of qualifying life events can be found at www.opm.gov/forms/pdf_fill/sf2809.pdf. For more

details about these and other qualifying life events, contact the human resources office of your

employing agency or retirement system.

From Not Enrolled

to Enrolled

From Self Only to

Self and Family

From One Plan or

Option to Another

Change in family status based on

addition of family members who

are also eligible family members

of the employee or annuitant.

No Yes Yes

Former spouse or eligible child

loses FEHB coverage due to

termination, cancellation, or

change to Self Only of the

covering enrollment.

Yes Yes Yes

On becoming eligible for

Medicare. (This change may be

made only once in a lifetime.)

Not

Applicable

No Yes

Enrolled former spouse or eligible

child loses coverage under

another group insurance plan, for

example:.

• Loss of coverage under

another federally­sponsored

health benefits program;

• Loss of coverage under a

non­Federal health plan

Not

Applicable

Yes Yes

10
Appendix C
 

Qualifying Life Events (QLEs)
 

that May Permit a Change in Your FEHB Enrollment
 

(for Temporary Continuation of Coverage for Eligible Former Employees,
 

Former Spouses, and Children)
 

Below is a brief list of the more common qualifying life events for Temporary Continuation of

Coverage (TCC) for Eligible Former Employees, Former Spouses, and Children. Be aware

that time limits apply for requesting changes. A complete listing of qualifying life events can be

found at www.opm.gov/forms/pdf_fill/sf2809.pdf. For more details about these and other

qualifying life events, contact the human resources office of your employing agency or retirement

system.

From Not Enrolled

to Enrolled

From Self Only to

Self and Family

From One Plan or

Option to Another

Change in family status (except

former spouse): for example,

marriage, birth or death of family

member, adoption, legal

separation, or divorce

No Yes Yes

On becoming eligible for

Medicare

Not

Applicable

No Yes

Change in family status of former

spouse, based on addition of

family members who are eligible

family members of the employee

or annuitant.

No Yes Yes

11
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 wanted?

• 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 your health plan’s customer service department give you

the information or help you needed? How often did your health plan’s customer service staff

treat you with courtesy and respect? 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).

12
Appendix E
 

FEHB Plan Comparison Charts
 

Nationwide Fee­for­Service Plans

(Pages 14 through 17)

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 resources office first.

13
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

Total

Monthly

Premium

102% of

Total

Monthly

Premium

Self

only

Self &

family

Self

only

Self &

family

Self

only

Self &

family

APWU Health Plan (APWU) ­high 800­222­2798 471 472 428.72 969.37 437.29 988.76

Blue Crossand BlueShieldService Benefit Plan (BCBS) ­std Localphone# 104 105 489.32 1120.47 499.11 1142.88

Blue Crossand BlueShieldService Benefit Plan (BCBS) ­basic Localphone# 111 112 369.76 865.93 377.16 883.25

GEHA Benefit Plan (GEHA) ­high 800­821­6136 311 312 535.49 1165.45 546.20 1188.76

GEHA Benefit Plan (GEHA) ­std 800­821­6136 314 315 297.05 675.09 302.99 688.59

Mail Handlers Benefit Plan (MH) ­std 800­410­7778 454 455 466.96 1042.64 476.30 1063.49

Mail Handlers Benefit Plan Value (MHV) 800­410­7778 414 415 186.59 444.88 190.32 453.78

NALC ­high 888­636­6252 321 322 459.68 1008.58 468.87 1028.75

SAMBA­high 800­638­6589 441 442 549.36 1293.76 560.35 1319.64

SAMBA­std 800­638­6589 444 445 409.85 936.02 418.05 954.74

Association Benefit Plan (ABP) ­high

Plan Name: Open Only to Specific Groups

800­634­0069 421 422 459.98 1059.61 469.18 1080.80

Foreign Service Benefit Plan (FS) ­high 202­833­4910 401 402 419.49 1036.77 427.88 1057.51

Panama CanalArea Benefit Plan (PCABP) ­high 800­424­8196 431 432 397.32 829.34 405.27 845.93

Rural Carrier Benefit Plan (Rural) ­high 800­638­8432 381 382 516.73 1051.33 527.06 1072.36

14
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. 

Deductible

Per Person

Medical­Surgical – You Pay

Copay ($)/Coinsurance (%)

Hospital

Inpatient

Doctors Prescription Drugs

Level II/Level III Mail Order

Discounts

25%/25% Yes

50%/50% Yes

30%/30% Yes

45%+/45%+ Yes

$35/$45or50% No

25%/N/A Yes

25%+/N/A Yes

50%/50% Yes

50%+/50%+ Yes

$40/$60 Yes

50%/50% Yes

50%/50% Yes

Not Covered No

25%/25% Yes

50%+/50%+ Yes

$30/$45 Yes

$30/$45 Yes

25% $60max/35% $90max Yes

25% $60max/35% $90max Yes

$30/30% or$45 Yes

$30/30% or$45 Yes

25%/$25min/30%/$40min Yes

25%/$25min/30%/$40min Yes

40%/40% No

40%/40% No

30%/30% Yes

30%/30% Yes

Plan

APWU ­high

BCBS­std

BCBS­basic

GEHA­high

GEHA­std

MH ­std

MH Value

NALC ­high

SAMBA­high

SAMBA­std

ABP

FS

PCABP

Rural

Benefit
 

Type
 

PPO $275 None None $18 10% 10% $8

Non­PPO $500 None $300 30%+diff. 30%+diff. 30% 50%

PPO $300 None $200 $20 15% $200 20%

Non­PPO $300 None $300 + 30% 30% $300 + 30% 45% +

PPO None None $100/dayx5 $25 $100 Nothing $10

PPO $350 None $100 $20 10% Nothing $5

Non­PPO $350 None $300 25% 25% Nothing $5

PPO $350 None None $10 15% 15% $5

Non­PPO $350 None None 35% 35% 35% $5

PPO $350 None $200 $20/Nothing 10% Nothing $10

Non­PPO $500 None $400 30% 30% 30% 50%

PPO $500 None None $30 20% 20% $10

Non­PPO $800 Not Covered None 40% 40% 40% Not Covered

PPO $250 None $100 $15 10% Nothing 25%

Non­PPO $300 $25 $100 25% 25% 30% 50%+

PPO $250 None $200 $20/$0 10% Nothing $10

Non­PPO $250 None $300 30% 30% 30% $10

PPO $300 None $200 $20/$0 15% Nothing $10

Non­PPO $300 None $300 30% 30% 30% $10

PPO $300 None $150 $10 10% Nothing $5

Non­PPO $300 None $350 30% 30% Nothing $5

PPO $300 None Nothing 10% 10% Nothing $10

Non­PPO $300 None $200 30% 30% 20% $10

POS None None $50 $10 Nothing Nothing 40%

FFS None None $125 50% 50% 50% 40%

PPO $350 $200 $100 $20 10% Nothing 30%

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

Calendar
 

Year
 

Prescription
 

Drug
 

Hospital
 

Inpatient
 Office
 

Visits
 

Inpatient
 

Surgical
 

Services
 R&B
 Level I

*The Panama CanalArea Plan providesa Point­of­Serviceproduct within the Republicof Panama.

15

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?

APWU Health Plan ­high

Plan Name: Open to All

Member Survey Results 

(with national averages for Fee­for­Service plans in each category)

47

Plan

Code

82.3

Overall plan

satisfaction

81.3

92

Getting

needed care

91.9

92.2

Getting

care quickly

92.4

95.9

How well

doctors

communicate

94.5

84.4

Customer

service

89.5

92.1

Claims

processing

94

53

Shared

Decision

Making

56.8

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

Association Benefit Plan

SAMBA­std

Plan Name: Open Only to Specific Gr

42

44

oups

86.4

74.7

93.6

93.2

95.8

94.6

93.5

95.7

94.7

87.7

97.4

91.2

56.8

59.8

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

16
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

17
This page intentionally left blank

18
 
Appendix E
 

FEHB Plan Comparison Charts
 

Health Maintenance Organization Plans and

Plans Offering a Point­of­Service Product

(Pages 20 through 43)

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.

19
Health Maintenance Organization (HMO) and Point­of­Service (POS) Plans

See page 19 for an explanation of the columns on these pages.

Telephone

Enrollment

Code

Total

Monthly

Premium

102% of

Total

Monthly

Premium

Self Self & Self Self & Self Self &

Arizona

Aetna Open Access ­high­ Phoenixand Tucson Areas

Plan Name – Location

877­459­6604

Number

WQ1

only

WQ2

family

427.09

only

1067.82

family

435.63

only

1089.18

family

Health NetofArizona, Inc. ­high­ Maricopa/Pima/OtherAZcounties 800­289­2818 A71 A72 422.02 1068.15 430.46 1089.51

Health NetofArizona, Inc. ­std­ Maricopa/Pima/OtherAZcounties 800­289­2818 A74 A75 381.96 967.70 389.60 987.05

PacifiCareofArizona­high­ Maricopa, Pimaand Pinal Counties

California

Aetna HMO ­ LosAngelesandSan DiegoAreas

866­546­0510

877­459­6604

A31

2X1

A32

2X2

474.50

338.39

1138.91

833.63

483.99

345.16

1161.69

850.30

Anthem Blue Cross ­ HMO ­high­ Mostof California 800­235­8631 M51 M52 520.56 1299.03 530.97 1325.01

BlueShieldof CAAccess+HMO ­high­ Southern Region 800­880­8086 SI1 SI2 442.95 1023.23 451.81 1043.69

BlueShieldof CAAccess+HMO ­high­ Northern Region 800­880­8086 SJ1 SJ2 607.73 1403.83 619.88 1431.91

Health Netof California­high­ Northern Region 800­522­0088 LB1 LB2 595.36 1376.46 607.27 1403.99

Health Netof California­std­ Northern Region 800­522­0088 LB4 LB5 567.47 1312.09 578.82 1338.33

Health Netof California­high­ Southern Region 800­522­0088 LP1 LP2 456.56 1055.67 465.69 1076.78

Health Netof California­std­ Southern Region 800­522­0088 LP4 LP5 433.01 1001.11 441.67 1021.13

KaiserFoundation Health Plan of California­high­ Northern California 800­464­4000 591 592 527.58 1259.42 538.13 1284.61

KaiserFoundation Health Plan of California­std­ Northern California 800­464­4000 594 595 397.76 949.46 405.72 968.45

KaiserFoundation Health Plan of California­high­ Southern California 800­464­4000 621 622 443.28 1024.53 452.15 1045.02

KaiserFoundation Health Plan of California­std­ Southern California 800­464­4000 624 625 280.15 647.49 285.75 660.44

PacifiCareof California­high­ Mostof California

Colorado

KaiserFoundation Health Plan of Colorado­high­ Denver/ColoradoSpringsareas

866­546­0510

800­632­9700

CY1

651

CY2

652

439.49

459.46

1003.38

1052.16

448.28

468.65

1023.45

1073.20

KaiserFoundation Health Plan of Colorado­std­ Denver/ColoradoSpringsareas 800­632­9700 654 655 300.41 687.94 306.42 701.70

PacifiCareof Colorado­high­ Metro Denver/Boulder/ColoradoSprings

Connecticut

Aetna Open Access ­high­ Allof Connecticut

866­546­0510

877­459­6604

D61

JC1

D62

JC2

526.31

498.07

1244.51

1225.99

536.84

508.03

1269.40

1250.51

Aetna Open Access ­basic­ Allof Connecticut 877­459­6604 JC4 JC5 447.81 1088.10 456.77 1109.86

ConnectiCare ­high­ Allof Connecticut 800­251­7722 TE1 TE2 485.40 1104.44 495.11 1126.53

ConnectiCare ­basic­ Allof Connecticut 800­251­7722 TE4 TE5 391.50 890.76 399.33 908.58

20
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

21

60.8

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

See page 19 for an explanation of the columns on these pages.

Telephone

Enrollment

Code

Total

Monthly

Premium

102% of

Total

Monthly

Premium

Self Self & Self Self & Self Self &

Delaware

Aetna Open Access ­high­ Kent/New Castle/Sussexareas

Plan Name – Location

877­459­6604

Number

P31

only

P32

family

625.30

only

1508.76

family

637.81

only

1538.94

family

Aetna Open Access ­basic­ Kent/New Castle/Sussexareas 877­459­6604 P34 P35 427.68 987.59 436.23 1007.34

Coventry Health Care ­high­ Allof Delaware 800­833­7423 2J1 2J2 550.59 1376.42 561.60 1403.95

Coventry Health Care ­std­ Allof Delaware

District of Columbia

Aetna Open Access ­high­ Washington, DC Area

800­833­7423

877­459­6604

2J4

JN1

2J5

JN2

451.62

567.32

1128.94

1270.73

460.65

578.67

1151.52

1296.14

Aetna Open Access ­basic­ Washington, DC Area 877­459­6604 JN4 JN5 372.36 871.39 379.81 888.82

CareFirst BlueChoice ­high­ Washington, D.C. MetroArea 866­296­7363 2G1 2G2 450.08 1012.53 459.08 1032.78

KaiserFoundation Health Plan Mid­AtlanticStates ­high­ Washington, DC area 1­877­574­3337 E31 E32 464.01 1087.02 473.29 1108.76

KaiserFoundation Health Plan Mid­AtlanticStates ­std­ Washington, DC area 1­877­574­3337 E34 E35 264.51 629.46 269.80 642.05

M.D. IPA­high­ Washington, DC area

Florida

Av­Med Health Plan ­high­ Broward, Dadeand Palm Beach

877­835­9861

800­882­8633

JP1

ML1

JP2

ML2

444.80

431.47

1025.70

1035.58

453.70

440.10

1046.21

1056.29

Av­Med Health Plan ­std­ Broward, Dadeand Palm Beach 800­882­8633 ML4 ML5 332.89 799.00 339.55 814.98

Capital Health Plan ­high­ Tallahasseearea 850­383­3311 EA1 EA2 383.98 1017.45 391.66 1037.80

Humana, Inc. ­high­ South Florida 888­393­6765 EE1 EE2 431.97 993.53 440.61 1013.40

Humana, Inc. ­std­ South Florida 888­393­6765 EE4 EE5 341.21 784.81 348.03 800.51

Humana, Inc. ­high­ Tampa 888­393­6765 LL1 LL2 439.94 1011.86 448.74 1032.10

Humana, Inc. ­std­ Tampa 888­393­6765 LL4 LL5 396.70 912.43 404.63 930.68

JMH Health Plan ­high­ Broward­Dade counties 800­721­2993 J81 J82 450.30 1114.58 459.31 1136.87

JMH Health Plan ­std­ Broward­Dade counties 800­721­2993 J84 J85 393.03 1005.66 400.89 1025.77

United HealthcareofFlorida­high­ CentralandSouthwestFlorida 877­835­9861 R31 R32 443.54 1006.85 452.41 1026.99

Vista Healthplan ofSouth Florida­high­ Southern Florida 800­441­5501 5E1 5E2 354.64 975.39 361.73 994.90

Vista Healthplan ofSouth Florida­std­ Southern Florida 800­441­5501 5E4 5E5 310.20 853.13 316.40 870.19

22
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

Prescription

Drugs

Hospital

per stay

deductible

Primary

care/

Specialist

office copay Level I

Level II/

Level III

Mail

order

discount Plan Name – Location

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

Member Survey Results

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

23
 
Health Maintenance Organization (HMO) and Point­of­Service (POS) Plans

See page 19 for an explanation of the columns on these pages.

Telephone

Enrollment

Code

Total

Monthly

Premium

102% of

Total

Monthly

Premium

Self Self & Self Self & Self Self &

Georgia

Aetna Open Access ­high­ AtlantaandAthensAreas

Plan Name – Location

877­459­6604

Number

2U1

only

2U2

family

499.18

only

1145.41

family

509.16

only

1168.32

family

Humana, Inc. ­high­ Atlanta 888­393­6765 DG1 DG2 411.15 945.66 419.37 964.57

Humana, Inc. ­std­ Atlanta 888­393­6765 DG4 DG5 373.75 859.67 381.23 876.86

KaiserFoundation Health Plan of Georgia, Inc. ­high­ Atlanta,Athens,Columbus, Macon.Savannah 888­865­5813 F81 F82 428.83 982.02 437.41 1001.66

KaiserFoundation Health Plan of Georgia, Inc. ­std­ Atlanta,Athens,Columbus, Macon.Savannah

Guam

TakeCare ­high­ Guam/N.MarianaIslands/Belau(Palau)

888­865­5813

671­647­3526

F84

JK1

F85

JK2

293.17

536.27

671.39

1409.31

299.03

547.00

684.82

1437.50

TakeCare ­std­ Guam/N.MarianaIslands/Belau(Palau)

Hawaii

HMSA­high­ Allof Hawaii

671­647­3526

808­948­6499

JK4

871

JK5

872

423.02

375.66

1117.11

836.18

431.48

383.17

1139.45

852.90

KaiserFoundation Health Plan of Hawaii ­high­ Hawaii/Kauai/Lanai/Maui/Molokai/Oahu 808­432­5955 631 632 403.43 867.40 411.50 884.75

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

187.81

496.12

403.78

1091.55

191.57

506.04

411.86

1113.38

Altius Health Plans ­std­ Southern Region 800­377­4161 DK4 DK5 423.15 930.93 431.61 949.55

Group Health Cooperative ­high­ KootenaiandLatah 888­901­4636 VR1 VR2 567.13 1219.29 578.47 1243.68

Group Health Cooperative ­std­ KootenaiandLatah 888­901­4636 VR4 VR5 351.76 809.10 358.80 825.28

24
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

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 HP­High $15/$15 None $15 $15/$15 Yes 64.1 77 79.6 91.8 76.5 79.5 58.3

KaiserFoundation HP­Std $25/$25 10% $20 $20/$20 Yes 64.1 77 79.6 91.8 76.5 79.5 58.3

Idaho

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

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

Prescription

Drugs

Hospital

per stay

deductible

Primary

care/

Specialist

office copay Level I

Level II/

Level III

Mail

order

discount Plan Name – Location

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

Member Survey Results

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

25
 
Health Maintenance Organization (HMO) and Point­of­Service (POS) Plans

See page 19 for an explanation of the columns on these pages.

Telephone

Enrollment

Code

Total

Monthly

Premium

102% of

Total

Monthly

Premium

Self Self & Self Self & Self Self &

Illinois

Aetna Open Access ­high­ ChicagoArea

Plan Name – Location

877­459­6604

Number

IK1

only

IK2

family

364.07

only

924.17

family

371.35

only

942.65

family

Blue Preferred HMO ­high­ Madison andSt. Clair counties 888­811­2092 9G1 9G2 486.50 1053.33 496.23 1074.40

Group Health Plan, Inc. ­high­ Southern/Central 800­755­3901 MM1 MM2 607.95 1313.26 620.11 1339.53

Group Health Plan, Inc. ­std­ Southern/Central 800­755­3901 MU4 MU5 578.54 1249.63 590.11 1274.62

Health Alliance HMO ­high­ Central/E.Central/N. Cent/South/West IL 800­851­3379 FX1 FX2 505.53 1179.92 515.64 1203.52

Health Alliance HMO ­std­ Central/E.Central/N. Cent/South/West IL 800­851­3379 FX4 FX5 373.56 944.82 381.03 963.72

Humana Health Plan Inc. ­high­ Chicagoarea 888­393­6765 751 752 494.80 1138.04 504.70 1160.80

Humana Health Plan Inc. ­std­ Chicagoarea 888­393­6765 754 755 318.48 732.51 324.85 747.16

OSF HealthPlans, Inc. ­high­ Cental/Central­Northwestern Illinois 800­673­5222 9F1 9F2 481.02 1202.61 490.64 1226.66

OSF HealthPlans, Inc. ­std­ Central/Central­Northwestern Illinois 800­673­5222 AB4 AB5 373.25 933.18 380.72 951.84

PersonalCare Insuranceof Illinois, Inc. ­high­ Central Illinois 800­431­1211 GE1 GE2 458.08 1177.30 467.24 1200.85

Unicare HMO ­high­ ChicagolandArea 888­234­8855 171 172 500.05 1108.99 510.05 1131.17

Unicare HMO ­std­ ChicagolandArea 888­234­8855 174 175 348.08 771.94 355.04 787.38

Union Health Service ­high­ Chicagoarea 312­829­4224 761 762 348.38 863.98 355.35 881.26

United Healthcareof the Midwest ­high­ Southwest llinois 877­835­9861 B91 B92 450.73 1007.00 459.74 1027.14

UnitedHealthcare Plan of the RiverValley Inc. ­high­ West Central Illinois

Indiana

Aetna Open Access ­high­ Northern IndianaArea

800­247­9110

877­459­6604

YH1

IK1

YH2

IK2

356.89

364.07

874.36

924.17

364.03

371.35

891.85

942.65

Aetna Open Access ­high­ Southeastern IndianaArea 877­459­6604 RD1 RD2 646.45 1598.29 659.38 1630.26

Health Alliance HMO ­high­ Western Indiana 800­851­3379 FX1 FX2 505.53 1179.92 515.64 1203.52

Health Alliance HMO ­std­ Western Indiana 800­851­3379 FX4 FX5 373.56 944.82 381.03 963.72

Humana Health Plan Inc. ­high­ Lake/Porter/LaPorte Counties 888­393­6765 751 752 494.80 1138.04 504.70 1160.80

Humana Health Plan Inc. ­std­ Lake/Porter/LaPorte Counties 888­393­6765 754 755 318.48 732.51 324.85 747.16

Physicians Health Plan of Northern Indiana­high­ Northeast Indiana 260­432­6690 DQ1 DQ2 489.54 1091.37 499.33 1113.20

Unicare HMO ­high­ Lake/Porter Counties 888­234­8855 171 172 500.05 1108.99 510.05 1131.17

Unicare HMO ­std­ Lake/Porter Counties 888­234­8855 174 175 348.08 771.94 355.04 787.38

Welborn Health Plans ­high­ EvansvilleArea 800­521­0265 W11 W12 523.42 1224.82 533.89 1249.32

26
Primary

care/

Specialist

office copay Plan Name – Location

Hospital

per stay

deductible

Member Survey Results Prescription (with national averages for HMO/POS plans in each category) Drugs

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

Illinois

Aetna Open Access­High

Group Health Plan, Inc.­High

Health Alliance HMO­High

Humana Health Plan Inc.­High

OSF HealthPlans, Inc.­High

PersonalCare Insurance­High

Unicare HMO­Std

United Healthcare­High

$20/$30

$25/$25

$15/$25

$15/$25

$20/$20

$30/$35

$20/$35

$20/$30

$150/dayx5
 

$250/dayx3
 

$500
 

$200/dayx3
 

$500

$350/dayx4
 

10%

$150a day x3
 

$10

$10

$10

$10

$10

$15

$15

$7

$25/$50

$30/$50

$20/$40

$25/$45

$30/$50

$35/$65

$30/$60/20%

$30/$50

Yes

Yes

Yes
 

Yes
 

Yes
 

No
 

Yes
 

Yes
 

55.6

61.6

73.9

59.8

72.6

77.6

58.1

53.2

78.5

83.4

86.6

83.7

86.2

90.2

78
 

84.3

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

90.4 92.8 86.4 90
 66.2

78.3 88.5 69.1 74.3 69.6

85
 96.9 71.3 83.1 57.8

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

Unicare HMO­High $15/$15 $250 $10 $25/$50/20% Yes 58.1 78 78.3 88.5 69.1 74.3 69.6

Union Health Service­High $10/$10 None $15 $15/$15 No

UnitedHealthcare RiverValley­High $15/$30 $100/5days $10 $30/$45 Yes 65.2 86.8 88.5 94.5 78.9 91.9 53.7

Indiana

Aetna Open Access­High

Health Alliance HMO­High

Humana Health Plan Inc.­High

Physicians Health Plan­High

$20/$30

$15/$25

$15/$25

$15/$15

$150/dayx5
 

$500

$200/dayx3
 

20%

$10

$10

$10

$5

$25/$50

$20/$40

$25/$45

$20/25%/$45

Yes

Yes

Yes

Yes

55.6

73.9

59.8

56.7

78.5

86.6

83.7

89
 

84.1 91.1 82.1 81.8 55.1

86.9 93.7 89.9 89.7 61.8

85.6 88.9 76.7 75.3 58.8

90.2 92.8 88.7 94.1 59.3

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 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

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

27
 
Health Maintenance Organization (HMO) and Point­of­Service (POS) Plans

See page 19 for an explanation of the columns on these pages.

Telephone

Enrollment

Code

Total

Monthly

Premium

102% of

Total

Monthly

Premium

Self Self & Self Self & Self Self &

Iowa

Coventry Health Careof Iowa­high­ Central/Eastern/Western Iowa

Plan Name – Location

800­257­4692

Number

SV1

only

SV2

family

434.14

only

1172.04

family

442.82

only

1195.48

family

Coventry Health Careof Iowa­std­ Central/Eastern/Western Iowa 800­257­4692 SY4 SY5 344.05 808.49 350.93 824.66

Health Alliance HMO ­high­ Central Iowa 800­851­3379 FX1 FX2 505.53 1179.92 515.64 1203.52

Health Alliance HMO ­std­ Central Iowa 800­851­3379 FX4 FX5 373.56 944.82 381.03 963.72

HealthPartners Open Access Copay ­high­ Iowa 952­883­5000 V31 V32 532.55 1224.86 543.20 1249.36

HealthPartners Three forFree ­std­ Iowa 952­883­5000 V34 V35 280.65 645.47 286.26 658.38

Sanford Health Plan ­high­ Northwestern Iowa 800­752­5863 AU1 AU2 513.41 1181.40 523.68 1205.03

Sanford Health Plan ­std­ Northwestern Iowa 800­752­5863 AU4 AU5 488.93 1124.41 498.71 1146.90

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

356.89

403.04

874.36

1017.42

364.03

411.10

891.85

1037.77

Coventry Health Careof Kansas ­std­ Kansas City/Wichita/Salinaareas 800­969­3343 HA4 HA5 317.83 746.72 324.19 761.65

Humana Health Plan, Inc. ­high­ Kansas Cityarea 888­393­6765 MS1 MS2 627.12 1442.37 639.66 1471.22

Humana Health Plan, Inc. ­std­ Kansas Cityarea 888­393­6765 MS4 MS5 365.06 839.61 372.36 856.40

United Healthcareof the Midwest ­high­ Kansas CityArea

Kentucky

Aetna Open Access ­high­ Northern KentuckyArea

Louisiana

Coventry Health CareofLouisiana­high­ New Orleansarea

877­835­9861

877­459­6604

800­­341­6613

GX1

RD1

BJ1

GX2

RD2

BJ2

503.51

646.45

454.11

1183.20

1598.29

1054.60

513.58

659.38

463.19

1206.86

1630.26

1075.69

Coventry Health CareofLouisiana­std­ New Orleansarea 800­­341­6613 BJ4 BJ5 456.80 1060.87 465.94 1082.09

Vantage Health Plan, Inc. ­high­ Alexandria/Baton Rouge/Monroe/Shreveport 888­823­1910 MV1 MV2 460.50 1059.15 469.71 1080.33

Vantage Health Plan, Inc. ­std­ Alexandria/Baton Rouge/Monroe/Shreveport 888­823­1910 MV4 MV5 403.59 928.42 411.66 946.99

28
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

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

Coventry Health Care­Std $25/$50 30% $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

Vantage Health Plan, Inc.­Std $30/$50 $500 $15 $40/$60 Yes

Prescription

Drugs

Hospital

per stay

deductible

Primary

care/

Specialist

office copay Level I

Level II/

Level III

Mail

order

discount Plan Name – Location

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

Member Survey Results

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

29
 
Health Maintenance Organization (HMO) and Point­of­Service (POS) Plans

See page 19 for an explanation of the columns on these pages.

Telephone

Enrollment

Code

Total

Monthly

Premium

102% of

Total

Monthly

Premium

Self Self & Self Self & Self Self &

Maryland

Aetna Open Access ­high­ Northern/Central/Southern MarylandAreas

Plan Name – Location

877­459­6604

Number

JN1

only

JN2

family

567.32

only

1270.73

family

578.67

only

1296.14

family

Aetna Open Access ­basic­ Northern/Central/Southern MarylandAreas 877­459­6604 JN4 JN5 372.36 871.39 379.81 888.82

CareFirst BlueChoice ­high­ Allof Maryland 866­296­7363 2G1 2G2 450.08 1012.53 459.08 1032.78

Coventry Health Care ­high­ Allof Maryland 800­833­7423 IG1 IG2 405.17 1016.73 413.27 1037.06

Coventry Health Care ­std­ Allof Maryland 800­833­7423 IG4 IG5 318.80 797.01 325.18 812.95

KaiserFoundation Health Plan Mid­AtlanticStates ­high­ Baltimore/Washington, DC areas 1­877­574­3337 E31 E32 464.01 1087.02 473.29 1108.76

KaiserFoundation Health Plan Mid­AtlanticStates ­std­ Baltimore/Washington, DC areas 1­877­574­3337 E34 E35 264.51 629.46 269.80 642.05

M.D. IPA­high­ Allof Maryland

Massachusetts

Blue CHiP Coordinated Health Plan ­ BCBSof RI ­high­ Southeastern Massachusetts

877­835­9861

401­274­3500

JP1

DA1

JP2

DA2

444.80

589.57

1025.70

1562.30

453.70

601.36

1046.21

1593.55

ConnectiCare ­high­ Counties Hampden, Hampshire,Franklin 800­251­7722 TE1 TE2 485.40 1104.44 495.11 1126.53

ConnectiCare ­basic­ Counties Hampden, Hampshire,Franklin 800­251­7722 TE4 TE5 391.50 890.76 399.33 908.58

Fallon Community Health Plan ­std­ Central/Eastern/Western Massachusetts 800­868­5200 JV4 JV5 566.97 1377.96 578.31 1405.52

Fallon Community Health Plan ­basic­ Central/Eastern/Western Massachusetts

Michigan

Bluecare Networkof MI ­high­ Midland CountyArea

800­868­5200

800­662­6667

JG1

K51

JG2

K52

521.47

522.71

1267.31

1191.86

531.90

533.16

1292.66

1215.70

Bluecare Networkof MI ­high­ Southeast MI 800­662­6667 LX1 LX2 378.06 982.32 385.62 1001.97

GrandValley Health Plan ­high­ Grand Rapidsarea 616­949­2410 RL1 RL2 434.01 1136.96 442.69 1159.70

GrandValley Health Plan ­std­ Grand Rapidsarea 616­949­2410 RL4 RL5 383.80 997.92 391.48 1017.88

Health Alliance Plan ­high­ Southeastern Michigan/Flintarea 800­556­9765 521 522 392.51 1020.37 400.36 1040.78

HealthPlus MI ­high­ East Central Michigan 800­332­9161 X51 X52 476.54 1086.71 486.07 1108.44

Physicians Health Plan of Mid­Michigan ­high­ Mid­Michigan 517­364­8400 9U1 9U2 506.98 1221.81 517.12 1246.25

Physicians Health Plan of Mid­Michigan ­std­ Mid­Michigan

Minnesota

HealthPartners Open Access Copay ­high­ Minnesota

517­364­8400

952­883­5000

9U4

V31

9U5

V32

423.95

532.55

1021.67

1224.86

432.43

543.20

1042.10

1249.36

HealthPartners Three forFree ­std­ Minnesota 952­883­5000 V34 V35 280.65 645.47 286.26 658.38

Medica Health Plan ­high­ Mostof Minnesota 800­952­3455 M21 M22 487.09 1115.40 496.83 1137.71

30
Primary

care/

Specialist

office copay Plan Name – Location

Hospital

per stay

deductible

Member Survey Results Prescription (with national averages for HMO/POS plans in each category) Drugs

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

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

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

$5

$10

$10

or50%/$30or

$15/$15

$40/$40

$25/$40

50% Yes 65.2 86.7 87.3 92.6 84.2 91.1 60.9

No 73.3 81.9 89.1 94.8 89.9 86.6 54.1

Yes 76.9 83.8 88.2 92.9 84.4 91.2 59.4

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

HealthPartners3forFree $0for3, then 20%/$0for3, then 20% 20% in/40% out $6 $30/$60 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

31
Health Maintenance Organization (HMO) and Point­of­Service (POS) Plans

See page 19 for an explanation of the columns on these pages.

Missouri

Blue Preferred HMO ­high­ StLouis/Central/SW areas

Coventry Health Careof Kansas ­high­ Kansas Cityarea

Coventry Health Careof Kansas ­std­ Kansas Cityarea

Group Health Plan, Inc. ­high­ St. LouisArea

Group Health Plan, Inc. ­std­ St.LouisArea

Humana Health Plan, Inc. ­high­ Kansas Cityarea

Humana Health Plan, Inc. ­std­ Kansas Cityarea

United Healthcareof the Midwest ­high­ St.LouisArea

United Healthcareof the Midwest ­high­ Kansas CityArea

Montana

New West Health Services ­high­ Mostof Montana

New West Health Services ­POS­ Mostof Montana

Nevada

Aetna Open Access ­high­ LasVegasand RenoAreas

Health Plan of Nevada­high­ LasVegasarea

PacifiCareof Nevada­high­ LasVegas/Clark County

New Jersey

Aetna Open Access ­high­ Northern New Jersey

Aetna Open Access ­basic­ Northern New Jersey

Aetna Open Access ­high­ Southern NJ

Aetna Open Access ­basic­ Southern NJ

AmeriHealth HMO ­high­ Allof New Jersey

AmeriHealth HMO ­std­ Allof New Jersey

Coventry Health Care ­high­ Southern New Jersey

Coventry Health Care ­std­ Southern New Jersey

GHI Health Plan ­high­ Northern New Jersey

GHI Health Plan ­std­ Northern New Jersey

New Mexico

Lovelace Health Plan ­high­ Allof New Mexico

Presbyterian Health Plan ­high­ All counties in New Mexico

Presbyterian Health Plan ­std­ All counties in New Mexico

Plan Name – Location

888­811­2092

800­969­3343

800­969­3343

800­755­3901

800­755­3901

888­393­6765

888­393­6765

877­835­9861

877­835­9861

800­290­3657

800­290­3657

877­459­6604

800­777­1840

866­546­0510

877­459­6604

877­459­6604

877­459­6604

877­459­6604

800­454­7651

800­454­7651

800­833­7423

800­833­7423

212­501­4444

212­501­4444

800­808­7363

800­356­2219

800­356­2219

Telephone

Number

Enrollment

Code

Total

Monthly

Premium

102% of

Total

Monthly

Premium

9G1

HA1

HA4

MM1

MU4

MS1

MS4

B91

GX1

NV1

NV1

Y11

NM1

K91

JR1

JR4

P31

P34

FK1

FK4

2J1

2J4

801

804

Q11

P21

P24

Self

only

9G2

HA2

HA5

MM2

MU5

MS2

MS5

B92

GX2

NV2

NV2

Y12

NM2

K92

JR2

JR5

P32

P35

FK2

FK5

2J2

2J5

802

805

Q12

P22

P25

Self &

family

486.50

403.04

317.83

607.95

578.54

627.12

365.06

450.73

503.51

497.25

497.25

395.68

282.53

417.39

559.82

439.55

625.30

427.68

532.26

504.23

550.59

451.62

541.52

386.19

454.72

570.77

514.39

Self

only

1053.33

1017.42

746.72

1313.26

1249.63

1442.37

839.61

1007.00

1183.20

1062.19

1062.19

985.21

723.47

947.48

1287.76

1014.67

1508.76

987.59

1259.14

1193.25

1376.42

1128.94

1353.86

901.49

1114.10

1296.30

1168.18

Self &

family

496.23

411.10

324.19

620.11

590.11

639.66

372.36

459.74

513.58

507.20

507.20

403.59

288.18

425.74

571.02

448.34

637.81

436.23

542.91

514.31

561.60

460.65

552.35

393.91

463.81

582.19

524.68

Self

only

1074.40

1037.77

761.65

1339.53

1274.62

1471.22

856.40

1027.14

1206.86

1083.43

1083.43

1004.91

737.94

966.43

1313.52

1034.96

1538.94

1007.34

1284.32

1217.12

1403.95

1151.52

1380.94

919.52

1136.38

1322.23

1191.54

Self &

family

32
Primary

care/

Specialist

office copay Plan Name – Location

Hospital

per stay

deductible

Member Survey Results Prescription (with national averages for HMO/POS plans in each category) Drugs

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

Missouri

Blue Preferred HMO­High

Coventry Health Care­Std

Group Health Plan, Inc.­Std

Humana Health Plan, Inc.­Std

United Healthcare­High

$25/$25

$20/$40

$20/$40

$20/$30

$20/$30

$500 $10

20% $10

20%after$500/dayx2 $12

$400/dayx3 $10

$150a day x3 $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

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

Nevada

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

PacifiCareof Nevada­High $15/$30 $150/dayx5 $10 $30/$50 Yes 51.1 75 75.3 85.8 68.2 78.3 53.3

Health Plan of Nevada­High $10/$10 $50 $5 $35/$55 Yes 50.6 72.4 73.2 85 79.8 82

New Jersey

Aetna Open Access­High

Aetna Open Access­High

AmeriHealth HMO­High

Coventry Health Care­High

GHI Health Plan­ In­Network

GHI Health Plan­ Out­Network

$20/$30

$20/$30

$25/$40

$10/$20

$15/$15

+50% of sch

$150/dayx5
 

$150/dayx5
 

$150/dayx5
 

$100
 

$100
 

+50% of sch.
 

$10

$10

$5

$10

$15

N/A

$25/$50

$25/$50

$40/50%

$20/$45

$25/$50

N/A/N/A

Yes

Yes

Yes

Yes

Yes

No

50.5

63.9

61.2

53.9

69.6

69.6

84.2

87.4

86.6

83.9

87.1

87.1

86.9 91.9 85.2 79.7 52.4

92 93.7 83 86.7 53.4

86.3 94.1 83 80.8 65.3

85.6 91.7 79.4 80.6 59.9

86.8 92.1 76.2 86.8 65.3

86.8 92.1 76.2 86.8 65.3

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 Access­Basic $15/$30 20% Plan Allow $5 $30/$50 Yes 63.9 87.4 92 93.7 83 86.7 53.4

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 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 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

33

58.1

53.3
Health Maintenance Organization (HMO) and Point­of­Service (POS) Plans

See page 19 for an explanation of the columns on these pages.

Telephone

Enrollment

Code

Total

Monthly

Premium

102% of

Total

Monthly

Premium

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

498.07

only

1225.99

family

508.03

only

1250.51

family

Aetna Open Access ­basic­ NYC Area/Upstate NY 877­459­6604 JC4 JC5 447.81 1088.10 456.77 1109.86

Blue Choice ­high­ Rochesterarea 800­462­0108 MK1 MK2 453.66 1139.69 462.73 1162.48

Blue Choice ­std­ Rochesterarea 800­462­0108 MK4 MK5 349.64 865.52 356.63 882.83

CDPHP Universal Benefits ­high­ Upstate, Hudson Valley, Cent New York 877­269­2134 SG1 SG2 483.25 1223.93 492.92 1248.41

CDPHP Universal Benefits ­std­ Upstate, Hudson Valley, Cent New York 877­269­2134 SG4 SG5 377.43 973.77 384.98 993.25

Community Blue ­high­ Northeastern NY­Clinton/Essex Counties 800­544­2583 BS1 BS2 643.52 1726.75 656.39 1761.29

Community Blue ­high­ Western New York 800­459­7587 BX1 BX2 474.57 1313.48 484.06 1339.75

Community Blue ­high­ Northeastern NY­Capital Region 800­544­2583 BZ1 BZ2 601.84 1614.93 613.88 1647.23

GHI HMO ­high­ Brnx/Brklyn/Manhat/Queen/Richmon/Westche 877­244­4466 6V1 6V2 467.11 1187.03 476.45 1210.77

GHI HMO ­high­ Capital/Hudson Valley Regions 877­244­4466 X41 X42 446.36 1141.40 455.29 1164.23

GHI Health Plan ­high­ Allof New York 212­501­4444 801 802 541.52 1353.86 552.35 1380.94

GHI Health Plan ­std­ New York City (the Boroughsof Manhattan, Brooklyn, Bronx, Queens,and

Staten Island), allof Nassau,Suffolk, Rockland,and Westchester Counties

212­501­4444 804 805 386.19 901.49 393.91 919.52

HIP of Greater New York­high­ New York Cityarea 800­HIP­TALK 511 512 461.85 1293.15 471.09 1319.01

HIP of Greater New York­std­ New York Cityarea 800­HIP­TALK 514 515 422.67 1183.48 431.12 1207.15

Independent Health Assoc ­high­ Western New York 800­501­3439 QA1 QA2 448.72 1184.34 457.69 1208.03

MVP Health Care ­high­ Eastern Region 888­687­6277 GA1 GA2 429.67 1110.11 438.26 1132.31

MVP Health Care ­std­ Eastern Region 888­687­6277 GA4 GA5 404.89 1046.00 412.99 1066.92

MVP Health Care ­high­ Central Region 888­687­6277 M91 M92 457.80 1182.70 466.96 1206.35

MVP Health Care ­std­ Central Region 888­687­6277 M94 M95 434.63 1122.81 443.32 1145.27

MVP Health Care ­high­ Northern Region 888­687­6277 MF1 MF2 507.15 1310.27 517.29 1336.48

MVP Health Care ­std­ Northern Region 888­687­6277 MF4 MF5 459.66 1187.51 468.85 1211.26

MVP Health Care ­high­ Mid­Hudson Region 888­687­6277 MX1 MX2 463.58 1194.98 472.85 1218.88

MVP Health Care ­std­ Mid­Hudson Region 888­687­6277 MX4 MX5 445.53 1151.71 454.44 1174.74

Preferred Care ­high­ Rochesterarea 800­950­3224 GV1 GV2 377.00 1007.67 384.54 1027.82

Preferred Care ­std­ Rochesterarea 800­950­3224 GV4 GV5 314.73 841.27 321.02 858.10

Univera Healthcare ­high­ Western New York(Southern Counties) 800­427­8490 KQ1 KQ2 657.28 1737.43 670.43 1772.18

Univera Healthcare ­high­ Western New York(Northern Counties) 800­427­8490 Q81 Q82 538.63 1527.11 549.40 1557.65

34
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 HMO $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

Prescription

Drugs

Hospital

per stay

deductible

Primary

care/

Specialist

office copay Level I

Level II/

Level III

Mail

order

discount Plan Name – Location

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

Member Survey Results

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

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

See page 19 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

Total

Monthly

Premium

102% of

Total

Monthly

Premium

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

567.32

372.36

532.55

280.65

368.05

454.24

530.68

646.45

509.69

532.22

520.07

339.95

530.83

418.49

490.84

550.18

549.16

365.58

356.81

519.50

500.67

414.46

Self

only

1270.73

871.39

1224.86

645.47

945.92

1081.19

1281.04

1598.29

1251.25

1361.40

1196.15

781.93

1273.94

962.52

1138.74

1269.52

1273.94

914.49

859.95

1215.74

1150.20

952.12

Self &

family

578.67

379.81

543.20

286.26

375.41

463.32

541.29

659.38

519.88

542.86

530.47

346.75

541.45

426.86

500.66

561.18

560.14

372.89

363.95

529.89

510.68

422.75

Self

only

1296.14

888.82

1249.36

658.38

964.84

1102.81

1306.66

1630.26

1276.28

1388.63

1220.07

797.57

1299.42

981.77

1161.51

1294.91

1299.42

932.78

877.15

1240.05

1173.20

971.16

Self &

family

36
Primary

care/

Specialist

office copay Plan Name – Location

Hospital

per stay

deductible

Member Survey Results Prescription (with national averages for HMO/POS plans in each category) Drugs

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

$150a day x3

$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

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

37

60.5
Health Maintenance Organization (HMO) and Point­of­Service (POS) Plans

See page 19 for an explanation of the columns on these pages.

Telephone

Enrollment

Code

Total

Monthly

Premium

102% of

Total

Monthly

Premium

Self Self & Self Self & Self Self &

Pennsylvania

Aetna Open Access ­high­ Philadelphia/Central/Southeastern PA

Plan Name – Location

877­459­6604

Number

P31

only

P32

family

625.30

only

1508.76

family

637.81

only

1538.94

family

Aetna Open Access ­basic­ Philadelphia/Central/Southeastern PA 877­459­6604 P34 P35 427.68 987.59 436.23 1007.34

Aetna Open Access ­high­ Pittsburgh and Western PAAreas 877­459­6604 YE1 YE2 307.19 847.04 313.33 863.98

Geisinger Health Plan ­high­ Northeastern/Central/South Centralareas 800­447­4000 GG1 GG2 505.09 1161.70 515.19 1184.93

Geisinger Health Plan ­std­ Northeastern/Central/South Centralareas 800­447­4000 GG4 GG5 443.21 1019.42 452.07 1039.81

HealthAmerica Pennsylvania­high­ Greater Pittsburgh area 866­351­5946 261 262 521.58 1330.12 532.01 1356.72

HealthAmerica Pennsylvania­std­ Greater Pittsburgh area 866­351­5946 264 265 427.01 1088.92 435.55 1110.70

HealthAmerica Pennsylvania­high­ Southeastern Pennsylvania 866­351­5946 PN1 PN2 570.20 1311.55 581.60 1337.78

HealthAmerica Pennsylvania­std­ Southeastern Pennsylvania 866­351­5946 PN4 PN5 496.08 1139.02 506.00 1161.80

HealthAmerica Pennsylvania­high­ Central Pennsylvania 866­351­5946 SW1 SW2 591.89 1361.25 603.73 1388.48

HealthAmerica Pennsylvania­std­ Central Pennsylvania 866­351­5946 SW4 SW5 455.59 1047.80 464.70 1068.76

Keystone Health Plan Central ­high­ Harrisburg/Northern Region/Lehigh Valley 800­622­2843 S41 S42 601.25 1436.67 613.28 1465.40

Keystone Health Plan Central ­std­ Harrisburg/Northern Region/Lehigh Valley 800­622­2843 S44 S45 552.33 1317.44 563.38 1343.79

Keystone Health Plan East ­high­ Philadelphiaarea 800­227­3115 ED1 ED2 561.80 1481.87 573.04 1511.51

Keystone Health Plan East ­std­ Philadelphiaarea 800­227­3115 ED4 ED5 497.49 1313.02 507.44 1339.28

UPMC Health Plan ­high­ Western Pennsylvania 888­876­2756 8W1 8W2 524.05 1205.32 534.53 1229.43

UPMC Health Plan ­std­ Western Pennsylvania

Puerto Rico

Humana Health Plansof Puerto Rico, Inc. ­high­ Puerto Rico

1­888­876­2756

800­314­3121

UW4

ZJ1

UW5

ZJ2

491.68

278.11

1130.81

639.62

501.51

283.67

1153.43

652.41

Triple­S­high­ Allof Puerto Rico

Rhode Island

Blue CHiP Coordinated Health Plan ­ BCBSof RI ­high­ Allof Rhode Island

787­774­6060

401­459­5500

891

DA1

892

DA2

284.14

589.57

653.51

1562.30

289.82

601.36

666.58

1593.55

38
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

Prescription

Drugs

Hospital

per stay

deductible

Primary

care/

Specialist

office copay Level I

Level II/

Level III

Mail

order

discount Plan Name – Location

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

Member Survey Results

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

39
 
Health Maintenance Organization (HMO) and Point­of­Service (POS) Plans

See page 19 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

Total

Monthly

Premium

102% of

Total

Monthly

Premium

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

532.55

280.65

513.41

488.93

593.19

377.46

515.65

484.01

386.95

529.92

681.87

372.28

441.57

401.42

536.47

496.12

423.15

412.19

Self

only

1224.86

645.47

1181.40

1124.41

1352.43

962.48

1287.39

1219.29

831.94

1139.30

1568.32

856.25

1015.60

923.26

1233.48

1091.55

930.93

936.09

Self &

family

543.20

286.26

523.68

498.71

605.05

385.01

525.96

493.69

394.69

540.52

695.51

379.73

450.40

409.45

547.20

506.04

431.61

420.43

Self

only

1249.36

658.38

1205.03

1146.90

1379.48

981.73

1313.14

1243.68

848.58

1162.09

1599.69

873.38

1035.91

941.73

1258.15

1113.38

949.55

954.81

Self &

family

40
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

Prescription

Drugs

Hospital

per stay

deductible

Primary

care/

Specialist

office copay Level I

Level II/

Level III

Mail

order

discount Plan Name – Location

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

Member Survey Results

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

41
 
Health Maintenance Organization (HMO) and Point­of­Service (POS) Plans

See page 19 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/Fredericksburgarea

KaiserFoundation Health Plan Mid­AtlanticStates ­std­ Northern Virginia/Fredericksburgarea

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

1­877­574­3337

1­877­574­3337

877­835­9861

800­206­1060

800­206­1060

888­674­3368

888­901­4636

888­901­4636

888­901­4636

888­901­4636

800­552­7114

800­552­7114

800­813­2000

800­813­2000

800­624­6961

800­279­1301

608­828­4827

952­883­5000

952­883­5000

800­377­4161

800­377­4161

Telephone

Number

Enrollment

Code

Total

Monthly

Premium

102% of

Total

Monthly

Premium

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

567.32

372.36

450.08

464.01

264.51

444.80

493.94

354.73

433.07

538.87

340.95

567.13

351.76

385.21

516.38

500.67

414.46

418.49

424.82

419.68

532.55

280.65

496.12

423.15

Self

only

1270.73

871.39

1012.53

1087.02

629.46

1025.70

1168.72

839.35

991.34

1158.56

769.77

1219.29

809.10

831.44

1128.36

1150.20

952.12

962.52

1062.06

1102.75

1224.86

645.47

1091.55

930.93

Self &

family

578.67

379.81

459.08

473.29

269.80

453.70

503.82

361.82

441.73

549.65

347.77

578.47

358.80

392.91

526.71

510.68

422.75

426.86

433.32

428.07

543.20

286.26

506.04

431.61

Self

only

1296.14

888.82

1032.78

1108.76

642.05

1046.21

1192.09

856.14

1011.17

1181.73

785.17

1243.68

825.28

848.07

1150.93

1173.20

971.16

981.77

1083.30

1124.81

1249.36

658.38

1113.38

949.55

Self &

family

42
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

Prescription

Drugs

Hospital

per stay

deductible

Primary

care/

Specialist

office copay Level I

Level II/

Level III

Mail

order

discount Plan Name – Location

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

Member Survey Results

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

43
 
Appendix E
 

FEHB Plan Comparison Charts
 

High Deductible and Consumer­Driven Health Plans

With a Health Savings Account or Health Reimbursement Arrangement
 

(Pages 48 through 81)
 

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 2008 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.

44
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
 

45
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.

46
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.

47
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

Total Monthly

Premium

102% of Total Monthly

Plan Name Telephone Premium

Number

Enrollment Code

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

336.70

380.81

301.77

757.47

869.79

683.82

343.43

388.43

307.81

772.62

887.19

697.50

48
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

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

49
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

50
This page intentionally left blank

51
 
High Deductible and Consumer­Driven Health Plans

See page 48­49 for an explanation of the columns on these pages.

Alabama

877­459­6604 221 222 350.83 806.89 357.85

Aetna HealthFund­HDHP­ MostofAlabama 877­459­6604 224 225 268.04 587.02 273.40 598.76

Alaska

877­459­6604 221 222 350.83 806.89 357.85

Aetna HealthFund­HDHP­ MostofAlaska 877­459­6604 224 225 268.04 587.02 273.40 598.76

Arizona

877­459­6604 221 222 350.83 806.89 357.85

Aetna HealthFund­HDHP­ AllofArizona 877­459­6604 224 225 268.04 587.02 273.40 598.76

888­393­6765 DB1 DB2 303.88 698.97 309.96

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Arizona 877­835­9861 E91 E92 305.31 682.07 311.42 695.71

877­835­9861 E94 E95 357.05 790.36 364.19

877­459­6604 221 222 350.83 806.89 357.85

Aetna HealthFund­HDHP­ MostofArkansas 877­459­6604 224 225 268.04 587.02 273.40 598.76

877­835­9861 E91 E92 305.31 682.07 311.42

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Arkansas 877­835­9861 E94 E95 357.05 790.36 364.19 806.17

California

877­459­6604 221 222 350.83 806.89 357.85

Aetna HealthFund­HDHP­ Mostof California 877­459­6604 224 225 268.04 587.02 273.40 598.76

877­835­9861 E91 E92 305.31 682.07 311.42

UnitedHealthcare Insurance Company, Inc. ­CDHP­ 877­835­9861 E94 E95 357.05 790.36 364.19 806.17

Mostof California

Telephone

Number

Self

Only

Self &

Family

Self

Only

Self &

Family

Self

Only

Enrollment Code

Total
 

Monthly Premium
 

Plan Name

Aetna HealthFund­CDHP­ MostofAlabama

Aetna HealthFund­CDHP­ MostofAlaska

Aetna HealthFund­CDHP­ AllofArizona

Humana CoverageFirst ­CDHP­ Phoenix/Tucson Area

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Arizona

Arkansas

Aetna HealthFund­CDHP­ MostofArkansas

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Arkansas

Aetna HealthFund­CDHP­ Mostof California

UnitedHealthcare Insurance Company, Inc. ­HDHPMostof California

102% of Total

Monthly Premium

Self &
 

Family
 

823.03

823.03

823.03

712.95

806.17

823.03

695.71

823.03

695.71

52
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

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

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Benefit

Type

Prescription

Drugs

Levels I, II,

III

53
 
High Deductible and Consumer­Driven Health Plans

See page 48­49 for an explanation of the columns on these pages.

Total 102% of Total

Telephone Enrollment Code Monthly Premium Monthly Premium

Number

Self Self & Self Self & Self Self &

Only Family Only Family Only Family Plan Name

Aetna HealthFund­CDHP­ Allof Colorado 877­459­6604 221 222 350.83 806.89 357.85 823.03

Aetna HealthFund­HDHP­ Allof Colorado 877­459­6604 224 225 268.04 587.02 273.40 598.76

Humana CoverageFirst ­CDHP­ DenverArea 888­393­6765 7T1 7T2 316.55 728.07 322.88 742.63

Humana CoverageFirst ­CDHP­ ColoradoSpringsArea 888­393­6765 FC1 FC2 316.55 728.07 322.88 742.63

UnitedHealthcare Insurance Company, Inc. ­HDHP­ DenverArea 877­835­9861 E91 E92 305.31 682.07 311.42 695.71

UnitedHealthcare Insurance Company, Inc. ­CDHP­ DenverArea 877­835­9861 E94 E95 357.05 790.36 364.19 806.17

Connecticut

Aetna HealthFund­CDHP­ Allof Connecticut 877­459­6604 221 222 350.83 806.89 357.85 823.03

Aetna HealthFund­HDHP­ Allof Connecticut 877­459­6604 224 225 268.04 587.02 273.40 598.76

Delaware

Aetna HealthFund­CDHP­ Allof Delaware 877­459­6604 221 222 350.83 806.89 357.85 823.03

Aetna HealthFund­HDHP­ Allof Delaware 877­459­6604 224 225 268.04 587.02 273.40 598.76

Coventry Health Care HDHP ­HDHP­ Allof Delaware 800/833­7423 LK1 LK2 353.15 855.62 360.21 872.73

District of Columbia

Aetna HealthFund­CDHP­ Allof Washington DC 877­459­6604 221 222 350.83 806.89 357.85 823.03

Aetna HealthFund­HDHP­ Allof Washington DC 877­459­6604 224 225 268.04 587.02 273.40 598.76

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Washington DC 877­835­9861 E91 E92 305.31 682.07 311.42 695.71

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Washington DC 877­835­9861 E94 E95 357.05 790.36 364.19 806.17

Colorado

54
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

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

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Benefit

Type

Prescription

Drugs

Levels I, II,

III

55
 
High Deductible and Consumer­Driven Health Plans

See page 48­49 for an explanation of the columns on these pages.

Florida

877­459­6604 221 222 350.83 806.89 357.85

Aetna HealthFund­HDHP­ MostofFlorida 877­459­6604 224 225 268.04 587.02 273.40 598.76

888­393­6765 BP1 BP2 386.97 890.07 394.71

Humana CoverageFirst ­CDHP­ DaytonaArea 888­393­6765 DL1 DL2 422.13 970.97 430.57 990.39

888­393­6765 MJ1 MJ2 371.41 854.27 378.84

Humana CoverageFirst ­CDHP­ JacksonvilleArea 888­393­6765 MQ1 MQ2 388.31 893.12 396.08 910.98

888­393­6765 QP1 QP2 303.88 698.97 309.96

Humana CoverageFirst ­CDHP­ OrlandoArea 888­393­6765 YG1 YG2 351.72 808.97 358.75 825.15

877­835­9861 E91 E92 305.31 682.07 311.42

UnitedHealthcare Insurance Company, Inc. ­CDHP­ 877­835­9861 E94 E95 357.05 790.36 364.19 806.17

CentralandSouthwestFlorida

Georgia

877­459­6604 221 222 350.83 806.89 357.85

Aetna HealthFund­HDHP­ Mostof Georgia 877­459­6604 224 225 268.04 587.02 273.40 598.76

888­393­6765 AD1 AD2 299.02 687.74 305.00

Humana CoverageFirst ­CDHP­ Macon Area 888­393­6765 LM1 LM2 369.35 849.55 376.74 866.54

888/865­5813 GW1 GW2 328.99 739.59 335.57

UnitedHealthcare Insurance Company, Inc. ­HDHP­ 877­835­9861 E91 E92 305.31 682.07 311.42 695.71

Atlanta,Athens, Macon Areas

Telephone

Number

Self

Only

Self &

Family

Self

Only

Self &

Family

Self

Only

Enrollment Code

Plan Name

Aetna HealthFund­CDHP­ MostofFlorida

Humana CoverageFirst ­CDHP­ PensacolaArea

Humana CoverageFirst ­CDHP­ TampaArea

Humana CoverageFirst ­CDHP­ South FloridaArea

UnitedHealthcare Insurance Company, Inc. ­HDHPCentralandSouthwestFlorida

Aetna HealthFund­CDHP­ Mostof Georgia

Humana CoverageFirst ­CDHP­ AtlantaArea

KaiserFoundation Health Plan of GeorgiaInc. HDHPAtlanta,Athens,Columbus,Macon,Savannah

UnitedHealthcare Insurance Company, Inc. ­CDHPAtlanta,Athens, Macon Areas

Total
 

Monthly Premium
 

877­835­9861 E94 E95 357.05 790.36

102% of Total

Monthly Premium

Self &
 

Family
 

823.03

907.87

871.36

712.95

695.71

823.03

701.49

754.38

364.19 806.17

56
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 Copayss $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

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

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Benefit

Type

Prescription

Drugs

Levels I, II,

III

57
 
High Deductible and Consumer­Driven Health Plans

See page 48­49 for an explanation of the columns on these pages.

Total 102% of Total

Telephone Enrollment Code Monthly Premium Monthly Premium

Number

Self Self & Self Self & Self Self &

Only Family Only Family Only Family Plan Name

Aetna HealthFund­HDHP­ Mostof Idaho 877­459­6604 224 225 268.04 587.02 273.40 598.76

800­377­4161 9K4 9K5 398.84 826.28 406.82

877­459­6604 221 222 350.83 806.89 357.85

Aetna HealthFund­HDHP­ Mostof Illinois 877­459­6604 224 225 268.04 587.02 273.40 598.76

800­755­3901 MM4 MM5 485.92 1052.72 495.64

Health Alliance HMO ­HDHP­ 800­851­3379 FM1 FM2 403.17 903.65 411.23 921.72

Central, E cent.,N. cent.So, W. Illinois

888­393­6765 MW1 MW2 287.32 660.81 293.07

Unicare HMO ­HDHP­ ChicagolandArea 888­234­8855 721 722 291.37 637.13 297.20 649.87

877­835­9861 E91 E92 305.31 682.07 311.42

UnitedHealthcare Insurance Company, Inc. ­CDHP­ 877­835­9861 E94 E95 357.05 790.36 364.19 806.17

St.LouisArea

Guam

TakeCare ­HDHP­ Guam/N. MarianaIslands/Belau (Palau)

Idaho

Aetna HealthFund­CDHP­ Mostof Idaho

Altius Health Plans ­HDHP­ Southern Region

Illinois

Aetna HealthFund­CDHP­ Mostof Illinois

Group Health Plan, Inc. ­HDHP­ Southern/Central

Humana CoverageFirst ­CDHP­ ChicagoArea

UnitedHealthcare Insurance Company, Inc. ­HDHPSt.LouisArea

671­647­3526

877­459­6604

KX1

221

KX2

222

380.40

350.83

959.66

806.89

388.01

357.85

978.85

823.03

842.81

823.03

1073.77

674.03

695.71

58
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

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

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Benefit

Type

Prescription

Drugs

Levels I, II,

III

59
 
High Deductible and Consumer­Driven Health Plans

See page 48­49 for an explanation of the columns on these pages.

Total 102% of Total

Telephone Enrollment Code Monthly Premium Monthly Premium

Number

Self Self & Self Self & Self Self &

Only Family Only Family Only Family Plan Name

Aetna HealthFund­CDHP­ Allof Indiana 877­459­6604 221 222 350.83 806.89 357.85 823.03

Aetna HealthFund­HDHP­ Allof Indiana 877­459­6604 224 225 268.04 587.02 273.40 598.76

BluegrassFamily Health ­HDHP­ Southern Indiana 800­787­2680 KV1 KV2 433.33 866.65 442.00 883.98

Health Alliance HMO ­HDHP­ Western Indiana 800­851­3379 FM1 FM2 403.17 903.65 411.23 921.72

Humana CoverageFirst ­CDHP­ Eastern IndianaArea 888­393­6765 L81 L82 351.72 808.97 358.75 825.15

Humana CoverageFirst ­CDHP­ Lake/Porter/LaPorte Counties 888­393­6765 MW1 MW2 287.32 660.81 293.07 674.03

Unicare HMO ­HDHP­ Lake/Porter Counties 888­234­8855 721 722 291.37 637.13 297.20 649.87

Iowa

Aetna HealthFund­CDHP­ Allof Iowa 877­459­6604 221 222 350.83 806.89 357.85 823.03

Aetna HealthFund­HDHP­ Allof Iowa 877­459­6604 224 225 268.04 587.02 273.40 598.76

Coventry Health Careof Iowa­HDHP­ Central/Eastern/Western Iowa800­257­4692 SV4 SV5 328.34 783.58 334.91 799.25

Health Alliance HMO ­HDHP­ Central Iowa 800­851­3379 FM1 FM2 403.17 903.65 411.23 921.72

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Central Iowa 877­835­9861 E91 E92 305.31 682.07 311.42 695.71

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Central Iowa 877­835­9861 E94 E95 357.05 790.36 364.19 806.17

Indiana

60
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%

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

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Benefit

Type

Prescription

Drugs

Levels I, II,

III

61
 
High Deductible and Consumer­Driven Health Plans

See page 48­49 for an explanation of the columns on these pages.

Kansas

877­459­6604 221 222 350.83 806.89 357.85

Aetna HealthFund­HDHP­ Mostof Kansas 877­459­6604 224 225 268.04 587.02 273.40 598.76

Localphone# 114 115 369.76 865.93 377.16

Coventry Health Careof Kansas (Kansas City)­HDHP ­HDHP­ 800­969­3343 9H1 9H2 291.55 685.12 297.38 698.82

Kansas City/Wichita/SalinaAreas

888­393­6765 PH1 PH2 271.22 623.87 276.64

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Kansas CityArea 877­835­9861 E91 E92 305.31 682.07 311.42 695.71

877­835­9861 E94 E95 357.05 790.36 364.19

877­459­6604 221 222 350.83 806.89 357.85

Aetna HealthFund­HDHP­ Mostof Kentucky 877­459­6604 224 225 268.04 587.02 273.40 598.76

800­787­2680 KV1 KV2 433.33 866.65 442.00

Humana CoverageFirst ­CDHP­ Lexington Area 888­393­6765 6N1 6N2 351.72 808.97 358.75 825.15

888­393­6765 L81 L82 351.72 808.97 358.75

877­459­6604 221 222 350.83 806.89 357.85

Aetna HealthFund­HDHP­ MostofLouisiana 877­459­6604 224 225 268.04 587.02 273.40 598.76

800/341­6613 HB1 HB2 378.65 879.43 386.22

Humana CoverageFirst ­CDHP­ New OrleansArea 888­393­6765 9J1 9J2 334.21 768.71 340.89 784.08

888­393­6765 9L1 9L2 369.35 849.55 376.74

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Louisiana 877­835­9861 E91 E92 305.31 682.07 311.42 695.71

Telephone

Number

Self

Only

Self &

Family

Self

Only

Self &

Family

Self

Only

Enrollment Code

Plan Name

Aetna HealthFund­CDHP­ Mostof Kansas

Blue Crossand BlueShieldService Benefit Plan ­HDHPCertain Counties in Kansas City

Humana CoverageFirst ­CDHP­ Kansas CityArea

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Kansas CityArea

Kentucky

Aetna HealthFund­CDHP­ Mostof Kentucky

BluegrassFamily Health ­HDHP­ Kentucky

Humana CoverageFirst ­CDHP­ Northern Kentucky

Louisiana

Aetna HealthFund­CDHP­ MostofLouisiana

Coventry Health CareofLouisiana HDHP ­HDHPNew Orleansarea

Humana CoverageFirst ­CDHP­ Baton RougeArea

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Louisiana

Total
 

Monthly Premium
 

877­835­9861 E94 E95 357.05 790.36

102% of Total

Monthly Premium

Self &
 

Family
 

823.03

883.25

636.35

806.17

823.03

883.98

825.15

823.03

897.02

866.54

364.19 806.17

62
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+

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

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Benefit

Type

Prescription

Drugs

Levels I, II,

III

63
 
High Deductible and Consumer­Driven Health Plans

See page 48­49 for an explanation of the columns on these pages.

Total 102% of Total

Telephone Enrollment Code Monthly Premium Monthly Premium

Number

Self Self & Self Self & Self Self &

Only Family Only Family Only Family Plan Name

Aetna HealthFund­HDHP­ Allof Maine 877­459­6604 224 225 268.04 587.02 273.40 598.76

877­459­6604 221 222 350.83 806.89 357.85

Aetna HealthFund­HDHP­ Allof Maryland 877­459­6604 224 225 268.04 587.02 273.40 598.76

800/833­7423 GZ1 GZ2 276.10 667.46 281.62

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Maryland 877­835­9861 E91 E92 305.31 682.07 311.42 695.71

877­835­9861 E94 E95 357.05 790.36 364.19

877­459­6604 221 222 350.83 806.89 357.85

Aetna HealthFund­HDHP­ Mostof Massachusetts 877­459­6604 224 225 268.04 587.02 273.40 598.76

877­459­6604 221 222 350.83 806.89 357.85

Aetna HealthFund­HDHP­ Allof Michigan 877­459­6604 224 225 268.04 587.02 273.40 598.76

800­556­9765 524 525 405.75 1015.99 413.87

877­459­6604 221 222 350.83 806.89 357.85

Aetna HealthFund­HDHP­ Mostof Minnesota 877­459­6604 224 225 268.04 587.02 273.40 598.76

Maine

Aetna HealthFund­CDHP­ Allof Maine

Maryland

Aetna HealthFund­CDHP­ Allof Maryland

Coventry Health Care HDHP ­HDHP­ Allof Maryland

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Maryland

Massachusetts

Aetna HealthFund­CDHP­ Mostof Massachusetts

Michigan

Aetna HealthFund­CDHP­ Allof Michigan

Health Alliance Plan ­HDHP­ Southeastern Michigan/Flintarea

Minnesota

Aetna HealthFund­CDHP­ Mostof Minnesota

Blue Crossand BlueShieldService Benefit Plan ­HDHP­ MI

877­459­6604 221 222 350.83 806.89 357.85

Localphone# 114 115 369.76 865.93 377.16

823.03

823.03

680.81

806.17

823.03

823.03

1036.31

823.03

883.25

64
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%

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

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Benefit

Type

Prescription

Drugs

Levels I, II,

III

65
 
High Deductible and Consumer­Driven Health Plans

See page 48­49 for an explanation of the columns on these pages.

Mississippi

877­459­6604 221 222 350.83 806.89 357.85

Aetna HealthFund­HDHP­ Mostof Mississippi 877­459­6604 224 225 268.04 587.02 273.40 598.76

877­835­9861 E91 E92 305.31 682.07 311.42

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Mississippi 877­835­9861 E94 E95 357.05 790.36 364.19 806.17

Missouri

877­459­6604 221 222 350.83 806.89 357.85

Aetna HealthFund­HDHP­ Mostof Missouri 877­459­6604 224 225 268.04 587.02 273.40 598.76

Localphone# 114 115 369.76 865.93 377.16

Coventry Health Careof Kansas (Kansas City)­HDHP ­HDHP­ 800/969­3343 9H1 9H2 291.55 685.12 297.38 698.82

Kansas CityArea

800­755­3901 MM4 MM5 485.92 1052.72 495.64

Humana CoverageFirst ­CDHP­ Kansas CityArea 888­393­6765 PH1 PH2 271.22 623.87 276.64 636.35

877­835­9861 E91 E92 305.31 682.07 311.42

UnitedHealthcare Insurance Company, Inc. ­CDHP­ 877­835­9861 E94 E95 357.05 790.36 364.19 806.17

Kansas City,Springfield,St.LouisArea

Montana

877­459­6604 221 222 350.83 806.89 357.85

Aetna HealthFund­HDHP­ South/Southeast/Western Montana 877­459­6604 224 225 268.04 587.02 273.40 598.76

Nebraska

877­459­6604 221 222 350.83 806.89 357.85

Aetna HealthFund­HDHP­ Mostof Nebraska 877­459­6604 224 225 268.04 587.02 273.40 598.76

Telephone

Number

Self

Only

Self &

Family

Self

Only

Self &

Family

Self

Only

Enrollment Code

Plan Name

Aetna HealthFund­CDHP­ Mostof Mississippi

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Mississippi

Aetna HealthFund­CDHP­ Mostof Missouri

Blue Crossand BlueShieldService Benefit Plan ­HDHPCertain Counties in Kansas City

Group Health Plan, Inc. ­HDHP­ St.LouisArea

UnitedHealthcare Insurance Company, Inc. ­HDHPKansas City,Springfield,St.LouisArea

Aetna HealthFund­CDHP­ South/Southeast/Western Montana

Aetna HealthFund­CDHP­ Mostof Nebraska

Total
 

Monthly Premium
 

102% of Total

Monthly Premium

Self &
 

Family
 

823.03

695.71

823.03

883.25

1073.77

695.71

823.03

823.03

66
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

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%

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Benefit

Type

Prescription

Drugs

Levels I, II,

III

67
 
High Deductible and Consumer­Driven Health Plans

See page 48­49 for an explanation of the columns on these pages.

Total 102% of Total

Telephone Enrollment Code Monthly Premium Monthly Premium

Number

Self Self & Self Self & Self Self &

Only Family Only Family Only Family Plan Name

Aetna HealthFund­CDHP­ LasVegas/Clarkand Nye Counties 877­459­6604 221 222 350.83 806.89 357.85 823.03

Aetna HealthFund­HDHP­ LasVegas/Clarkand Nye Counties 877­459­6604 224 225 268.04 587.02 273.40 598.76

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Nevada 877­835­9861 E91 E92 305.31 682.07 311.42 695.71

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Nevada 877­835­9861 E94 E95 357.05 790.36 364.19 806.17

New Hampshire

Aetna HealthFund­CDHP­ Allof New Hampshire 877­459­6604 221 222 350.83 806.89 357.85 823.03

Aetna HealthFund­HDHP­ Allof New Hampshire 877­459­6604 224 225 268.04 587.02 273.40 598.76

New Jersey

Aetna HealthFund­CDHP­ Allof New Jersey 877­459­6604 221 222 350.83 806.89 357.85 823.03

Aetna HealthFund­HDHP­ Allof New Jersey 877­459­6604 224 225 268.04 587.02 273.40 598.76

Coventry Health Care HDHP ­HDHP­ Southern New Jersey 800/833­7423 LK1 LK2 353.15 855.62 360.21 872.73

New Mexico

Aetna HealthFund­CDHP­ Albuquerque/DonaAna/HobbsAreas 877­459­6604 221 222 350.83 806.89 357.85 823.03

Aetna HealthFund­HDHP­ Albuquerque/DonaAna/HobbsAreas 877­459­6604 224 225 268.04 587.02 273.40 598.76

UnitedHealthcare Insurance Company, Inc. ­HDHP­ New Mexico 877­835­9861 E91 E92 305.31 682.07 311.42 695.71

UnitedHealthcare Insurance Company, Inc. ­CDHP­ New Mexico 877­835­9861 E94 E95 357.05 790.36 364.19 806.17

Nevada

68
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

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

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Benefit

Type

Prescription

Drugs

Levels I, II,

III

69
 
High Deductible and Consumer­Driven Health Plans

See page 48­49 for an explanation of the columns on these pages.

New York

877­459­6604 221 222 350.83 806.89 357.85

Aetna HealthFund­HDHP­ Mostof New York 877­459­6604 224 225 268.04 587.02 273.40 598.76

877/269­2134 SX1 SX2 284.72 734.61 290.41

Independent Health Assoc ­HDHP­ Western New York 800/501­3439 QA4 QA5 371.61 930.48 379.04 949.09

North Carolina

877­459­6604 221 222 350.83 806.89 357.85

Aetna HealthFund­HDHP­ Allof North Carolina 877­459­6604 224 225 268.04 587.02 273.40 598.76

877­835­9861 E91 E92 305.31 682.07 311.42

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Mostof NC 877­835­9861 E94 E95 357.05 790.36 364.19 806.17

North Dakota

877­459­6604 221 222 350.83 806.89 357.85

Aetna HealthFund­HDHP­ Mostof North Dakota 877­459­6604 224 225 268.04 587.02 273.40 598.76

Ohio

877­459­6604 221 222 350.83 806.89 357.85

Aetna HealthFund­HDHP­ Allof Ohio 877­459­6604 224 225 268.04 587.02 273.40 598.76

330­363­6360 3A4 3A5 365.15 731.66 372.45

Blue Crossand BlueShieldService Benefit Plan ­HDHP­ Ohio Localphone# 114 115 369.76 865.93 377.16 883.25

888­393­6765 L81 L82 351.72 808.97 358.75

Paramount Health Care ­HDHP­ Northwest/North Central Ohio 800/462­3589 U24 U25 389.26 907.99 397.05 926.15

877­835­9861 E91 E92 305.31 682.07 311.42

UnitedHealthcare Insurance Company, Inc. ­CDHP­ 877­835­9861 E94 E95 357.05 790.36 364.19 806.17

Clevelandand ColumbusAreas

Self

Only

Self &

Family

Self

Only

Self &

Family

Self

Only Plan Name

Aetna HealthFund­CDHP­ Mostof New York

CDPHP Universal Benefits ­ HDHP ­HDHP­ Upstate,

Hudson Valley, Cent New York

Aetna HealthFund­CDHP­ Allof North Carolina

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Mostof NC

Aetna HealthFund­CDHP­ Mostof North Dakota

Aetna HealthFund­CDHP­ Allof Ohio

AultCare HMO ­HDHP­ Stark/Carroll/Holmes/Tuscarawas/Wayne Co.

Humana CoverageFirst ­CDHP­ Cincinnati/Dayton Area

UnitedHealthcare Insurance Company, Inc. ­HDHPClevelandand ColumbusAreas

Total

Telephone Enrollment Code Monthly Premium

Number

102% of Total

Monthly Premium

Self &
 

Family
 

823.03

749.30

823.03

695.71

823.03

823.03

746.29

825.15

695.71

70
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%

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

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Benefit

Type

Prescription

Drugs

Levels I, II,

III

71
 
High Deductible and Consumer­Driven Health Plans

See page 48­49 for an explanation of the columns on these pages.

Oklahoma

877­459­6604 221 222 350.83 806.89 357.85

Aetna HealthFund­HDHP­ Mostof Oklahoma 877­459­6604 224 225 268.04 587.02 273.40 598.76

877­835­9861 E91 E92 305.31 682.07 311.42

UnitedHealthcare Insurance Company, Inc. ­CDHP­ 877­835­9861 E94 E95 357.05 790.36 364.19 806.17

Centraland North East Oklahoma

Oregon

877­459­6604 221 222 350.83 806.89 357.85

Aetna HealthFund­HDHP­ Mostof Oregon 877­459­6604 224 225 268.04 587.02 273.40 598.76

877­835­9861 E91 E92 305.31 682.07 311.42

UnitedHealthcare Insurance Company, Inc. ­CDHP­ 877­835­9861 E94 E95 357.05 790.36 364.19 806.17

Metro Portland/Salem/Corvalis/Eugene

Pennsylvania

877­459­6604 221 222 350.83 806.89 357.85

Aetna HealthFund­HDHP­ Allof Pennsylvania 877­459­6604 224 225 268.04 587.02 273.40 598.76

866­351­5946 9N1 9N2 435.07 982.84 443.77

HealthAmerica Pennsylvania­HDHP ­HDHP­ Greater Pittsburgh Area 866­351­5946 Y61 Y62 374.88 925.80 382.38 944.32

866­351­5946 YW1 YW2 446.83 1011.57 455.77

UPMC Health Plan ­HDHP­ Western Pennsylvania 888­876­2756 8W4 8W5 454.85 1009.75 463.95 1029.95

Rhode Island

877­459­6604 221 222 350.83 806.89 357.85

Aetna HealthFund­HDHP­ Allof Rhode Island 877­459­6604 224 225 268.04 587.02 273.40 598.76

877­835­9861 E91 E92 305.31 682.07 311.42

UnitedHealthcare Insurance Company, Inc. ­CDHP­ RI 877­835­9861 E94 E95 357.05 790.36 364.19 806.17

Telephone

Number

Self

Only

Self &

Family

Self

Only

Self &

Family

Self

Only

Enrollment Code

Plan Name

Aetna HealthFund­CDHP­ Mostof Oklahoma

UnitedHealthcare Insurance Company, Inc. ­HDHPCentraland North East Oklahoma

Aetna HealthFund­CDHP­ Mostof Oregon

UnitedHealthcare Insurance Company, Inc. ­HDHPMetro Portland/Salem/Corvalis/Eugene

Aetna HealthFund­CDHP­ Allof Pennsylvania

HealthAmerica Pennsylvania­HDHP ­HDHP­ Southeastern PA

HealthAmerica Pennsylvania­HDHP ­HDHP­ Central Pennsylvania

Aetna HealthFund­CDHP­ Allof Rhode Island

UnitedHealthcare Insurance Company, Inc. ­HDHP­ RI

Total
 

Monthly Premium
 

102% of Total

Monthly Premium

Self &
 

Family
 

823.03

695.71

823.03

695.71

823.03

1002.50

1031.80

823.03

695.71

72
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

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%z

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

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Benefit

Type

Prescription

Drugs

Levels I, II,

III

73
 
High Deductible and Consumer­Driven Health Plans

See page 48­49 for an explanation of the columns on these pages.

Total 102% of Total

Telephone Enrollment Code Monthly Premium Monthly Premium

Number

Self Self & Self Self & Self Self &

Only Family Only Family Only Family Plan Name

Aetna HealthFund­CDHP­ MostofSouth Carolina 877­459­6604 221 222 350.83 806.89 357.85 823.03

Aetna HealthFund­HDHP­ MostofSouth Carolina 877­459­6604 224 225 268.04 587.02 273.40 598.76

South Dakota

Aetna HealthFund­CDHP­ Rapid City/SiouxFallsAreas 877­459­6604 221 222 350.83 806.89 357.85 823.03

Aetna HealthFund­HDHP­ Rapid City/SiouxFallsAreas 877­459­6604 224 225 268.04 587.02 273.40 598.76

Tennessee

Aetna HealthFund­CDHP­ Mostof Tennessee 877­459­6604 221 222 350.83 806.89 357.85 823.03

Aetna HealthFund­HDHP­ Mostof Tennessee 877­459­6604 224 225 268.04 587.02 273.40 598.76

Blue Crossand BlueShieldService Benefit Plan ­HDHP­ Tennesee Localphone# 114 115 369.76 865.93 377.16 883.25

BluegrassFamily Health ­HDHP­ Knoxville/Nashville Areas 800­787­2680 KV1 KV2 433.33 866.65 442.00 883.98

Humana CoverageFirst ­CDHP­ NashvilleArea 888­393­6765 BT1 BT2 351.72 808.97 358.75 825.15

Humana CoverageFirst ­CDHP­ MemphisArea 888­393­6765 L61 L62 354.51 815.47 361.60 831.78

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Tennessee 877­835­9861 E91 E92 305.31 682.07 311.42 695.71

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Tennessee 877­835­9861 E94 E95 357.05 790.36 364.19 806.17

South Carolina

74
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%

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

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Benefit

Type

Prescription

Drugs

Levels I, II,

III

75
 
High Deductible and Consumer­Driven Health Plans

See page 48­49 for an explanation of the columns on these pages.

Total 102% of Total

Telephone Enrollment Code Monthly Premium Monthly Premium

Number

Self Self & Self Self & Self Self &

Only Family Only Family Only Family Plan Name

Aetna HealthFund­CDHP­ Mostof Texas 877­459­6604 221 222 350.83 806.89 357.85 823.03

Aetna HealthFund­HDHP­ Mostof Texas 877­459­6604 224 225 268.04 587.02 273.40 598.76

Humana CoverageFirst ­CDHP­ Houston Area 888­393­6765 T21 T22 354.16 814.60 361.24 830.89

Humana CoverageFirst ­CDHP­ Dallas/Ft. Worth Area 888­393­6765 T81 T82 438.92 1009.65 447.70 1029.84

Humana CoverageFirst ­CDHP­ Corpus ChristiArea 888­393­6765 TP1 TP2 354.21 814.71 361.29 831.00

Humana CoverageFirst ­CDHP­ San AntonioArea 888­393­6765 TU1 TU2 336.94 775.00 343.68 790.50

Humana CoverageFirst ­CDHP­ Austin Area 888­393­6765 TV1 TV2 354.51 815.45 361.60 831.76

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Mostof TX 877­835­9861 E91 E92 305.31 682.07 311.42 695.71

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Mostof TX 877­835­9861 E94 E95 357.05 790.36 364.19 806.17

Utah

Aetna HealthFund­CDHP­ Mostof Utah 877­459­6604 221 222 350.83 806.89 357.85 823.03

Aetna HealthFund­HDHP­ Mostof Utah 877­459­6604 224 225 268.04 587.02 273.40 598.76

Altius Health Plans ­HDHP­ Wasatch Front 800­377­4161 9K4 9K5 398.84 826.28 406.82 842.81

Humana CoverageFirst ­CDHP­ SaltLake CityArea 888­393­6765 IA1 IA2 351.72 808.97 358.75 825.15

Vermont

Aetna HealthFund­CDHP­ AllofVermont 877­459­6604 221 222 350.83 806.89 357.85 823.03

Aetna HealthFund­HDHP­ AllofVermont 877­459­6604 224 225 268.04 587.02 273.40 598.76

Texas

76
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

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%

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Benefit

Type

Prescription

Drugs

Levels I, II,

III

77
 
High Deductible and Consumer­Driven Health Plans

See page 48­49 for an explanation of the columns on these pages.

Total 102% of Total

Telephone Enrollment Code Monthly Premium Monthly Premium

Number

Self Self & Self Self & Self Self &

Only Family Only Family Only Family Plan Name

Aetna HealthFund­CDHP­ MostofVirginia 877­459­6604 221 222 350.83 806.89 357.85 823.03

Aetna HealthFund­HDHP­ MostofVirginia 877­459­6604 224 225 268.04 587.02 273.40 598.76

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Virginia 877­­835­9861 E91 E92 305.31 682.07 311.42 695.71

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Virginia 877­­835­9861 E94 E95 357.05 790.36 364.19 806.17

Washington

Aetna HealthFund­CDHP­ Mostof Washington 877­459­6604 221 222 350.83 806.89 357.85 823.03

Aetna HealthFund­HDHP­ Mostof Washington 877­459­6604 224 225 268.04 587.02 273.40 598.76

KPS Health Plans ­HDHP­ Allof Washington 800/552­7114 L14 L15 319.11 697.30 325.49 711.25

UnitedHealthcare Insurance Company, Inc. ­HDHP­ 877­835­9861 E91 E92 305.31 682.07 311.42 695.71

Mostof Washington

UnitedHealthcare Insurance Company, Inc. ­CDHP­ 877­835­9861 E94 E95 357.05 790.36 364.19 806.17

Mostof Washington

West Virginia

Aetna HealthFund­CDHP­ Mostof WestVirginia 877­459­6604 221 222 350.83 806.89 357.85 823.03

Aetna HealthFund­HDHP­ Mostof WestVirginia 877­459­6604 224 225 268.04 587.02 273.40 598.76

Virginia

78
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

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%

Plan Name

Premium

Contribution

to HSA/HRA

CY Ded.

Self/Family

Cat. Limit

Self/Family

Office

Visit

Inpatient

Hospital

Outpatient

Surgery

Preventive

Services

Benefit

Type

Prescription

Drugs

Levels I, II,

III

79
 
High Deductible and Consumer­Driven Health Plans

See page 48­49 for an explanation of the columns on these pages.

Total 102% of Total

Telephone Enrollment Code Monthly Premium Monthly Premium

Number

Self Self & Self Self & Self Self &

Only Family Only Family Only Family Plan Name

Aetna HealthFund­CDHP­ Allof Wisconsin 877­459­6604 221 222 350.83 806.89 357.85 823.03

Aetna HealthFund­HDHP­ Allof Wisconsin 877­459­6604 224 225 268.04 587.02 273.40 598.76

UnitedHealthcare Insurance Company, Inc. ­HDHP­ Wisconsin 877­835­9861 E91 E92 305.31 682.07 311.42 695.71

UnitedHealthcare Insurance Company, Inc. ­CDHP­ Wisconsin 877­835­9861 E94 E95 357.05 790.36 364.19 806.17

Wyoming

Aetna HealthFund­CDHP­ Allof Wyoming 877­459­6604 221 222 350.83 806.89 357.85 823.03

Aetna HealthFund­HDHP­ Allof Wyoming 877­459­6604 224 225 268.04 587.02 273.40 598.76

Altius Health Plans ­HDHP­ Uinta County 800­377­4161 9K4 9K5 398.84 826.28 406.82 842.81

Wisconsin

80
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

Benefit

Type

Prescription

Drugs

Levels I, II,

III

81