ATTACHMENT 2 – FEHB PROGRAM 

TABLE 1 

PLANS LEAVING THE FEHB PROGRAM 

Enrollees in these terminating plans who do not change health plans by making a positive 

election into another FEHB plan during Open Season will not have health benefits for 2010. 

 

State Plan Name 3 Digit Plan Code 

Arizona PacifiCare of Arizona A31, A32 

Colorado PacifiCare of Colorado D61, D62 

Connecticut ConnectiCare TE1, TE2 

TE4, TE5 

Florida UnitedHealthcare of Florida R31, R32 

Florida JMH Health Plan J81, J82 

J84, J85 

Illinois PersonalCare Insurance of Illinois GE1, GE2 

Illinois Group Health Plan MM1, MM2 

MU4, MU5 

MM4*, MM5* 

(*See Table 3 for 

MM4 & MM5) 

Illinois Unicare 171, 172, 

174, 175, 

721*, 722* 

(*See Table 3 for 

721 & 722) 

Indiana Unicare 171, 172, 

174, 175 

721*, 722* 

(*See Table 3 for 

721 & 722) 

Massachusetts ConnectiCare TE1, TE2 

TE4, TE5 

Missouri Group Health Plan MM1, MM2 

MU4, MU5 

MM4*, MM5* 

(*See Table 3 for 

MM4 & MM5) 

Oklahoma PacifiCare of Oklahoma 2N1, 2N2 

Ohio UnitedHealthcare of Ohio AK1, AK2 

CA1, CA2 

Ohio Paramount Health Care U21, U22 

U24*, U25* 

(See Table 3 for 

U24 & U25) 

Pennsylvania Keystone Health Plan Central S41, S42 

S44, S45 

Pennsylvania Keystone Health Plan East ED1, ED2 

ED4, ED5 

1
TABLE 2 

PLANS REDUCING THEIR SERVICE AREAS 

AND TERMINATING ENROLLMENT CODES 

Enrollees in these terminating enrollment codes who do not change health plans by making 

a positive election into another FEHB plan during Open Season will not have health 

benefits for 2010. 

State Plan Name 3 Plan Digit 

Code 

Area Dropped 

California Blue Shield of California 

Access+ HMO 

SJ1, SJ2 Northern California (except Tulare 

County-see Table 7) 

Colorado Humana CoverageFirst FC1, FC2 Colorado Springs 

7T1, 7T2 Denver 

Delaware Coventry Health Care 2J1, 2J2 

2J4, 2J5 

LK1*, LK2* 

(*See Table 4 

for LK1, LK2) 

State of Delaware 

Florida Humana CoverageFirst DL1, DL2 Daytona 

BP1, BP2 Pensacola/Fort Walton 

Indiana Aetna Open Access RD1, RD2 Southeastern Indiana 

Indiana Humana CoverageFirst L81, L82 Eastern Indiana 

Kansas UnitedHealthcare of 

Midwest, Inc. 

GX1, GX2 Kansas City 

Kentucky Aetna Open Access RD1, RD2 Northern Kentucky 

Kentucky Humana CoverageFirst L81, L82 Northern Kentucky 

Missouri UnitedHealthcare of 

Midwest, Inc. 

GX1, GX2 Kansas City 

Nevada Aetna Open Access Y11, Y12 Las Vegas and Reno areas 

New Jersey Coventry Health Care 2J1, 2J2 

2J4, 2J5 

LK1*, LK2* 

(*See Table 4 

for LK1, LK2) 

Southern New Jersey 

Ohio Aetna Open Access ND1, ND2 Columbus area 

RD1, RD2 Greater Cincinnati area 

Table 2 - continued on next page 2
TABLE 2 

(continued from previous page) 

PLANS REDUCING THEIR SERVICE AREAS 

AND TERMINATING ENROLLMENT CODES 

Enrollees in these terminating enrollment codes who do not change health plans by making 

a positive election into another FEHB plan during Open Season will not have health 

benefits for 2010. 

State Plan Name 3 Plan Digit 

Code 

Area Dropped 

Ohio Humana CoverageFirst L81, L82 Cincinnati / Dayton 

Oklahoma Aetna Open Access SL1, SL2 

SL4, SL5 

Oklahoma City / Tulsa areas 

Tennessee Aetna Open Access 6J1, 6J2 Nashville area 

Texas Aetna Open Access 8G1, 8G2 Houston area 

Texas FirstCare 6U1, 6U2 Central Texas 

3
TABLE 3 

EXISTING PLANS TERMINATING THEIR HIGH DEDUCTIBLE HEALTH PLANS 

(HDHP) AND TERMINATING THEIR HDHP ENROLLMENT CODES 

Enrollees in these enrollment codes who do not change health plans during Open Season 

will not have health benefits for 2010. 

Enrollees who are active employees and want to continue enrollment in 2010 in a HDHP 

and receive or make additional contributions to the Health Savings Account (HSA), must 

change to another HDHP in the FEHB Program during Open Season. They need to contact 

their current 2009 HDHP HSA Fiduciary and the Internal Revenue Service (IRS) for any 

guidance and questions about their HSA including tax considerations and penalties. If 

enrollees are interested in consolidating their HSA accounts, they also need to contact their 

upcoming 2010 HDHP HSA Fiduciary. 

If enrollees do not want to continue in a HDHP, they must change to another health plan 

option during Open Season or they will not have health benefits for 2010. However, the 

enrollees must contact the HDHP HSA Fiduciary and IRS for any guidance and questions 

about the HSA concerning tax considerations and penalties. 

State Plan Name 3 Digit Plan 

Code 

Illinois Group Health Plan – HDHP 

(See Table 1 also) 

MM4, MM5 

Illinois Unicare – HDHP 

(See Table 1 also) 

721, 722 

Indiana Unicare – HDHP 

(See Table 1 also) 

721, 722 

Missouri Group Health Plan – HDHP 

(See Table 1 also) 

MM4, MM5 

New York CDPHP Universal Benefits – HDHP SX1, SX2 

Ohio Paramount Health Care 

(See Table 1 also) 

U24, U25 

4
TABLE 4 

HIGH DEDUCTIBLE HEALTH PLANS (HDHP) REDUCING THEIR SERVICE AREAS 

BY TERMINATING ENROLLMENT CODES 

Enrollees in these enrollment codes who do not change health plans during Open Season 

will not have health benefits for 2010. 

Enrollees who are active employees and want to continue enrollment in 2010 in a HDHP 

and receive or make additional contributions to the Health Savings Account (HSA), must 

change to another HDHP in the FEHB Program during Open Season. They need to contact 

their current 2009 HDHP HSA Fiduciary and the Internal Revenue Service (IRS) for any 

guidance and questions about their HSA including tax considerations and penalties. If 

enrollees are interested in consolidating their HSA accounts, they also need to contact their 

upcoming 2010 HDHP HSA Fiduciary. 

If enrollees do not want to continue in a HDHP, they must change to another health plan 

option during Open Season or they will not have health benefits for 2010. However, the 

enrollees must contact their HDHP HSA Fiduciary and IRS for any guidance and questions 

about the HSA concerning tax considerations and penalties. 

State Plan Name 3 Digit Plan 

Code 

Area Dropped 

Delaware Coventry Health Care 

HDHP 

(See Table 2 also) 

LK1, LK2 State of Delaware 

New Jersey Coventry Health Care 

HDHP 

(See Table 2 also) 

LK1, LK2 Southern New Jersey 

5
TABLE 5 

PLANS REDUCING THEIR SERVICE AREAS 

WITHOUT TERMINATING ENROLLMENT CODES 

Enrollees in the service area being dropped who do not change health plans during Open 

Season will have to travel to their plan’s remaining service area to obtain medical care in 

order to receive full benefits from the plan in 2010. 

State Plan Name 3 Digit Plan 

Code 

Area Dropped 

California PacifiCare of California CY1, CY2 Entire counties of Alameda, Contra Costa, 

El Dorado, Marin, Placer, Sacramento, 

San Francisco, San Joaquin, San Mateo, 

Santa Clara, Santa Cruz, Solano, Sonoma, 

Stanislaus and Yolo 

California Anthem Blue Cross M51, M52 Entire counties of Butte, El Dorado, Lake 

Lassen, Modoc, Plumas, San Benito and 

Tulare 

Connecticut Aetna Open Access JC1, JC2 

JC4, JC5 

Entire state of Connecticut 

Florida Humana CoverageFirst QP1, QP2 Entire counties of St. Lucia, Indian River, 

and Okeehobee 

North 

Carolina 

Aetna Open Access JN1, JN2 

JN4, JN5 

Charlotte and Raleigh/Durham areas and 

entire counties of Anson, Cabarrus, 

Cleveland, Durham, Gaston, Iredell, 

Lincoln, Mecklenburg, Orange, Rowan 

Union and Wake 

Pennsylvania Aetna Open Access P31, P32 

P34, P35 

Entire counties of Adams, Cumberland, 

Dauphin, Franklin, Fulton, Lancaster, 

Lebanon, Perry, Schuylkill and York 

Texas PacifiCare of Texas GF1, GF2 Entire counties of Collin, Dallas, Denton, 

Ellis, Hood, Hunt, Johnson, Kaufman, 

Rockwell, Tarrant and Wise 

Texas FirstCare CK1, CK2 Entire counties of Andrews, Armstrong, 

Bailey, Borden, Brewster, Briscoe, Carson, 

Castro, Childress, Cochran, Collingsworth, 

Cottle, Crane, Crosby, Dallam, Dawson, 

Deaf Smith, Dickens, Donley, Ector, 

Floyd, Gaines, Garza, Glasscock, Gray, 

Hale, Hall, Hansford, Hartley, Hemphill, 

Hockley, Howard, Hutchinson, King, 

Lamb, Lipscomb, Loving, Lubbock, Lynn, 

Martin, Midland, Motley, Ochiltree, 

Oldham, Parmer, Pecos, Reagan, Reeves, 

Roberts, Scurry, Sherman, Terry, Upton, 

Ward, Wheeler, Winkler, and Yoakum 

6 Table 5 - continued on next page 
TABLE 5 

(continued from previous page) 

PLANS REDUCING THEIR SERVICE AREAS 

WITHOUT TERMINATING ENROLLMENT CODES 

Enrollees in the service area being dropped who do not change health plans during Open 

Season will have to travel to their plan’s remaining service area to obtain medical care in 

order to receive full benefits from the plan in 2010. 

State Plan Name 3 Digit Plan 

Code 

Area Dropped 

Virginia M.D. IPA JP1, JP2 Entire cities of Chesapeake, Clifton Forge, 

Covington, Franklin, Hampton, Newport 

News, Norfolk, Norton, Poquoson, 

Portsmouth, Radford, Roanoke, Salem, 

Staunton, Suffolk, Virginia Beach, 

Waynesboro, and Williamsburg; and 

Entire counties of Accomack, Allegheny, 

Augusta, Bath, Bedford, Bland, Botetourt, 

Buchanan, Buckingham, Charlotte, Craig, 

Floyd, Franklin, Giles, Gloucester, Isle of 

Wight, James City, Mathews, Middlesex, 

Montgomery, Nelson, Northampton, 

Patrick, Pulaski, Roanoke, Southampton, 

Surry, Tazewell and York 

7
TABLE 6 

PLANS DROPPING OPTIONS FOR 2010 

Enrollees in these plans will be automatically enrolled in their plans’ remaining option 

unless they make a positive enrollment change to another plan during Open Season. 

State Plan Name Dropping 

Options 

(end of 2009) 

Dropping 

Codes 

(end of 2009) 

Remaining Options 

and Codes for 2010 

Illinois Health Alliance – HMO Standard 

HDHP* 

FX4, FX5 

FM1*, FM2* 

High 

FX1, FX2 

Indiana Health Alliance – HMO Standard 

HDHP* 

FX4, FX5 

FM1*, FM2* 

High 

FX1, FX2 

Iowa Health Alliance – HMO Standard 

HDHP* 

FX4, FX5 

FM1*, FM2* 

High 

FX1, FX2 

New Mexico Presbyterian Health Plan Standard P24, P25 High 

P21, P22 

Pennsylvania 

(Central) 

High SW1, SW2 Standard 

SW4, SW5 

(**See Note Below) 

Pennsylvania 

(Southeastern) 

HealthAmerica 

Pennsylvania 

High PN1, PN2 Standard 

PN4, PN5 

(**See Note Below) 

* Health Alliance’s FM1 and FM2 High Deductible Health Plan (HDHP) enrollees who are 

active employees and want to continue enrollment in 2010 in a HDHP must change to 

another HDHP in the FEHB Program during Open Season if they want to continue to 

receive or make additional contributions to the Health Savings Account (HSA). They need 

to contact their current 2009 HDHP HSA Fiduciary and the Internal Revenue Service (IRS) 

for any guidance and questions about their HSA including tax considerations and penalties. 

If enrollees are interested in consolidating their HSA accounts, they also need to contact 

their upcoming 2010 HDHP HSA Fiduciary. 

If Health Alliance’s FM1 and FM2 enrollees do not make a positive enrollment change into 

another HDHP plan or another FEHB plan during Open Season, these enrollees will be 

moved automatically into Health Alliance’s remaining FX1 or FX2 High Option code. 

(These enrollees should also contact the HSA Fiduciary and the IRS for any guidance and 

questions about the HSA including tax considerations and penalties.) 

**NOTE: Enrollees in HealthAmerica Pennsylvania’s High Option codes SW1 and SW2 for 

Central PA and codes PN1 and PN2 for Southeastern PA will be automatically enrolled in 

the plan’s Standard Option codes SW4 and SW5 for Central PA and PN4 and PN5 for 

Southeastern PA unless they make a positive enrollment change to another plan during 

Open Season. However, enrollees in HealthAmerica’s HDHP codes YW1 and YW2 for 

Central PA and codes 9N1 and 9N2 for Southeastern PA are not affected by this change and 

will remain in their codes unless they make a positive election into another plan code. 

Table 6 - continued on next page 

8
TABLE 6 

(continued from previous page) 

PLANS DROPPING OPTIONS FOR 2010 

Enrollees in these plans will be automatically enrolled in their plans’ remaining option 

unless they make a positive enrollment change to another plan during Open Season. 

State Plan Name Dropping 

Options 

(end of 2009) 

Dropping 

Codes 

(end of 2009) 

Remaining Options 

and Codes for 2010 

Kansas Blue Cross and Blue Shield 

Service Benefit Plan 

(BCBS of Kansas City, 

Missouri) 

Basic Consumer 

Option Program 

(HDHP) 

114, 115 Basic 

111, 112 

(***See Note Below) 

Missouri Blue Cross and Blue Shield 

Service Benefit Plan 

(BCBS of Kansas City, 

Missouri) 

Basic Consumer 

Option Program 

(HDHP) 

114, 115 Basic 

111, 112 

(***See Note Below) 

Minnesota Blue Cross and Blue Shield 

Service Benefit Plan 

(BCBS of Minnesota) 

Basic Consumer 

Option Program 

(HDHP) 

114, 115 Basic 

111, 112 

(***See Note Below) 

Ohio Blue Cross and Blue Shield 

Service Benefit Plan 

(Anthem BCBS of Ohio) 

Basic Consumer 

Option Program 

(HDHP) 

114, 115 Basic 

111, 112 

(***See Note Below) 

Tennessee Blue Cross and Blue Shield 

Service Benefit Plan 

(BCBS of Tennessee) 

Basic Consumer 

Option Program 

(HDHP) 

114, 115 Basic 

111, 112 

(***See Note Below) 

***NOTE: Enrollees in Blue Cross and Blue Shield Service (BCBS) Benefit Plan’s Basic 

Consumer Option Program High Deductible Health Plan (HDHP) enrollment codes 114 and 

115 who are active employees and want to continue enrollment in 2010 in a HDHP must 

change to another HDHP in the FEHB Program during Open Season if they want to 

continue to receive or make additional contributions to the Health Savings Account (HSA). 

They need to contact their current 2009 HDHP HSA Fiduciary and the Internal Revenue 

Service (IRS) for any guidance and questions about their HSA including tax considerations 

and penalties. If enrollees are interested in consolidating their HSA accounts, they also 

need to contact their upcoming 2010 HDHP HSA Fiduciary. 

If enrollees in Blue Cross and Blue Shield Service Benefit Plan’s Basic Consumer Option 

Program HDHP codes 114 and 115 do not make a positive enrollment change into another 

HDHP plan or the BCBS Service Benefit Plan’s Standard Option or another FEHB plan 

during Open Season, these enrollees will be moved automatically into Blue Cross and Blue 

Shield Service Benefit Plan’s 111 or 112 Basic Option codes. (These enrollees should also 

contact the HSA Fiduciary and the IRS for any guidance and questions about the HSA 

including tax considerations and penalties.) 

9
TABLE 7 

SERVICE AREA MOVEMENT WITH ENROLLMENT CODE CHANGE 

For 2010, Blue Shield of California Access+HMO will be terminating its Northern California 

service area and enrollment codes SJ1 and SJ2 as indicated in Table 2 on page 2. However, 

Tulare County, which is currently in the SJ1 and SJ2 Northern California Region, will not be 

terminated because it will be merged into the Southern California Region under enrollment codes 

SI1 and SI2. 

Blue Shield of California Access+HMO enrollees residing or working in Tulare County and 

currently enrolled under code SJ for the Northern California Region must make a positive 

election into code SI for the Southern California Region during Open Season for their enrollment 

in the Plan to continue. If an enrollee in Tulare County does not make a positive election into 

code SI for the Southern California Region or into another health plan during Open Season, 

they will NOT have health benefits for 2010. 

 

State Location Plan Name Old 2009 Code 

& Service Area: 

Tulare County 

in Northern 

California 

New 2010 Code 

& Service Area: 

Tulare County 

in Southern 

California 

California Tulare County Blue Shield of California 

Access+HMO 

SJ1, SJ2 SI1, SI2 

10
TABLE 8 

ENROLLMENT CODE MERGERS 

The payroll office must automatically move enrollees into their plan’s surviving code unless 

the enrollees select another health plan during Open Season. 

State Plan Name Plan Codes (2009) 2010 Surviving 

Codes 

Idaho Group Health Cooperative VR1, VR2 

VR4, VR5 

541, 542 

544, 545 

Washington Group Health Cooperative 541, 542, 544, 545 

VR1, VR2, VR4, VR5 

541, 542 

544, 545 

 

TABLE 9 

PLAN NAME CHANGES 

State 2009 Plan Name (Old) Plan Codes 2010 Plan Name (New) 

Georgia Humana, Inc. DG1, DG2 

DG4, DG5 

Humana Employers Health 

Plan of GA, Inc. 

Illinois OSF HealthPlans, Inc 9F1, 9F2 

AB4, AB5 

Humana Benefit Plan of 

Illinois, Inc. 

New York Preferred Care GV1, GV2 

GV4, GV5 

MVP Health Care – 

Western Region 

Puerto Rico Triple-S 891, 892 Triple-S Salud 

U. S. Virgin Islands Triple-S 851, 852 Triple-S Salud 

TABLE 10 

NEW PLANS ENTERING THE FEHB PROGRAM 

State Plan Name Plan Type 3 Digit Plan Code General Location 

Arkansas QualChoice HMO 

DH1, DH2 

DH4, DH5 Entire State of Arkansas 

Wisconsin Physician Plus HMO LW1, LW2 Entire County of Dane 

11
TABLE 11 

SERVICE AREA EXPANSIONS WITH NEW ENROLLMENT CODES 

State Plan Name New 3 Digit 

Plan Code 

General Location 

Georgia Humana Employers Health 

Plan of Georgia, Inc. 

DN1, DN2 

DN4, DN5 

City of Macon and entire county 

of Bibb 

Georgia Humana Employers Health 

Plan of Georgia, Inc. 

CB1, CB2 

CB4, CB5 

City of Columbus and entire 

county of Muscogee 

Indiana Humana Health Plan, Inc. MH1, MH2 

MH4, MH5 

Entire counties of Clark, Floyd, 

Harrison, Scott and Washington 

Kentucky Humana Health Plan, Inc. MH1, MH2 

MH4, MH5 

City of Louisville and entire 

counties of Bullitt, Carroll, 

Green, Hardin, Henry, Jefferson, 

Larue, Marion, Meade, Nelson, 

Oldham, Shelby, Spencer, 

Taylor, Trimble and Washington 

Kentucky Humana Health Plan, Inc MI1, MI2 

MI4, MI5 

City of Lexington and entire 

counties of Adair, Anderson, 

Bracken, Breathitt, Bourbon, 

Boyle, Casey, Clay, Clark, 

Clinton, Cumberland, Estell, 

Fayette, Fleming, Franklin, 

Garrard, Harrison, Jackson, 

Jessamine, Knox, Laurel, Lee, 

Lincoln, Madison, Mason, 

Menifee, Mercer, Montgomery, 

Nicholas, Owen, Owsley, 

Powell, Pulaski, Robertson, 

Rockcastle, Russell, Scott, 

Wayne, Whitley, Wolfe, and 

Woodford 

Texas Humana Health Plan of 

Texas 

UC1, UC2 

UC4, UC5 

City of Corpus Christi and entire 

counties of Bee, Jim Wells, 

Kleberg, Nueces, Refugio and 

San Patricio 

12
TABLE 12 

SERVICE AREA EXPANSIONS WITHOUT NEW ENROLLMENT CODES 

State Plan Name 3 Digit Plan 

Code 

General Location of New Area 

Alabama Aetna HealthFund 221, 222 

224, 225 

Entire county of Pike 

Alaska Aetna HealthFund 221, 222 

224, 225 

Entire counties of Prince Wales Outer 

Ketchikan and Sitka 

Arkansas Aetna HealthFund 221, 222 

224, 225 

Entire counties of Newton, Union and Van 

Buren 

Colorado Kaiser Foundation 

Health Plan of 

Colorado 

651, 652 

654, 655 

Entire county of Pueblo; 

The following counties by zip code: 

Crowley: 81039, 81062 

Custer: 81069, 81523 

El Paso: 81226 

Fremont: 81215, 81221, 81222, 81223, 81226, 

81232, 81233, 81240, 81244, 81246, 81253, 

81290 

Huerfano: 81069 

Las Animas: 81039 

Otero: 81039 

Florida Aetna HealthFund 221, 222 

224, 225 

Entire counties of Citrus and Highlands 

Georgia Aetna HealthFund 221, 222 

224, 225 

Entire counties of Elbert, Fannin, Franklin, 

Gilmer, Habersham, Lumpkin, Murray, 

Stephens, Talbot, Towns, Union, White, 

Whitfield and Wilkinson 

Hawaii Aetna HealthFund 221, 222 

224, 225 

Entire counties of Hawaii, Honolulu, Kauai 

and Maui 

Idaho Aetna HealthFund 221, 222 

224, 225 

Entire county of Custer 

Idaho Altius Health Plans 9K1, 9K2 

9K4, 9K5 

DK4, DK5 

Entire counties of Jefferson and Madison 

Illinois Aetna HealthFund 221, 222 

224, 225 

Entire county of Stark 

Iowa Sanford Health Plan AU1, AU2 

AU4, AU5 

Entire counties of Ida and Woodbury 

Iowa UnitedHealthcare 

Plan of the River 

Valley Inc. 

YH1, YH2 Entire counties of Boone, Bremer, Butler, 

Buchanan, Dallas, Fayette, Grundy, Guthrie, 

Madison, and Warren 

Iowa Health Alliance 

HMO 

FX1, FX2 Entire counties of Benton, Blackhawk, Brewer, 

Clinton, Delaware, Johnson, Linn, Sac, 

Warren, and Washington 

Kentucky Aetna Health Fund 221, 222 

224, 225 

Entire counties of Bracken and Martin 

Table 12 – continued on next page 13
State Plan Name 3 Digit Plan 

Code 

General Location of New Area 

Louisiana Aetna HealthFund 221, 222 

224, 225 

Entire county of Rapides 

Louisiana Vantage Health Plan, 

Inc. 

MV1, MV2 

MV4, MV5 

The Parish of St. Helena 

Massachusetts Fallon Community 

Health Plan 

JV4, JV5 Entire cities of: Abington, Acushnet, Avon, 

Braintree, Bridgewater, Carver, Dartmouth, 

Dedham, East Bridgewater, Easton, 

East Taunton, East Walpole, East Wareham, 

East Weymouth, Fairhaven, Foxboro, Halifax, 

Manomet, Marion, Mansfield, Mattapoisett, 

Milton, New Bedford, North Carver, 

North Dighton, North Dartmouth, 

North Weymouth, Norton, Norwell, Norwood, 

Pembroke, Plymouth, Randolph, Rochester, 

South Carver, South Dartmouth, 

South Weymouth, Wareham, Westport, 

Westport Point, West Wareham, Westwood, 

and White Horse Beach 

Massachusetts Fallon Community 

Health Plan 

JG1, JG2 Entire cities of: Abington, Avon, Braintree, 

Bridgewater, Dedham, East Bridgewater, 

Easton, East Taunton, East Weymouth, 

East Walpole, Foxboro, Halifax, Mansfield, 

Milton, North Dighton, North Weymouth, 

Norton, Norwell, Norwood, Pembroke, 

Randolph, South Weymouth, and Westwood 

 

Michigan HealthPlus MI X51, X52 Entire county of St. Clair 

Minnesota Aetna HealthFund 221, 222 

224, 225 

Entire county of Rock 

Mississippi Aetna HealthFund 221, 222 

224, 225 

Entire counties of Lincoln and Tishomingo 

Missouri Aetna HealthFund 221, 222 

224, 225 

Entire counties of Carroll, Cedar, Knox, 

Mercer, Ralls and Vernon 

Montana Aetna HealthFund 221, 222 

224, 225 

Entire counties of Blaine, Broadwater, 

Chouteau, Daniels, Fallon, Glacier, Golden 

Valley, Judith Basin, Liberty, Lincoln, 

Meagher, Musselshell, Petroleum, Phillips, 

Prairie, Richland, Sheridan, Treasure and 

Valley 

Montana New West Health 

Services 

NV1, NV2 Entire cities of Butte, Chester, Conrad, Fallon, 

Fort Benton, Galata, Inverness, Joplin, 

Lewistown, Mildred, Plentywood, Rudyard, 

Sidney, Terry, and White Sulphur Springs 

Table 12 – continued on next page 14
State Plan Name 3 Digit Plan 

Code 

General Location of New Area 

Nebraska Aetna HealthFund 221, 222 

224, 225

Entire counties of Arthur, Banner, Blaine, 

Boyd, Garfield, Grant, Greeley, Hayes, 

Hitchcock, Hooker, Keya Paha, 

Logan, Loup, McPherson, Rock, Sioux, 

Thomas and Wheeler 

Nevada Aetna HealthFund 221, 222 

224, 225 

Entire counties of Carson City, Churchill, 

Douglas, Elko, Humboldt, Lander, Lyon, 

Mineral, Pershing, Storey, Washoe 

and White Pine 

New York GHI Health Plan 804, 805 Entire counties of Broome, Cayuga, Chemung, 

Chenango, Columbia, Cortland, Delaware, 

Dutchess, Franklin, Greene, Hamilton, 

Herkimer, Jefferson, Lewis, Madison, Oneida, 

Onondaga, Orange, Oswego, Otsego, Putnam, 

St. Lawrence, Schuyler, Steuben, Sullivan, 

Tioga, Tompkins, and Ulster 

Oklahoma Aetna HealthFund 221, 222 

224, 225 

Entire counties of McCurtain and Stephens 

Oregon Aetna HealthFund 221, 222 

224, 225 

Entire counties of Baker, Curry and Union 

Oregon Kaiser Foundation 

Health Plan of 

Northwest 

571, 572 

574, 575 

The following counties by zip code: 

Clackamas: 97028, 97049, 97269 

Hood River: 97014, 97031, 97041, 97044 

Marion: 97342, 97346, 97350, 97373 

Washington: 97298 

South 

Carolina 

Aetna HealthFund 221, 222 

224, 225 

Entire county of Hampton 

Tennessee Bluegrass Family 

Health 

KV1, KV2 Entire counties of Campbell, Claiborne, Clay, 

Dekalb, Fentress, Hickman, Jackson, Lewis, 

Marshall, Montgomery, Morgan, Overton, 

Pickett, Putnam, Scott, Trousdale and White 

Texas Aetna HealthFund 221, 222 

224, 225 

Entire counties of Andrews, Archer, Bailey, 

Baylor, Borden, Cochran, Cottle, Dawson, 

Foard, Dickens, Fisher, Gaines, Garza, 

Glasscock, Haskell, Howard, Jack, Kent, Knox, 

King, Lamb, Lynn, Martin, Mitchell, Nolan, 

Scurry, Shackelford, Stephens, Stonewall, 

Throckmorton, Upton, Yoakum and Young 

Texas Aetna Open Access P11, P12 Entire county of Bell 

Utah Aetna HealthFund 221, 222 

224, 225 

Entire county of Emery 

Virginia Aetna HealthFund 221, 222 

224, 225 

Entire county of Louisa 

Table 12 – continued on next page 15
State Plan Name 3 Digit Plan 

Code 

General Location of New Area 

Virginia Optima Health Plan 9R1 

9R2 

Entire cities of Emporia, Harrisonburg, and 

Winchester; 

Entire counties of Brunswick, Charlotte, 

Clarke, Culpeper, Frederick, Greenville, 

Lancaster, Lunenburg, Mecklenburg, 

Northumberland, Nottoway, Page, 

Rappahannock, Richmond, Rockingham, 

Shenandoah, Spotsylvania, Stafford, Warren, 

and Westmoreland 

Washington Kaiser Foundation 

Health Plan of 

Northwest 

571, 572 

574, 575 

The following county by zip code: 

Skamania: 98610, 98639, 98651, 98671, and 

98648 

West Virginia Aetna HealthFund 221, 222 

224, 225 

Entire county of Webster 

16