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RI 73-778
Aetna U. S. Healthcare 2002 http:// www. aetnaushc. com/ feds
A Health Maintenance Organization
Serving the following states:
Arizona
California
Georgia

Nevada
New Jersey
Pennsylvania
Washington

Enrollment in this Plan is limited. You must live or work in our geographic service area to
enroll. See page 9 for requirements.

Arizona

2/ 99
This service has
Commendable
accreditation from
the NCQA.
See the 2002 Guide for
more information on
accreditation.

California
5/ 00
This service has
Commendable
accreditation from
the NCQA.
See the 2002 Guide for
more information on
accreditation.

Georgia
10/ 00
This service has
Excellent
accreditation from
the NCQA.
See the 2002 Guide for
more information on
accreditation.

New Jersey
3/ 01
This service has
Excellent
accreditation from
the NCQA.
See the 2002 Guide for
more information on
accreditation.

Pennsylvania
12/ 99
This service has
Excellent
accreditation from
the NCQA.
See the 2002 Guide for
more information on
accreditation.

Special Notice 1
Members in Pennsylvania, New Jersey and Delaware:

If you live in Pennsylvania, New Jersey and Delaware your Aetna plan now has only one option. If you were a
Standard Option enrollee, you will be automatically transferred to High Option, unless you make an Open Season
change. We will send you brochure RI 73-778 before Open Season. Please review it for your benefit changes.

Your enrollment in code SU will automatically merge into enrollment code P3.
If you live in Delaware, we removed Delaware from our service area. You must travel to our service area in New
Jersey or certain Pennsylvania counties in order to receive full HMO benefits.

For changes
in benefits
see page 11.

Special Notice 2
Members in Indiana, Kentucky, New York, Ohio and Tennessee:

Your enrollment was automatically transferred to our new Plan described in Federal brochure RI 73-806. We will
send you brochure RI 73-806 before Open Season. Please review it for details about how your 2002 benefits change. 1
1 Page 2 3

2002 Aetna U. S. Healthcare HMO 2 Table of Contents
Table of Contents
Introduction ........................................................................................................................................................................... 4
Plain Language...................................................................................................................................................................... 4
Inspector General Advisory ................................................................................................................................................. 5
Section 1. Facts about this HMO plan.................................................................................................................................. 6
How we pay providers........................................................................................................................................ 6
Your Rights......................................................................................................................................................... 7
Service Area........................................................................................................................................................ 9
Section 2. How we change for 2002................................................................................................................................... 11
Program-wide changes..................................................................................................................................... 11
Changes to this Plan ......................................................................................................................................... 11
Section 3. How you get care ............................................................................................................................................... 14
Identification cards........................................................................................................................................... 14
Where you get covered care............................................................................................................................. 14
Plan providers ............................................................................................................................................ 14
Plan facilities.............................................................................................................................................. 14
What you must do to get covered care............................................................................................................. 14

Primary care............................................................................................................................................... 14
Specialty care............................................................................................................................................. 14
Hospital care............................................................................................................................................... 15
Circumstances beyond our control .................................................................................................................. 16
Services requiring our prior approval.............................................................................................................. 16
Section 4. Your costs for covered services......................................................................................................................... 17
Copayments................................................................................................................................................ 17
Coinsurance................................................................................................................................................ 17
Deductible .................................................................................................................................................. 17
Your out-of-pocket maximum ......................................................................................................................... 17
Section 5. Benefits............................................................................................................................................................... 18
Overview........................................................................................................................................................... 18
(a) Medical services and supplies provided by physicians and
other health care professionals.............................................................................................................. 19

(b) Surgical and anesthesia services provided by physicians and
other health care professionals.............................................................................................................. 27

(c) Services provided by a hospital or other facility, and ambulance services......................................... 31
(d) Emergency services/ accidents .............................................................................................................. 34
(e) Mental health and substance abuse benefits......................................................................................... 37
(f) Prescription drug benefits ..................................................................................................................... 39
(g) Special features...................................................................................................................................... 42 2
2 Page 3 4

2002 Aetna U. S. Healthcare HMO 3 Table of Contents
(h) Dental benefits....................................................................................................................................... 43
(i) Non-FEHB benefits available to Plan members .................................................................................. 46
Section 6. General exclusions things we don't cover................................................................................................... 47
Section 7. Filing a claim for covered services ................................................................................................................... 48
Section 8. The disputed claims process.............................................................................................................................. 49
Section 9. Coordinating benefits with other coverage....................................................................................................... 51
When you have
Other health coverage.............................................................................................................................. 51
Original Medicare.................................................................................................................................... 51
Medicare managed care plan................................................................................................................... 53
TRICARE/ Workers' Compensation/ Medicaid ............................................................................................... 54
Other Government agencies............................................................................................................................. 54
When others are responsible for injuries......................................................................................................... 54
Section 10. Definitions of terms we use in this brochure.................................................................................................. 56
Section 11. FEHB facts....................................................................................................................................................... 59
Coverage information....................................................................................................................................... 59
No pre-existing condition limitation ....................................................................................................... 59
Where you get information about enrolling in the FEHB Program....................................................... 59
Types of coverage available for you and your family............................................................................ 59
When benefits and premiums start.......................................................................................................... 60
Your medical and claims records are confidential ................................................................................. 60
When you retire........................................................................................................................................ 60
When you lose benefits .................................................................................................................................... 60

When FEHB coverage ends..................................................................................................................... 60
Spouse equity coverage ........................................................................................................................... 60
Temporary Continuation of Coverage (TCC)......................................................................................... 61
Converting to individual coverage .......................................................................................................... 61
Getting a Certificate of Group Health Plan Coverage............................................................................ 61
Long Term Care Insurance is coming later in 2002........................................................................................................... 62
Department of Defense/ FEHB Demonstration Project...................................................................................................... 64
Index .................................................................................................................................................................................... 66
Summary of benefits ........................................................................................................................................................... 70
Rates..................................................................................................................................................................................... 71 3
3 Page 4 5
2002 Aetna U. S. Healthcare HMO 4 Introduction/ Plain Language
Introduction
Aetna U. S. Healthcare, Inc.
1425 Union Meeting Road
P. O. Box 1126, Mail Stop U32A
Blue Bell, PA 19422

This brochure describes the benefits you can receive from Aetna U. S. Healthcare* under our contract (CS 2836) with
the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. This
brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations,
and exclusions of this brochure.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled for Self
and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits
that were available before January 1, 2002, unless these benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2002, and changes
are summarized on page 11. Rates are shown at the end of this brochure.

Plain language
Teams of Government and health plan's staff worked on all FEHB brochures to make them responsive, accessible, and
understandable to the public. For instance,

Except for necessary technical terms, we use common words. "You" means the enrollee or family member; "we"
means Aetna U. S. Healthcare.

We limit acronyms to ones you know. FEHB is Federal Employees Health Benefits Program. OPM is the Office of
Personnel Management. If we use others, we tell you what they mean first.

Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you
compare plans.

If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM's
"Rate Us" feedback area at www. opm. gov/ insure or email OPM at fehbwebcomments@ opm. gov. You may also write
to OPM at the Office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street
NW, Washington, DC 20415-3650.

*HMO benefits are provided or administered by:
Carrier Code Legal Entity
P3 (PA) United States Health Care Systems of Pennsylvania, Inc. D/ B/ A Aetna U. S. Healthcare Inc. (PA)
P3 (NJ) Aetna U. S. Healthcare Inc.
2X Aetna U. S. Healthcare of California Inc.
2U Aetna U. S. Healthcare of Georgia Inc.
WQ/ 8L Aetna U. S. Healthcare Inc. (AZ)
8J Aetna U. S. Healthcare Inc. (WA) 4
4 Page 5 6
2002 Aetna U. S. Healthcare HMO 5 Inspector General Advisory
Inspector General Advisory Stop health care fraud! Fraud increases the cost of health care for everyone. If you suspect that a physician, pharmacy, or hospital has
charged you for services you did not receive, billed you twice for the same
service, or misrepresented any information, do the following:

Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 1-800-537-9384 and explain the situation.

If we do not resolve the issue, call THE HEALTH CARE FRAUD HOTLINE 202-418-3300 or write to: The United States Office of
Personnel Management, Office of the Inspector General Fraud
Hotline, 1900 E Street, NW, Room 6400, Washington, DC 20415.

Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud. Also, the Inspector General may investigate anyone

who uses an ID card if the person tries to obtain services for someone who
is not an eligible family member, or is no longer enrolled in the Plan and
tries to obtain benefits. Your agency may also take administrative action
against you. 5
5 Page 6 7
2002 Aetna U. S. Healthcare HMO 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other
providers that contract with us. These Plan providers coordinate your health care services.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in
addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing
any course of treatment.

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the
copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan
providers, you may have to submit claim forms.

You should join an HMO because you prefer the plan's benefits, not because a particular provider is available.
You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract with us.

How we pay providers Provider Compensation We contract with individual physicians, medical groups, and hospitals
to provide the benefits in this brochure. These Plan providers accept a
negotiated payment from us, and you will only be responsible for your
copayments or coinsurance.

This is a direct contract prepayment Plan, which means that participating
providers are neither agents nor employees of the Plan. Rather, they are
independent doctors and providers who practice in their own offices or
facilities. The Plan arranges with licensed providers and hospitals to
provide medical services for both the prevention of disease and the
treatment of illness and injury for benefits covered under the Plan.

Plan providers in our network have agreed to be compensated in
various ways. Many participating primary care physicians (PCPs) are
paid by capitation. Under capitation, a physician receives payment for a
patient whether the physician sees the patient that month or not.

Specialists, hospitals, primary care physicians and other providers in
the Aetna U. S. Healthcare network may also be paid in the following
ways:

Per individual service (fee-for-service at contracted rates),
Per hospital day (per diem contracted rates),
Under other capitation methods (a certain amount per member, per month), and

By Integrated Delivery Systems (" IDS"), Independent Practice Associations (" IPAs"), Physician Medical Groups (" PMGs"),
Physician Hospital Organizations (" PHOs"), behavioral health
organizations and similar provider organizations or groups that are
paid by Aetna U. S. Healthcare; the organization or group pays the
physician or facility directly. In such arrangements, that group or
organization has a financial incentive to control the costs of providing
care.

You are encouraged to ask your physicians and other providers how
they are compensated for their services, including whether their specific
arrangements include any financial incentives to control costs. 6
6 Page 7 8
2002 Aetna U. S. Healthcare HMO 7 Section 1
Your Rights OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about
us, or our networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types of
information that we must make available to you. Some of the required information is listed below.

Medical Necessity
Covered services include most types of treatment by PCPs, specialists and hospitals. However, the health plan also
excludes or limits coverage for some services, including but not limited to cosmetic surgery and experimental
procedures. In addition, in order to be covered, all services, including the location (type of facility), duration and costs
of services, must be medically necessary as defined in this Plan and as determined by us. (See definition on Page 57.)

Direct Access Ob/ Gyn Program
This program allows female members to visit any participating gynecologist for a routine well-woman exam, including
a Pap smear (if appropriate) and an unlimited number of visits for gynecologic problems and follow-up care as
described in your benefits plan. Gynecologists may also refer a woman directly for covered gynecologic services
without the patient's having to go back to her participating primary care physician. If your Ob/ Gyn is part of an
Independent Practice Association (IPA), a Physician Medical Group (PMG) or a similar organization, covered care must
be coordinated through the IPA, the PMG or the similar organization.

Mental Health/ Substance Abuse
In most areas, certain behavioral health care services (e. g., treatment or care for mental disease or illness, alcohol abuse
and/ or substance abuse) are managed by an independently contracted organization. This organization makes initial
coverage determinations and coordinates referrals; any behavioral health care referrals will generally be made to
providers affiliated with the organization, unless your needs for covered services extend beyond the capability of the
affiliated providers. You can receive information regarding the appropriate way to access the behavioral health care
services that are covered under your specific plan by calling Member Services at 1-800-537-9384. As with other
coverage determinations, you may appeal behavioral health care coverage decisions in accordance with the provisions
of your Plan.

Ongoing Reviews
We conduct ongoing reviews of those services and supplies which are recommended or provided by health
professionals to determine whether such services and supplies are covered benefits under this Plan. If we determine
that the recommended services and supplies are not covered benefits, you will be notified. If you wish to appeal such
determination, you may then contact us to seek a review of the determination.

Authorization
Certain services and supplies under this Plan may require authorization by us to determine if they are covered benefits
under this Plan.

Patient Management
We have developed a patient management program to assist in determining what health care services are covered under
the health plan and the extent of such coverage. The program assists members in receiving the appropriate health care
and maximizing coverage for those health care services.

Only medical directors make decisions denying coverage for services for reasons of medical necessity. Coverage denial
letters delineate any unmet criteria, standards and guidelines, and inform the provider and member of the appeal
process.

Our patient management staff uses national guidelines and resources to guide the precertification, concurrent review and
retrospective review processes. Using the information obtained from providers, patient management staff utilize
Milliman & Robertson Health Care Management Guidelines when conducting concurrent review. If there is no
applicable Milliman & Robertson Guideline, patient management staff utilizes InterQual ISD criteria. When applicable,
Medicare National Coverage Decisions are followed for Medicare managed care members. To the extent certain patient
management functions are delegated to integrated delivery systems, independent practice associations or other provider
groups (" Delegates"), such Delegates utilize criteria that they deem appropriate.

Precertification Certain health care services, such as hospitalization or outpatient surgery, require precertification by us to ensure coverage. When a member is to

obtain services requiring precertification through a Plan provider, this
provider should precertify those services prior to treatment. 7
7 Page 8 9
2002 Aetna U. S. Healthcare HMO 8 Section 1
Concurrent Review The concurrent review process assesses the necessity for continued stay, level of care, and quality of care for members receiving inpatient services.
All inpatient services extending beyond the initial certification period will
require Concurrent Review.

Discharge Planning Discharge planning may be initiated at any stage of the patient management process and begins immediately upon identification of post-discharge

needs during precertification or concurrent review. The
discharge plan may include initiation of a variety of services/ benefits to be
utilized by the member upon discharge from an inpatient stay.

Retrospective Record Review The purpose of retrospective review is to retrospectively analyze potential quality and utilization issues, initiate appropriate follow-up action based on

quality or utilization issues, and review all appeals of inpatient concurrent
review decisions for coverage and payment of health care services. Our
effort to manage the services provided to members includes the
retrospective review of claims submitted for payment, and of medical
records submitted for potential quality and utilization concerns.

Member Services
Representatives from Member Services are trained to answer your questions and to assist you in using the Aetna
U. S. Healthcare plan properly and efficiently. After you receive your ID card, you can call the Member Services toll-free
number on the card when you need to:

Ask questions about benefits and coverage.
Notify us of changes in your name, address or telephone number.
Change your primary care physician or office.
Obtain information about how to file a grievance or an appeal.

Confidentiality
We protect the privacy of confidential Plan member medical information. We contractually require that participating
providers keep member information confidential in accordance with applicable laws. Furthermore, you have the right to
access you medical records from participating providers, at any time. Aetna U. S. Healthcare (including its affiliates and
authorized agents, collectively (" Aetna U. S. Healthcare") and participating providers require access to member medical
information for a number of important and appropriate purposes, including claims payment, fraud prevention,
coordination of care, data collection, performance measurement, fulfilling state and federal requirements, quality
management, utilization review, research and accreditation activities, preventive health, early detection and disease
management programs. Accordingly, for these purposes, members authorize the sharing of member medical information
about themselves and their dependents between Aetna U. S. Healthcare and Plan providers and health delivery systems.

If you want more information about us, call 1-800-537-9384, or write to 1425 Union Meeting Road, P. O. Box 1126,
Mail Stop U32A, Blue Bell, PA 19422. You may also contact us by fax at 215-775-6550 or visit our website at
www. aetnaushc. com/ feds. 8
8 Page 9 10
2002 Aetna U. S. Healthcare HMO 9 Section 1
Service Area To enroll in this Plan, you must live or work in our service area. This is where our providers practice. Our service
area is:

Arizona

2/ 99
This service has Commendable
accreditation from the NCQA.
See the 2002 Guide for more
information on accreditation.

Serving: Phoenix and Tucson areas
Enrollment Code:
WQ1 Self Only
WQ2 Self and Family

Cochise, Maricopa, Pima and Santa Cruz counties and portions of Pinal as defined
by the towns of Apache Junction and Casa Grande

California
5/ 00
This service has Commendable
accreditation from the NCQA.
See the 2002 Guide for more
information on accreditation.

Serving: Southern California area
Enrollment Code:
2X1 Self Only
2X2 Self and Family

Los Angeles, Orange, San Diego, Santa Barbara and Ventura counties, and portions
of Riverside, Kern and San Bernardino defined by listed towns:

Riverside County: all towns except Blythe, Mesa Verde, Ripley and Desert Center
San Bernardino County: All towns except Nipton, Ivonpah, Needles, Lake Havasu,
Parker Dam, Earp, Big River, Cima, Kelso, Baker, Amboy, Cadiz, Vidal, Rice,
Essex and Danby

Kern County: All towns except Ridgecrest, China Lake, Mojave, Garlock,
Johannesburg and Cantil

Georgia

10/ 00
This service has Excellent
accreditation from the NCQA.
See the 2002 Guide for more
information on accreditation.

Serving: The Atlanta and Athens areas
Enrollment Code:
2U1 Self Only
2U2 Self and Family

Barrow, Bartow, Butts, Cherokee, Clarke, Clayton, Cobb, Coweta, Dawson,
Dekalb, Douglas, Fayette, Forsyth, Fulton, Gwinnett, Hall, Haralson, Heard,
Henry, Jackson, Lamar, Madison, Newton, Oconee, Oglethorpe, Paulding,
Pickens, Pike, Rockdale, Spalding and Walton counties

Nevada Serving: Southern Nevada and Las Vegas area
Enrollment Code:

8L1 Self Only
8L2 Self and Family

Clark county 9
9 Page 10 11
2002 Aetna U. S. Healthcare HMO 10 Section 1
New Jersey
3/ 01
This service has Excellent
accreditation from the NCQA.
See the 2002 Guide for more
information on accreditation.

Serving: All of New Jersey
Enrollment Code:
P31 Self Only
P32 Self and Family

The State of New Jersey

Pennsylvania
12/ 99
This service has Excellent
accreditation from the NCQA.
See the 2002 Guide for more
information on accreditation.

Serving: Southeastern Pennsylvania
Enrollment Code:
P31 Self Only
P32 Self and Family

Berks, Bucks, Chester, Delaware, Lehigh, Monroe, Montgomery and
Northampton counties, and Philadelphia

Washington Serving: Western and Southeast Washington areas
Enrollment Code:
8J1 Self Only
8J2 Self and Family

King, Kitsap, Pierce and Snohomish counties

Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we
will pay only for emergency care benefits. We will not pay for any other health care services out of our area unless the
services have prior plan approval.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents
live out of area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service
plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not
have to wait until Open Season to change plans. Contact your employing or retirement office. 10
10 Page 11 12
2002 Aetna U. S. Healthcare HMO 11 Section 2
Section 2. How we change for 2002
Program-wide changes Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5

benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.

Changes to this Plan Code WQ. Your share of the non-postal premium will increase by 18.7% for Self Only or increase by 18.8% for Self

and Family.
Code 2X. Your share of the non-postal premium will increase by 12.6% for Self Only or increase by 12.7% for Self
and Family.

Code 2U. Your share of the non-postal premium will increase by 16.4% for Self Only or increase by 16.4% for Self
and Family.

Code 8L. Your share of the non-postal premium will increase by 21.5% for Self Only or increase by 20.6% for Self
and Family.

Code P3. Your share of the non-postal premium will decrease by 7.8% for Self Only or decrease by 3.5% for Self and
Family.

Code 8J. Your share of the non-postal premium will increase by 25.0% for Self Only or increase by 25.4% for Self
and Family.

New Jersey, Code P3. With the elimination of the Standard Option, your share of the non-postal bi-weekly premium
(to go from the Standard Option to the High Option) will increase by $11.85 for Self Only and by $28.82 for Self and
Family. Non-postal monthly premiums will increase by $25.67 for Self Only and increase by $62.44 for Self and
Family.

Pennsylvania, Code P3 (formerly Code SU High Option). As a result of this plan merging under P3, your share of
the non-postal bi-weekly premium will increase by $9.73 for Self Only and by $31.39 for Self and Family. Non-postal
monthly premiums will increase by $21.25 for Self Only and increase by $68.01 for Self and Family.

Pennsylvania, Code P3 (formerly Code SU Standard Option). With the elimination of the Standard Option and
Code SU merging under P3, your share of the non-postal bi-weekly premium for the High Option will increase by
$19.02 for Self Only and by $67.73 for Self and Family. Non-postal monthly premiums will increase by $41.22 for
Self Only and increase by $146.75 for Self and Family.

We no longer limit total blood cholesterol tests to certain age groups. (Section 5( a))
We now cover routing screening for chlamydial infection. (Section 5( a))
We changed speech therapy benefits by removing the requirement that services must be required to restore functional
speech. (Section 5( a))

We changed the address for sending disputed claims to OPM. (Section 8)
We eliminated a portion of our service and enrollment areas for calendar year 2002. Members who live or work in the
following states must select a new Plan under the FEHB Program: California (code BU), Colorado (code 6F),
Connecticut (code H1), Indiana (XC), Illinois (codes XC and D4), Kansas (code 7K), Louisiana (code NG),
Massachusetts (code NE), Michigan (code 8Z), Missouri (codes 7K and D4), North Carolina (code 3G), Ohio
(code 7J), Oklahoma (code 8V), Rhode Island (code 5U), and Texas (codes 5B and 8X). If you do not change to
another Plan during Open Season you will not have benefits in 2002.

We reduced our service and enrollment area for this Plan. Members who live or work in Indiana (codes 7L or RD),
Kentucky (codes 7L or RD), New York (codes JC or TG), Ohio (codes RD or 7D) and Tennessee (code 6J), your
enrollment was automatically transferred to Aetna's new Plan. Please review brochure RI 73-806 for details about
your benefits. 11
11 Page 12 13
2002 Aetna U. S. Healthcare HMO 12 Section 2
We expanded our service and enrollment area to include Southeastern Pennsylvania and all of New Jersey. See page
9 for details.

We moved members who are enrolled in Pennsylvania (code SU) and New Jersey (code P3) from our Aetna
U. S. Healthcare Plan described in brochure, RI73-052, to this Plan. If you do not make an Open Season change for
contract year 2002, you will be enrolled in this Plan, under code P3. If you were a Standard Option enrollee, you will
be automatically transferred to High Option unless you make an Open Season change.

Members enrolled in Delaware who do not make an Open Season change must receive services in our service area in
Southeastern Pennsylvania or New Jersey except for emergency care.

If you are enrolled in code WQ in Arizona and live or work in the following counties: Graham, Yuma, and Yavapai,
you must select another Plan during Open Season. We eliminated these counties from our service and enrollment
area. If you do not change plans, you will have to travel to our remaining service area for code WQ to receive full
HMO benefits.

If you are enrolled in code 2X in California and live or work in the following counties: San Bernadino, Kerns and
Riverside, you must select another Plan during Open Season. We reduced the size of these counties in our service and
enrollment area. If you do not change plans, you will have to travel to our remaining service area for code 2X to
receive full HMO benefits.

If you are enrolled in code 2U in Georgia and live or work in the following counties: Burke, Columbia, Glascock,
Lincoln, McDuffie, Richmond, Taliaferro, Warren and Wilkes, you must select another Plan during Open Season.
We eliminated these counties from our service and enrollment area. If you do not change plans, you will have to
travel to our remaining service area for code 2U to receive full HMO benefits.

If you are enrolled in code 8J in Washington and live or work in the following counties: Columbia and Walla Walla, you
must select another Plan during Open Season. We eliminated these counties from our service and enrollment area. If you
do not change plans, you will have to travel to our remaining service area for code 8J to receive full HMO benefits.

We now cover certain intestinal transplants. See Section 5( b).
We changed the primary care doctor office visit copay to $15. See Section 5( a).
We changed the primary care doctor home visit copay to $20. See Section 5( a).
We changed the increase the specialty care office visit copay to $20. See Section 5( a).
We changed the specialty care home visit copay to $25. See Section 5( a).
We removed the age limit for hearing tests. See Section 5( a).
We removed the copay for professional services of a physician during an in-patient hospital stay. See Section 5( b).
We added a $75 copay per date of service for outpatient surgery. See Section 5( c).
We added an inpatient hospital copay of $100 per day up to a maximum $300 per admission. See Section 5( c).
We reduced the skilled nursing facility visit maximum from unlimited to 90-day maximum. See Section 5( c).
We increased the copay from $35 to $75 per emergency room visit. See Section 5( d).
We added coverage for air ambulance. See Section 5( d).
We added a $20 copay per visit for outpatient mental health and substance abuse services provided by a hospital or
other facility, including alternative care settings such as partial hospitalization, full-day hospitalization and facility
based outpatient treatment centers. See Section 5( e).

We added a copay of $100 per day up to a maximum of $300 per admission. This applies to medical confinements,
residential treatment facilities and inpatient hospital admissions to treat mental health and substance abuse. See Section 5( e).

We increased the copay for generic formulary prescription drugs from $5 to $10 for up to a 30-day supply. The copay
increased from $10 to $20 per prescription per mail order 31-to 90-day supply of generic formulary prescription
drug. See Section 5( f). 12
12 Page 13 14
2002 Aetna U. S. Healthcare HMO 13 Section 2
We increased the copay for brand name formulary drugs from $10 to $20 for up to a 30-day supply. The copay
increased from $20 to $40 per prescription per mail order 31 to 90-day supply of brand name formulary prescription
drug. See Section 5( f).

We increased the copay for non-formulary generic and brand name drugs from $25 to 50% for up to a 30-day supply.
The copay increased from $50 to 50% per prescription per mail order 31 to 90-day supply of non-formulary generic
or brand name prescription drug. See Section 5( f).

We increased the copay to $20 per diaphragm. See Section 5( f).
We increased the copay for Depo Provera to $20 per vial. See Section 5( f).
We increased the copay for certain dental services. See Section 5( h).
We stated your out-of-pocket maximum of $1,500 for self-only and $3,000 for self and family enrollments. See Section 4.
We clarified the benefit for blood or blood plasma. See Section 5( c).
We clarified the Preventive care, adult benefits by removing the entry for blood lead level testing for adults because it is a
test more typically done for children. See Section 5( a).

We stated growth hormone therapy requires prior authorization. 13
13 Page 14 15
2002 Aetna U. S. Healthcare HMO 14 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you

receive services from a Plan provider, or fill a prescription at a Plan
pharmacy. Until you receive your ID card, use your copy of the Health
Benefits Election Form, SF-2809, your health benefits enrollment
confirmation (for annuitants), or your Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of
your enrollment, or if you need replacement cards, call us at 1-800-537-9384.

Where you get covered care You get covered care from "Plan providers" and "Plan facilities." You will only pay copayments or coinsurance, and you will not have to file claims.
Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our
members. We credential Plan providers according to national standards.
We list Plan providers in the provider directory, which we update
periodically. The most current information on our Plan providers is also
on our website at www. aetnaushc. com/ feds.

Plan facilities Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these

facilities in the provider directory, which we update periodically. The most
current information on our Plan facilities is also on our website at
www. aetnaushc. com/ feds.

What you must do
to get covered care It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since

your primary care physician provides or arranges for most of your health
care. You must select a Plan provider who is located in your service area as
defined by your enrollment code.

Primary care Your primary care physician can be a general practitioner, family practitioner, internist or pediatrician. Your primary care physician will provide or coordinate

most of your health care, or give you a referral to see a specialist.
If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us or visit our website. We will change your
primary care physician to a newly-selected primary care physician.

Specialty care Your primary care physician will refer you to a specialist for needed care. If you need laboratory, radiological and physical therapy services, your primary care

physician must refer you to certain plan providers. Your primary care physician
may refer you to any participating specialist for other specialty care. When you
receive a referral from your primary care physician, you must return to the
primary care physician after the consultation, unless your primary care physician
authorized a certain number of visits without additional referrals. The primary
care physician must provide or authorize follow-up care. Do not go to the
specialist for return visits unless your primary care physician gives you a referral.
However, you may see a Plan gynecologist, (within an IPA, you must see an IPA-approved
gynecologist), for a routine well-woman exam, including a pap smear
(if appropriate) and an unlimited number of visits for gynecological problems 14
14 Page 15 16
2002 Aetna U. S. Healthcare HMO 15 Section 3
and follow-up care as described in your benefit plan without a referral. You
may also see a Plan mental health provider, Plan vision specialist or a Plan
dentist without a referral.

Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop a

treatment plan that allows you to see your specialist for a certain number
of visits without additional referrals. Your primary care physician will use
our criteria when creating your treatment plan (the physician may have to
get an authorization or approval beforehand).

If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what

treatment you need. If he or she decides to refer you to a specialist, ask
if you can see your current specialist. If your current specialist does
not participate with us, you must receive treatment from a specialist
who does. Generally, we will not pay for you to see a specialist who
does not participate with our Plan.

If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another

specialist. You may receive services from your current specialist until
we can make arrangements for you to see someone else.

If you have a chronic or disabling condition and lose access to your specialist because we:

Terminate our contract with your specialist for other than cause; or
Drop out of the Federal Employees Health Benefits (FEHB)
Program and you enroll in another FEHB Plan; or

Reduce our service area and you enroll in another FEHB Plan,
You may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or, if we drop out of

the Program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access
to your specialist based on the above circumstances, you can continue to
see your specialist until the end of your postpartum care, even if it is
beyond the 90 days.

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise covered care. This includes admission

to a skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our
customer service department immediately at 1-800-537-9384. If you are
new to the FEHB Program, we will arrange for you to receive care.

If you changed from another FEHB plan to us, your former plan will pay
for the hospital stay until:

You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person. 15
15 Page 16 17
2002 Aetna U. S. Healthcare HMO 16 Section 3
Circumstances beyond
our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In

that case, we will make all reasonable efforts to provide you with the
necessary care.

Services requiring our
prior approval Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain approval from

us. Before giving approval, we consider if the service is covered, medically
necessary, and follows generally accepted medical practice.

We call this review and approval process precertification.
You must obtain approval for certain services such as:
For artificial insemination you must contact the Infertility Case Manager at 1-800-575-5999;

You must obtain precertification from your primary care doctor and Aetna U. S. Healthcare for covered follow-up care with
nonparticipating provider;
You must contact Customer Service at 1-800-537-9384 for information on precertification before you have mental health and

substance abuse services;
Your Plan physician must obtain approval for certain services such as
hospitalization and the following services:

For surgical treatment of morbid obesity;
For outpatient surgery;
For covered transplant surgery from the Plan's medical director;
When full-time skilled nursing care is necessary in an extended care facility;

For ambulance transportation service; and
For certain drugs before they can be prescribed;
For growth hormone therapy treatment.
You or your physician must obtain an approval for certain durable
medical equipment. Members must call 1-800-537-9384 for authorization. 16
16 Page 17 18
2002 Aetna U. S. Healthcare HMO 17 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc. when you receive services.

Example: When you see your primary care physician you pay a copayment
of $15 per office visit or $20 when you see a participating specialist.

Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.

Example: In our Plan, you pay 50% of negotiated charges for
nonformulary drugs.

Deductible We do not have a deductible.

Your catastrophic protection
out-of-pocket maximum for
copayments and coinsurance After your copayments and coinsurance total $1,500 per person or $3,000 per family enrollment in any calendar year, you do not have to pay any

more for covered services. However, copayments and coinsurance for the
following services do not count toward your out-of-pocket maximum, and
you must continue to pay copayments and coinsurance for these services:

Prescription drugs
Dental services
Be sure to keep accurate records of your copayments and coinsurance since
you are responsible for informing us when you reach the maximum. 17
17 Page 18 19
2002 Aetna U. S. Healthcare HMO 18 Section 5
Section 5. Benefits OVERVIEW
(See page 11 for how our benefits changed this year and page 70 for a benefits summary.) NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at

the beginning of each subsection. Also read the General Exclusions in Section 6, they apply to the benefits in the
following subsections. For more information about our benefits, contact us at 1-800-537-9384 or at our website at
www. aetnaushc. com/ feds.

(a) Medical services and supplies provided by physicians and other health care professionals .................................... 19
Diagnostic and treatment services Speech therapies
Lab, X-ray, and other diagnostic tests Hearing services (testing, treatment, and supplies)
Preventive care, adult Vision services (testing, treatment, and supplies)
Preventive care, children Foot care
Maternity care Orthopedic and prosthetic devices
Family planning Durable medical equipment (DME)
Infertility services Home health services
Allergy care Chiropractic
Treatment therapies Alternative treatments
Physical and occupational therapies Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals ................................ 27
Surgical procedures Organ/ tissue transplants
Reconstructive surgery Anesthesia
Oral and maxillofacial surgery

(c) Services provided by a hospital or other facility, and ambulance services ............................................................... 31
Inpatient hospital Hospice care
Outpatient hospital or ambulatory surgical center Ambulance
Extended care benefits/ skilled nursing care facility benefits

(d) Emergency services/ accidents..................................................................................................................................... 34
Medical emergency Ambulance

(e) Mental health and substance abuse benefits ............................................................................................................... 37
(f) Prescription drug benefits............................................................................................................................................ 39
(g) Special features ............................................................................................................................................................ 42
Services for deaf and hearing-impaired ................................................................................................................... 42
Informed Health Line ............................................................................................................................................... 42
Reciprocity ................................................................................................................................................................ 42
High risk pregnancies ............................................................................................................................................... 42
Centers of Excellence for transplants/ surgery etc. .................................................................................................. 42
Travel benefit/ services overseas............................................................................................................................... 42

(h) Dental benefits ............................................................................................................................................................. 43
(i) Non-FEHB benefits available to Plan members......................................................................................................... 46
Summary of benefits ........................................................................................................................................................... 70 18
18 Page 19 20
2002 Aetna U. S. Healthcare HMO 19 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine

they are medically necessary.
Plan physicians must provide or arrange your covered care.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about

coordinating benefits with other coverage, including with Medicare.

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Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office
Office medical consultations
Second surgical or medical opinion
Initial examination of a newborn child covered under a family
enrollment

$15 per primary care
physician (PCP) visit
$20 per specialist visit

Professional services of physicians
In an urgent care center for a routine service
In a skilled nursing facility

$15 per PCP visit
$20 per specialist visit

At home $20 per PCP visit
$25 per specialist visit

At home visits by nurses and health aides Nothing

Lab, X-ray and other diagnostic tests
Test, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing if you receive
these services during
your office visit;
otherwise, $15 per PCP
visit or $20 per specialist
visit 19
19 Page 20 21
2002 Aetna U. S. Healthcare HMO 20 Section 5( a)
Preventive care, adult You pay
Routine screenings, such as:
Total Blood Cholesterol
Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening every five years starting at age 50

Prostate Specific Antigen (PSA test) one annually for men age 40
and older

Routine Pap test
NOTE: No copay for the pap test if performed on the same day as the
office visit

Routine mammogram covered for women age 35 and older, as follows:
From age 35 through 39, one during this five year period
From age 40 through 64, one every calendar year
At age 65 and older, one every two consecutive calendar years

$15 per PCP visit
$20 per specialist visit
Nothing if provided
during the office visit

Routine immunizations limited to:
Tetanus-diphtheria (Td) booster once every 10 years, ages 19 and over (except as provided for under childhood immunizations

Influenza/ Pneumococcal vaccines, annually, age 65 and over

Nothing if provided
during the office visit

Not covered:
Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel.

Immunizations and boosters for travel or work-related exposure.

All charges

Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics Nothing

Well-child visits for routine examinations, immunizations and care (up to age 22) $15 per PCP visit $20 per specialist visit
Examinations, such as:
Eye exams through age 17 to determine the need for vision
correction.

Ear exams to determine the need for hearing correction
Examinations done on the day of immunizations (up to age 22)

$15 per PCP visit
$20 per specialist visit 20
20 Page 21 22
2002 Aetna U. S. Healthcare HMO 21 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care

NOTE: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see below for other circumstances, such as extended stays for you or your baby.

You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will cover an extended
inpatient stay if your Physician determines it is medically necessary.
We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other care of an

infant who requires non-routine treatment only if we cover the infant
under a Self and Family enrollment.

We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and Surgery

benefits (Section 5b).

$15 for the first PCP visit
only or $20 for the first
specialist visit only

Not covered: Routine sonograms to determine fetal age, size or sex All charges
Family planning
A broad range of voluntary family planning services, limited to:
Voluntary sterilization
Surgically implanted contraceptives, such as Norplant
Injectable contraceptive drugs, such as Depo Provera
Intrauterine devices (IUDs)
Diaphragms

NOTE: We cover oral contraceptives and Depo Provera under the
prescription drug benefit.

$15 per PCP visit
$20 per specialist visit

Not covered: reversal of voluntary surgical sterilization, genetic counseling. All charges
Infertility services
Diagnosis and treatment of infertility, such as:
Artificial insemination:
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
NOTE: Coverage is for 6 cycles. Artificial insemination must be authorized.
You must contact the Infertility Case Manager at 1-800-575-5999. You must
use our select network of Plan infertility providers.

Fertility drugs except injectables
NOTE: We cover oral fertility drugs under the prescription drug benefit.

$20 per specialist visit

Infertility services Continued on the next page 21
21 Page 22 23
2002 Aetna U. S. Healthcare HMO 22 Section 5( a)
Infertility services (Continued) You pay
Not covered:
Reversal of voluntary, surgically-induced sterility.

Treatment for infertility when the cause of the infertility was a previous sterilization.

Injectable fertility drugs are not covered.
Infertility treatment when the FSH level is greater than 19 mIU/ ml.
The purchase, freezing and storage of donor sperm and donor embryos.

Assisted reproductive technology (ART) procedures, such as in vitro fertilization and embryo transfer including, but not limited to, GIFT
and ZIFT.

All charges

Allergy care
Testing and treatment
Allergy injection

NOTE: You pay the applicable copay for each doctor visit. Each visit to a
nurse for an injection only you pay nothing.

$15 per PCP visit
$20 per specialist visit
Nothing for a visit to a nurse

Allergy serum Nothing
Treatment therapies
Chemotherapy and radiation therapy
NOTE: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 29.

Respiratory and inhalation therapy
Dialysis Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy
Growth hormone therapy (GHT)

NOTE: Growth hormone is covered under Medical Benefits, office copay
applies.

NOTE: We will only cover GHT when we preauthorize the treatment.
Call 1-800-245-1206 for preauthorization. We will ask you to submit
information that establishes that the GHT is medically necessary. Ask us
to authorize GHT before you begin treatment; otherwise, we will only
cover GHT services from the date you submit the information. If you do
not ask or if we determine GHT is not medically necessary, we will not
cover the GHT or related services and supplies. See Services Requiring
Our Prior Approval in Section 3.

$20 per specialist visit 22
22 Page 23 24
2002 Aetna U. S. Healthcare HMO 23 Section 5( a)
Physical, pulmonary and occupational therapies You pay
Two consecutive months per condition, beginning with the first day of treatment for each of the following:

Qualified physical therapies
Occupational therapy
Pulmonary rehabilitation
NOTE: Occupational therapy is limited to services that assist the
member to achieve and maintain self-care and improved functioning in
other activities of daily living. Inpatient rehabilitation is covered under
Hospital/ Extended Care Benefits.

Cardiac rehabilitation following angioplasty, cardiovascular surgery, congestive heart failure or a myocardial infarction is provided for up

to 3 visits a week for a total of 18 visits.
Physical therapy to treat temporomandibular joint (TMJ) dysfunction syndrome.

$20 per visit
Nothing during a covered
inpatient admission

Not covered:
Long-term rehabilitative therapy.
All charges

Speech therapy
Two consecutive months per condition, beginning with the first day of treatment. $20 per visit, Nothing during a covered
inpatient admission

Hearing services (testing, treatment, and supplies)
Covered for audiological testing and medically necessary treatment for hearing problems. $15 per PCP visit $20 per specialist visit

Not covered:
Hearing aids, testing and examinations for them.
All charges 23
23 Page 24 25
2002 Aetna U. S. Healthcare HMO 24 Section 5( a)
Vision services (testing, treatment, and supplies) You pay
Treatment of eye diseases and injury $15 per PCP visit $20 per specialist visit

Corrective eyeglasses and frames or contact lenses (hard or soft) per 24 month period. All charges over $100
Routine eye refraction based on the following schedule:
If member wears eyeglasses or contact lenses:
Age 1 through 18 once every 12-month period
Age 19 and over once every 24-month period
If member does not wear eyeglasses or contact lenses:
To age 45 once every 36-month period
Age 45 and over once every 24-month period refractions

NOTE: See Preventive Care, Children, for eye exams for children.

$20 per specialist visit

Not covered:
Fitting of contact lenses
Eye exercises
Radial keratotomy and other refractive surgery

All charges

Foot care
Routine foot care when you are under active treatment for a metabolic or
peripheral vascular disease, such as diabetes.

See Orthopedic and Prosthetic Devices for more information.

$15 per PCP visit
$20 per specialist visit

Not covered:
Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except

as stated above
Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment

is by open cutting surgery)
Foot orthotics
Podiatric shoe inserts

All charges 24
24 Page 25 26
2002 Aetna U. S. Healthcare HMO 25 Section 5( a)
Orthopedic and prosthetic devices You pay
External prosthetic devices which replace all or part of an internal or external body organ or an external body part

Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy, orthopedic devices
such as braces and prosthetic devices such as artificial limbs
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, defibrillator, surgically implanted breast implant

following mastectomy, and lenses following cataract removal. See
5( b) for coverage of the surgery to insert the device.

Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

NOTE: Coverage includes repair and replacement when due to growth
or normal wear and tear.

Nothing

Not covered:
Orthopedic and corrective shoes not attached to a covered brace
Arch supports
Foot orthotics
Heel pads and heel cups
Lumbosacral supports

All charges

Durable medical equipment (DME)
Rental or purchase, including replacement, repair and adjustment, of
durable medical equipment prescribed by your Plan Physician, such as
oxygen equipment. Under this benefit, we also cover:

Hospital beds
Wheelchairs
Crutches
Walkers
Insulin pumps

NOTE: Some DME may require precertification by you or your
physician.

Nothing

Not covered:
Elastic stockings and support hose
Bathroom equipment such as bathtub seats, benches, rails and lifts
Home modifications such as stairglides, elevators, and wheelchair ramps

All charges 25
25 Page 26 27
2002 Aetna U. S. Healthcare HMO 26 Section 5( a)
Home health services You pay
Home health care ordered by a Plan Physician and provided by nurses and home health aides. Your Plan Physician will periodically review
the program for continuing appropriateness and need.
Services include intravenous therapy and medications.

Nothing

Not covered:
Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic or rehabilitative
All charges

Chiropractic care
Chiropractic services up to 20 visits per calendar year
Manipulation of the spine and extremities
Adjunctive procedures such as ultrasound, electric muscle stimulation, vibratory therapy and cold pack application

$20 per specialist visit

Not covered: Any services not listed above All charges
Alternative treatments
No benefits All charges

Educational classes and programs
Asthma
Diabetes
Congestive heart failure
Low back pain
Coronary artery disease
Also see the Non-FEHB page for our Member Health Education,
Informed Health Line and Intelihealth.

Nothing 26
26 Page 27 28
2002 Aetna U. S. Healthcare HMO 27 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine

they are medically necessary.
Plan physicians must provide or arrange covered care.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about

coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section (c) for

charges associated with the facility (i. e. hospital, surgical center, etc.)
YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES.

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Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity a condition in which an individual weighs 100 pounds or 100% over his or her normal weight

according to current underwriting standards; eligible members must
be age 18 or over. This procedure must be approved in advance by
the HMO.

Insertion of internal prosthetic devices. See 5( a) Orthopedic and prosthetic devices for device coverage information.

Voluntary sterilization
Treatment of burns

NOTE: Generally, we pay for internal prostheses (devices) according to
where the procedure is done. For example, we pay Hospital benefits for a
pacemaker and Surgery benefits for insertion of the pacemaker.

$15 per PCP office visit,
$20 per specialist visit

Not covered:
Reversal of voluntary surgically-induced sterilization

Surgery primarily for cosmetic purposes
Refractive eye surgery, such as radial keratotomy
Blood and blood derivatives, except blood derived clotting factors, and the storage of the patient's own blood for later administration

All charges 27
27 Page 28 29
2002 Aetna U. S. Healthcare HMO 28 Section 5( b)
Reconstructive surgery You pay
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
The condition produced a major effect on the member's appearance
and

The condition can reasonably be expected to be corrected by such
surgery

Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of

congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.

All stages of breast reconstruction surgery following a mastectomy, such as:

Surgery to produce a symmetrical appearance on the other breast;
Treatment of any physical complications, such as lymphedema;
Breast prostheses and surgical bras and replacements (see Prosthetic
devices)

NOTE: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48 hours
after the procedure.

$20 per specialist visit

Not covered:
Cosmetic surgery any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance

through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation

All charges

Oral and maxillofacial surgery
Oral surgical procedures, such as:
Treatment of fractures of the jaws or facial bones;
Surgical correction of congenital defects, such as cleft lip and cleft palate;

Medically necessary surgical treatment of TMJ;
Removal of stones from salivary ducts;
Excision of leukoplakia or malignancies;
Removal of bony impacted wisdom teeth;
Excision of tumors and cysts
Other surgical procedures that do not involve the teeth or their supporting structures.

$20 per specialist visit

Not covered:
Dental implants
Dental care involved with the treatment of temporomandibular joint dysfunction

All charges 28
28 Page 29 30
2002 Aetna U. S. Healthcare HMO 29 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Liver
Lung: Single Double
Pancreas
Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach

and pancreas
Skin
Tissue
Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute

lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors

National Transplant Program (NTP) Transplants which are non-experimental or non-investigational are a covered benefit. Covered

transplants must be ordered by your primary care doctor and plan
specialist physician and approved by our medical director in advance
of the surgery. The transplant must be performed at hospitals
specifically approved and designated by us to perform these
procedures. A transplant is non-experimental and non-investigational
when we have determined, in our sole discretion, that the medical
community has generally accepted the procedure as appropriate
treatment for your specific condition. Coverage for a transplant where
you are the recipient includes coverage for the medical and surgical
expenses of a live donor, to the extent these services are not covered
by another plan or program.

Limited Benefits Treatment for breast cancer, multiple myeloma and
epithelial ovarian cancer may be provided in an NCI-or NHI-approved
clinical trial at a Plan-designated center of excellence and if approved by
the Plan's medical director in accordance with the Plan's protocols.

NOTE: We cover related medical and hospital expenses of the donor
when we cover the recipient.

$20 per specialist office
visit and nothing for the
surgery

Not covered:
Transplants not listed as covered
All charges 29
29 Page 30 31
2002 Aetna U. S. Healthcare HMO 30 Section 5( b)
Anesthesia You pay
Professional services provided in
Hospital (inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office

Nothing 30
30 Page 31 32
2002 Aetna U. S. Healthcare HMO 31 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I
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Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine

they are medically necessary.
Plan physicians must provide or arrange your covered care and you must be hospitalized in a Plan facility.

Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by the facility (i. e., hospital or surgical center) or ambulance service for your surgery or

covered care. Any costs associated with the professional charge (i. e.,
physicians, etc.) are covered in Section 5( a) or (b).

YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services

require precertification.

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Benefit Description You pay
Inpatient hospital
Room and board, such as
Ward, semiprivate, or intensive care accommodations;
General nursing care; and
Meals and special diets.

NOTE: If you want a private room when it is not medically necessary,
you pay the additional charge above the semiprivate room rate.

$100 per day up to a
maximum of $300 per
admission

Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
The withdrawal, processing and storage of the patient's own blood for later administration, and the administration of this blood to the patient

Serum, clotting factors and immunoglobulins
Blood or blood plasma, if donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Take-home items
Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

Nothing

Inpatient hospital Continued on the next page 31
31 Page 32 33
2002 Aetna U. S. Healthcare HMO 32 Section 5( c)
Inpatient hospital (Continued) You pay
Not covered: Blood and blood derivatives, except blood clotting factors,
and the storage of the patient's own blood for later administration.
All charges

Not covered:
Custodial care, rest cures, domiciliary or convalescent cares
Personal comfort items, such as telephone and television

All charges

Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Radiologic procedures, diagnostic laboratory tests, and X-rays when associated with a medical procedure being done the same day

Pathology Services
Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service

NOTE: We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do not cover the dental procedures.

$75 per day

Services not associated with a medical procedure being done the same
day, such as:

Mammogram
Radiologic procedures
Heart catheterization

$20 per specialist visit

Not covered: Blood and blood derivatives, except blood clotting factors,
and the storage of the patient's own blood for later administration.
All charges

Extended care benefits/ skilled nursing care facility benefits
Extended care benefit: All necessary services during confinement in a
skilled nursing facility with a 90-day limit per calendar year when full-time
nursing care is necessary and the confinement is medically
appropriate as determined by a Plan doctor and approved by the Plan.

Nothing

Not covered: custodial care All charges 32
32 Page 33 34
2002 Aetna U. S. Healthcare HMO 33 Section 5( c)
Hospice care You pay
Supportive and palliative care for a terminally ill member in the home or
hospice facility, including inpatient and outpatient care and family
counseling, when provided under the direction of a Plan doctor, who
certifies the patient is in the terminal stages of illness, with a life
expectancy of approximately 6 months or less.

Nothing

Ambulance
Ambulance service ordered or authorized by a Plan doctor Nothing
Not covered: Ambulance services for routine transportation to receive
outpatient or inpatient services.
All charges 33
33 Page 34 35
2002 Aetna U. S. Healthcare HMO 34 Section 5( d)
Section 5 (d). Emergency services/ accidents
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.

Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.

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What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe
endangers your life or could result in serious injury or disability, and requires immediate medical or surgical
care. Some problems are emergencies because, if not treated promptly, they might become more serious;
examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening,
such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There
are many other acute conditions that we may determine are medical emergencies what they all have in
common is the need for quick action.

What to do in case of emergency:
If you need emergency care, you are covered 24 hours a day, 7 days a week, anywhere in the world. An
emergency medical condition is one manifesting itself by acute symptoms of sufficient severity such that a
prudent layperson, who possesses average knowledge of health and medicine, could reasonably expect the
absence of immediate medical attention to result in serious jeopardy to the person's health, or with respect to a
pregnant woman, the health of the woman and her unborn child.

Whether you are in or out of an Aetna U. S. Healthcare HMO service area, we simply ask that you follow the
guidelines below when you believe you need emergency care.

Call the local emergency hotline (ex. 911) or go to the nearest emergency facility. If a delay would not be detrimental to your health, call your primary care provider. Notify your primary care provider as soon as

possible after receiving treatment.
After assessing and stabilizing your condition, the emergency facility should contact your primary care physician so they can assist the treating physician by supplying information about your medical history.

If you are admitted to an inpatient facility, you or a family member or friend on your behalf should notify your primary care physician or us as soon as possible.

What to Do Outside Your Aetna U. S. Healthcare HMO Service Area
Members who are traveling outside their HMO service area or students who are away at school are covered
for emergency and urgently needed care. Urgent care may be obtained from a private practice physician, a
walk-in clinic, an urgent care center or an emergency facility. Certain conditions, such as severe vomiting,
earaches, sore throats or fever, are considered "urgent care" outside your Aetna U. S. Healthcare HMO service
area and are covered in any of the above settings.

If, after reviewing information submitted to us by the provider that supplied care, the nature of the urgent or
emergency problem does not qualify for coverage, it may be necessary to provide us with additional
information. We will send you an Emergency Room Notification Report to complete, or a Member Services
representative can take this information by telephone. 34
34 Page 35 36
2002 Aetna U. S. Healthcare HMO 35 Section 5( d)
Follow-up Care after Emergencies All follow-up care should be coordinated by your PCP. Follow-up care with nonparticipating providers is only covered
with a referral from your primary care physician and pre-approval from Aetna U. S. Healthcare. Whether you were
treated inside or outside your Aetna U. S. Healthcare service area, you must obtain a referral before any follow-up care
can be covered. Suture removal, cast removal, X-rays and clinic and emergency room revisits are some examples of
follow-up care.

What to do in case of emergency:
Emergencies within our service area: If you are in an emergency situation, call you primary care doctor. In extreme emergencies or if you are unable to contact your doctor, contact the local emergency system (e. g. the 911

telephone system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you
are a Plan member so they can notify your primary care doctor. You or a family member must notify your primary care
doctor as soon as possible after receiving emergency care. It is your responsibility to ensure that your primary care
doctor has been timely notified.

If you need to be hospitalized, the Plan must be notified as soon as possible. If you are hospitalized in non-Plan facilities
and a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically
feasible with any ambulance charges covered in full.

To be covered by this Plan, any follow-up care recommended by non-participating providers must be approved by us or
provided by plan providers.

Emergencies outside our service area: Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.

If you need to be hospitalized, the Plan must be notified as soon as possible. If a Plan doctor believes care can be better
provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

To be covered by this Plan, any follow-up care recommended by non-participating providers must be approved by us or
provided by plan providers.

Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office $15 per PCP visit $20 per specialist visit

Emergency care as an outpatient in a hospital or an urgent care center
NOTE: If the emergency results in admission to a hospital, the copay is
waived.

$75 per visit

Not covered: Elective care or non-emergency care All charges
Emergency outside our service area
Emergency care at a doctor's office $20 per specialist visit

Emergency care as an outpatient in a hospital or an urgent care center
NOTE: If the emergency results in admission to a hospital, the copay is
waived.

$75 per visit

Emergency outside our service area Continued on the next page 35
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2002 Aetna U. S. Healthcare HMO 36 Section 5( d)
Emergency outside our service area (Continued) You pay
Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area.

All charges

Ambulance
Professional ambulance service when medically appropriate. Air
ambulance may be covered. Prior approval is required.

See 5( c) for non-emergency service.

Nothing for covered care

Not covered: air ambulance without prior approval All charges 36
36 Page 37 38
2002 Aetna U. S. Healthcare HMO 37 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
Network Benefit

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Parity
When you get our approval for services and follow a treatment plan we approve,
cost-sharing and limitations for Plan mental health and substance abuse benefits
will be no greater than for similar benefits for other illnesses and conditions.

Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in this brochure.

Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

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Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and
contained in a treatment plan that we approve. The treatment plan may
include services, drugs, and supplies described elsewhere in this brochure.

NOTE: Plan benefits are payable only when we determine the care is
clinically appropriate to treat your condition and only when you receive
the care as part of a treatment plan that we approve.

Your cost sharing
responsibilities are no
greater than for other
illness or conditions.

Professional services, including individual or group therapy by providers such as psychiatrists, psychologists, or clinical social workers
Medication management
$20 per visit

Diagnostic tests $20 per visit
Services provided by a hospital or other facility
Services in approved alternative care settings such as partial hospitalization, full-day hospitalization, facility based intensive

outpatient treatment

$20 per outpatient visit

Inpatient service:
Approved residential treatment facility
Hospital services

$100 per day up to
a maximum of $300
per admission

Mental health and substance abuse benefits Continued on the next page 37
37 Page 38 39
2002 Aetna U. S. Healthcare HMO 38 Section 5( e)
Mental health and substance abuse benefits (Continued) You pay
Not covered:
Services we have not approved
Out of network mental health and substance abuse services

NOTE: OPM will base its review of disputes about treatment plans on the
treatment plan's clinical appropriateness. OPM will generally not order us to
pay or provide one clinically appropriate treatment plan in favor of another.

All charges

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all the following authorization processes:
Contact Customer Services at 1-800-537-9384 to identify providers and
obtain information on the referral process.

Limitation We may limit your benefits if you do not obtain a treatment plan. 38
38 Page 39 40
2002 Aetna U. S. Healthcare HMO 39 Section 5( f)
Section 5 (f). Prescription drug benefits
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Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.

All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically
necessary.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about

coordinating benefits with other coverage, including with Medicare.
Certain drugs require your doctor to get precertification from the Plan before they can be prescribed under the Plan. Upon approval by the Plan, the

prescription is good for the current calendar year or a specified time period,
whichever is less.

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There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician or dentist must write the prescription.
Where you can obtain them. You must fill non-emergency prescriptions at a Plan pharmacy for up to a 30-day supply, or by mail for a 31-90 day supply of medication (if authorized by your physician). Please

call Member Services at 1-800-537-9384 for more details on how to use the mail order program. In an
emergency or urgent care situation, you may fill your covered prescription at any retail pharmacy. If you
obtain your prescription at a participating pharmacy and request direct reimbursement from us, we will
review your claim to determine whether the claim is covered under the terms and conditions of your
benefit. If you obtain your prescription at a pharmacy that does not participate with the plan, you will need
to pay the pharmacy the full price of the prescription and submit a claim for reimbursement subject to the
terms and conditions of the plan.

We use a formulary. Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary. The Plan's formulary does not exclude medications from coverage, but requires a higher

copayment for nonformulary drugs. We cover nonformulary drugs when prescribed by a Plan doctor at
a 50% copayment. For covered nonformulary drugs you pay 50% of the negotiated rate for the drug
between the Plan and the participating retail or mail order pharmacy. Certain drugs require your doctor
to get precertification from the Plan before they can be prescribed under the Plan. Visit our website at
www. aetnaushc. com/ feds to review our Formulary Guide or call 1-800-537-9384.

Precertification. Your pharmacy benefits plan includes our precertification program. Precertification helps encourage the appropriate and cost-effective use of certain drugs. These drugs must be pre-authorized by

our Pharmacy Management Precertification Unit before they will be covered. Only your physician or
pharmacist in the case of an antibiotic or analgesic can request prior authorization for a drug.

The precertification program is based upon current medical findings, manufacturer labeling, FDA
guidelines and cost information.

The drugs requiring precertification are subject to change. Visit our website for the current Precertification
List.

These are the dispensing limitations. Covered prescription drugs prescribed by a licensed physician or dentist and obtained at a Participating Plan Pharmacy may be dispensed for up to a 30-day supply. Members

must obtain a 31-to 90 day supply of covered prescription medication through mail order. A generic
equivalent will be dispensed if available, unless your physician specifically requires a name brand.

Why use generic drugs? Generics contain the same active ingredients in the same amounts as their brand name counterparts and must have been approved by the FDA. By using generic drugs, when available,

most members see cost savings, without jeopardizing clinical outcome or compromising quality.
When you have to file a claim. Send your itemized bill( s) to: Aetna U. S. Healthcare, Pharmacy Management, Claim Processing, P. O. Box 398106, Minneapolis, MN 55439-8106.

Prescription drug benefits Begin on the next page 39
39 Page 40 41
2002 Aetna U. S. Healthcare HMO 40 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician or dentist and obtained from a Plan pharmacy or through our
mail order program:

Drugs for which a prescription is required by Federal law
Oral contraceptive drugs
Insulin
Disposable needles and syringes need to inject covered prescribed medication, including insulin

Diabetic supplies limited to lancets, alcohol swabs, urine test strips/ tablets, and blood glucose test strips
Contraceptive drugs and devices
Oral fertility drugs

Intravenous fluids and medications for home use, implantable drugs, such as Norplant, IUDs and some injectable drugs are covered under

Medical and Surgical benefits. See Section 5( a) for details.

$10 per covered generic
formulary prescription/ refill
(up to a 30 day supply) or
$20 for a 31-to 90-day
supply through mail order

$20 per covered brand name
formulary prescription/ refill
(up to a 30 day supply) or $40
for a 31-to 90-day supply
through mail order

50% of the negotiated rate
between the Plan and the
participating retail or mail
order pharmacy per covered
non-formulary (generic or
brand) prescription/ refill.

Limited benefits
Drugs to treat sexual dysfunction are limited. Contact the Plan for dose limits

Depo Provera is limited to 5 vials per calendar year
One diaphragm per calendar year

50%
$20 copay per vial
$20 per diaphragm

Here are some things to keep in mind about our prescription drug program:
A generic equivalent may be dispensed if it is available, and where allowed by law.

To request a copy of the Aetna U. S. Healthcare Medication Formulary Guide, call 1-800-537-9384. The information in the Medication
Formulary Guide is subject to change. Please visit our website at
www. aetnaushc. com/ feds for current Medication Formulary Guide
information.

Covered medications and supplies Continued on the next page 40
40 Page 41 42
2002 Aetna U. S. Healthcare HMO 41 Section 5( f)
Covered medications and supplies (Continued) You pay
Not covered:
Drugs available without a prescription or for which there is a nonprescription equivalent available, (i. e., an over-the-counter (OTC)

drug)
Drugs obtained at a non-Plan pharmacy except when related to out-of-area emergency care

Vitamins and nutritional substances that can be purchased without prescription.
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance.
Smoking-cessation drugs and medication, including, but not limited to, nicotine patches and sprays.

Injectable fertility drugs
Drugs used for the purpose of weight reduction (i. e., appetite suppressants)

All charges 41
41 Page 42 43
2002 Aetna U. S. Healthcare HMO 42 Section 5( g)
Section 5 (g). Special Features
Feature Description
Services for the deaf and
hearing-impaired

1-800-628-3323

Informed Health Line Provides eligible members with telephone access to registered nurses experienced in providing information on a variety of health topics.
Informed Health Line is available 24 hours a day, 7 days a week. You
may call Informed Health Line at 1-800-556-1555, Informed health Line
nurses cannot diagnose, prescribe medication or give medical advice.

Reciprocity benefit If you need to visit a participating primary care physician for a covered service, and you are 50 mile or more away from home you may visit a
primary care physician from our Plan's approved network.
Call 1-800-537-9384 for provider information and location
Select a doctor from 3 primary care doctors in that area
The Plan will authorize you for one visit and any tests or X-rays ordered by that primary care physician.

You must coordinate all subsequent visits through your own participating care physician.

High-risk pregnancies The Aetna U. S. Healthcare Moms-to-Babies Maternity Management Program TM helps members give their babies a healthy start with
educational materials and services that complement covered benefits. This
program includes nurse case management, educational materials, one
prenatal and one newborn home nurse visit, breast feeding information
and support, and other benefits.

Centers of Excellence for
transplants/ heart
surgery/ etc

Our National Medical Excellence Program coordinates services for
complicated or rare illnesses and transplants. The National Medical
Excellence Program is unique to Aetna U. S. Healthcare and has been created
for members with particularly difficult conditions such as rare cancers and
other complicated diseases and disorders.

Usually, the recommended treatment can be found in your area. But if your
needs extend beyond your region, the National Medical Excellence Program
may be available to send you to out-of-area experts.

The first priority is to determine an appropriate treatment program. If your
treatment program cannot be provided in the local area, we will arrange and
pay for covered care as well as related travel expenses to wherever the
necessary care is available. Prior approval is required.

Travel benefit/ services
overseas

Our National Medical Excellence Program is a case management program
that provides consistency in the coordination of care for life threatening
and complex illnesses. This includes bone marrow and solid organ
transplants, investigational and new technology (when covered), and
unique services that are offered at a limited number of medical facilities.
We also coordinate care for members if they need covered care that is not
available in their local area and if they become ill when traveling
temporarily outside the Continental United States. 42
42 Page 43 44
2002 Aetna U. S. Healthcare HMO 43 Section 5( h)
Section 5 (h). Dental benefits
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and
exclusions in this brochure and are payable only when we determine they are
medically necessary.

Your selected Plan primary care dentist must provide or arrange covered care.
We cover hospitalization for dental procedures only when a nondental physical
impairment exists which makes hospitalization necessary to safeguard the health of
the patient; we do not cover the dental procedure unless it is described below.

Be sure to read Section 4, Your costs for covered services for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare.

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Accidental injury benefit
No benefits other than those listed on the following schedule.

Dental Benefits You pay
Service
Diagnostic
Office visit for oral evaluation limited to 2 visits per year
Bitewing x-rays limited to 2 sets of bitewing x-rays per year
Entire x-ray series limited to 1 entire x-ray series in any 3 year period
Periapical x-rays and other dental x-rays as necessary
Diagnostic models

Preventive
Prophylaxis (cleaning of teeth) limited to 2 treatments per year
Topical fluoride limited to 2 courses of treatment per year and to
children under age 18

Oral hygiene instruction

Restorative (Fillings)
Amalgam (primary) 1 surface
Amalgam (primary) 2 surfaces
Amalgam (primary) 3 surfaces
Amalgam (primary) 4 surfaces
Amalgam (permanent) 1 surface
Amalgam (permanent) 2 surfaces
Amalgam (permanent) 3 surfaces
Amalgam (permanent) 4 surfaces

$5
$5
$5
$5
$5

$5
$5

$5

$5
$5
$5
$5
$5
$5
$5
$5

Dental Benefits Continued on the next page 43
43 Page 44 45
2002 Aetna U. S. Healthcare HMO 44 Section 5( h)
Dental Benefits (Continued) You pay
Service
Prosthodontics Removable
Denture adjustments (complete or partial/ upper or lower)

Endodontics
Pulp cap direct
Pulp cap indirect

$5
$5
$5

NOTE: The above services are only covered when provided by your selected participating primary care
dentist in accordance with the terms of your Plan. If rendered by a participating specialist, they are provided
at reduced fees. Pediatric dentists are considered specialists. Certain other services will be provided by your
selected participating primary care dentist at reduced fees. A partial list appears below. Ask your selected
participating primary care dentist for a complete schedule of current reduced member fees. All member fees
must be paid directly to the participating dentist.

Each employee and dependent must select a primary care dentist from the directory and include the dentist's
name on the enrollment or provider selection form.

The following procedures are also available from your selected participating primary care dentist up to the
maximum fee shown. These same services received from a participating specialist may require you to pay a
fee that is higher than the stated maximum. Call your selected participating primary care dentist or
participating dental specialist for the specific fee in your area.

Service
You pay up to
a maximum fee of

Diagnostic
Sealant per permanent tooth
Space maintainer

Restorative (Fillings)
Resin (anterior) 1 surface
Resin (anterior) 2 surfaces
Resin (anterior) 3 surfaces
Resin (anterior) 4 or more surfaces or incisal angle
Metallic inlay

$35
$560

$110
$145
$175
$190
$725

Prosthodontics, removable
Complete denture, (upper or lower)
Immediate denture (upper or lower)
Partial denture resin base (upper or lower)
Partial denture cast metal framework with resin base (upper or lower)
Denture repairs
Add tooth to existing partial
Add clasp to existing partial

$1,025
$1,110
$790
$1,200
$150
$135
$150

Dental benefits Continued on the next page 44
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2002 Aetna U. S. Healthcare HMO 45 Section 5( h)
Dental Benefits (Continued)
Service
You pay up to
a maximum fee of

Prosthodontics, removable (Continued)
Denture rebase
Denture relines
Interim denture (complete or partial/ upper or lower)
Tissue conditioning

Prosthodontics, fixed
Bridge pontic
Metallic inlay/ onlay
Cast metal retainer for resin bonded prosthesis
Crown porcelain
Crown cast
Recement bridge
Post and core

Oral surgery
Extractions (nonsurgical and tissue impacted)
Anesthesia (general in office, first half-hour session)

$375
$325
$465
$110

$875
$815
$315
$860
$865
$85
$315

$475
$270

Periodontics (Gum treatment)
Gingivectomy per quadrant
Gingival curretage per quadrant
Periodontal surgery
Provisional splinting
Scaling and root planing per quadrant
Periodontal maintenance procedure

Endodontics (Root canal)
Therapeutic pulpotomy
Root canals (anterior, bicuspid, molar) excluding final restoration
Apicoectomy anterior

Orthodontics
Pre-orthodontic treatment visit
Fully banded case (adult age 19 and over)
Fully banded case (child age 18 and under)

$315
$150
$760
$160
$150
$110

$125
$760
$510

$350
$5,625
$5,625

Specific fees vary by area of the country up to the stated maximum. Ask
your primary care dentist for a complete schedule of reduced fees.

Services not received from a participating dental provider are not
covered. We offer no other dental benefits than those shown above.
All charges

When you have to file a claim Send your itemized bills to Aetna U. S. Healthcare, One Imeson Place. 1 Imeson Park Drive, Bldg. 100, Mezz. Floor, Jacksonville FL 32218. 45
45 Page 46 47
2002 Aetna U. S. Healthcare HMO 46 Section 5 (i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits and programs on this page are not part of the FEHB contract or premium, and you cannot file an
FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or
out-of-pocket maximums.

Intelihealth InteliHealth. com offers comprehensive health information which is interactive and easy-to-use. Harvard
Medical School and the University of Pennsylvania School of Dental Medicine help InteliHealth to provide
trusted and credible health information to its users. InteliHealth features include: a Drug Resource Center,
Disease and Condition Management tools, Health Risk Assessments, the Harvard Symptom Scout (an
interactive symptom checker that provides guidance about a variety of symptoms), Daily Health News and
much more.

Vision One 1 You are eligible to receive substantial discounts on eyeglasses, contact lenses, Lasik the laser vision

corrective procedure, and nonprescription items including sunglasses and eyewear products through the Vision
One Program at more than 4,000 locations across the country.

This eyewear discount enriches the routine vision care coverage provided in your health plan, which includes an
eye exam from a participating provider. If your health plan also includes coverage for eyewear such as
prescription eyeglasses or contact lens, your out-of-pocket expense can be reduced when you use Vision One
discount. You may purchase your eyewear at Vision One locations at discounted rates, and your allowance will
automatically be applied at point of purchase. You don't have to submit the receipt for reimbursement. Your
allowance applies to prescription eyeglasses or contact lenses only.

For more information on Vision One eyewear call toll free 1-800-793-8616. For a referral to a Lasik provider,
call 1-800-422-6600.

Fitness Program Aetna U. S. Healthcare offers members access to discounted fitness services provided by GlobalFit TM . Programs

offer Plan participants:
Low or discounted membership rates at independent health clubs contracted with