RI 70-5
Revised November 2003
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OFFICE OF THE DIRECTOR
UNITED STATES
OFFICE OF PERSONNEL MANAGEMENT
WASHINGTON, DC 20415-1000
Dear Federal Employees Health Benefits Program Participant:
It is hard to believe that a year has passed and the Federal Employees Health Benefits (FEHB) Open Season is here again. This is your annual opportunity to evaluate your personal needs and, if necessary, change health plans. I am pleased to present the 2004 FEHB Guide to help you with your evaluation.
It takes a lot of information to help a consumer make wise healthcare decisions. The information in this Guide and our web-based resources make it easier than ever to get information about premiums, to compare benefits, to read customer service satisfaction ratings for the national and local plans that may be of interest, and to learn about quality information from the National Committee for Quality Assurance, the Joint Commission on Accreditation of Healthcare Organizations, and URAC.
The FEHB Program continues to be an enviable national model that offers exceptional choice, and uses private-sector competition to keep costs reasonable, ensure high-quality care, and spur innovation. The Program, which began in 1960, is sound and has stood the test of time. It enjoys one of the highest levels of customer satisfaction of any healthcare program in the country. President Bush has chosen the FEHB as a model for modernizing and improving Medicare.
I continue to take aggressive steps to keep the FEHB Program on the cutting edge of employer-sponsored health benefits. We demand cost-effective quality care from our FEHB carriers and we have encouraged Federal agencies and departments to pay the full FEHB health benefit premium for their employees called to active duty in the Reserve and National Guard so they can continue FEHB coverage for themselves and their families. Our carriers have also responded to my request to help our members to be prepared by making additional supplies of medications available for emergencies as well as call-up situations and you can help by getting an Emergency Preparedness Guide at www.opm.gov. OPM's HealthierFeds campaign is another way the carriers are working with us to ensure Federal employees and retirees are informed on healthy living and best-treatment strategies. You can help to contain healthcare costs and keep premiums down by living a healthy life style.
Open Season is your opportunity to review your choices and to become a better educated consumer to meet your healthcare needs. Use this Guide, the health plan brochures, and the web resources at www.opm.gov/insure to make your choice an informed one. Finally, if you know someone interested in Federal employment, refer them to www.usajobs.gov.
Sincerely,
Kay Coles James
Director
The information in this Guide gives you an overview of the FEHB Program and its participating plans. Read the plan brochures before you make any final decisions about health plans.
These individuals are eligible to enroll in the FEHB Program but do not receive a Government contribution toward the cost of their enrollment:
Individuals eligible for temporary continuation of coverage (TCC), including:You may voluntarily cancel your enrollment at any time. However, once your cancellation takes effect, you probably will not be able to enroll again. You will not be entitled to a 31-day extension of coverage for conversion to a non-group (private) policy. Family members may enroll only if they are eligible in their own right as Federal employees or annuitants.
TCC enrollees who cancel cannot reenroll unless they cancel because they acquire other FEHB coverage, and that coverage ends before the period of temporary continuation of coverage ends.
Former spouses enrolled under the spouse equity law or similar statute who canceled cannot reenroll as a former spouse unless they either cancel because they acquire other coverage under the FEHB Program, and that coverage ends, or suspend their FEHB coverage to enroll in a Medicare+Choice health plan under the Social Security Act or because they are eligible under Medicaid or similar State-sponsored program of medical assistance for the needy. (For information about the reenrollment opportunity, contact the Human Resources office or retirement system that handles your account.)
Strict time limits for electing TCC apply. As early as possible before (or after) the event causing the need for TCC happens, contact the employees Human Resources office or the annuitants retirement system to get more facts about the requirements for electing coverage.
Former (divorced) spouses eligible to enroll under the spouse equity law or similar statutes. If you are the spouse of a Federal employee or an annuitant and lose FEHB coverage because of divorce, you may elect FEHB coverage under certain circumstances. Contact the employees Human Resource office or the annuitants retirement system for the requirements for electing cov erage.
For more information on how to suspend your FEHB enrollment, contact the Human Resources office or retirement system that handles your account. Time limitations and other restrictions apply. For instance, you must submit documentation that you are suspending FEHB to enroll in a Medicare+Choice health plan or furnish proof of eligibility for coverage under the Medicaid program or similar State-sponsored program of medical assistance for the needy, in case you wish to reenroll in the FEHB Program at a later time.
If you had suspended FEHB coverage for either one of these reasons (and had submitted the required documentation) but now want to enroll in the FEHB Program again, you may enroll during Open Season. You may reenroll outside Open Season only if you move out of the Medicare+Choice health plans service area, the Medicare+Choice health plan is discontinued, or you involuntarily lose coverage under the Medicaid program or similar State-sponsored program of medical assistance for the needy. If you cancelled your coverage for any other reason, you cannot reenroll.
Step 1: What type of health plan is best for you? You have some basic questions to answer about how you pay for and access medical care. This is because Fee-for-Service (FFS) plans -- with and without a Preferred Provider Organization (PPO), Health Maintenance Organizations (HMO), Point-of-Service (POS) plans, and Consumer-Driven plans all operate differently.
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Fee-for-Service |
Fee-for-Service |
Health Maintenance Organization |
Point-of-Service |
Consumer-Driven Plans |
|---|---|---|---|---|---|
Choice of doctors, hospitals, pharmacies, and other providers |
You must use the plan's network for full benefits. Not using PPO providers means only some or none of your benefits will be paid. |
You may use any doctor, hospital, etc. Benefits are not limited by where you get care. |
You generally must use the network; no benefits outside of the network - you pay all costs. |
You must use network for full benefits. You may go outside the network but it will cost you more. |
You may use network and non-network providers. Not using the network will cost you more. |
Specialty care |
Referral not required to get full benefits. |
Referral not required to get full benefits. |
Referral generally required from primary care doctor to get benefits. |
Referral required to get full benefits. |
Referral not required to get full benefits. |
Out-of-pocket costs |
You pay fewer costs if you use a PPO provider than if you don't. |
You pay regular plan out-of-pocket costs. |
Your out-of-pocket costs are generally limited to copayments. |
You pay less if you use a network provider than if you don't. |
You pay less if you use a network provider than if you don't. |
Paperwork |
Some if you don't use network providers. |
You have to file your own claims. |
Little, if any. |
Little if you use the network. You will have to file your own claims if you don't use the network. |
Some if you don't use network providers. |
Step 2: What services are important to you and what health care do you expect to use? Refer to your medical and insurance records from last year as a guide to what services you might use this year. Add up the actual costs to you, including premiums. Estimate what you might spend on your health care for deductibles, coinsurance/copayments, and services that are not covered. Are there any annual limits for days or services covered and on the dollar amount the plan will spend on you? What is the maximum you will have to pay out-of-pocket each year?
Consult the health plans' brochures to find this benefit information. Copies of brochures as well as a tool to complete this sheet on-line are on our web site at www.opm.gov/insure/health.
| Health Plan ___________ | Health Plan ___________ | Health Plan ___________ |
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Annual premium |
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Office visit to primary care doctor |
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Office visit to specialist |
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Hospital inpatient deductible/ copay/ coinsurance |
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Hospital room & board charges |
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Generic drug (local pharmacy) |
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Brand name drug (local pharmacy) |
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Catastrophic protection limit |
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Mental health care visits |
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Home health care visits |
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Durable medical equipment |
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Maternity care |
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Well-child care |
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Routine physicals |
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Accreditation |
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The following information can be found in the Member Survey Results section in the benefit charts. |
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Overall member satisfaction with plan |
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Getting needed care |
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Getting care quickly |
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How well doctors communicate |
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Customer service |
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Claims processing |
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Step 3: Consider quality. Quality is how well health plans keep their members healthy or treat them when they are sick. Good quality doesn't always mean receiving more care. Good quality health care means doing the right thing at the right time, in the right way, for the right person to achieve the best possible results. We provide two types of quality information in the plan benefit charts: independent evaluations (accreditation) from private organizations and evaluations by enrollees (member survey).
Accreditation evaluations shown in this Guide are performed by the National Committee for Quality Assurance (NCQA), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and URAC. The following are the accreditation levels used by each organization. The codes correspond to a plan's accreditation level as shown in the plan comparison section.
National Committee for Quality Assurance (www.ncqa.org) |
Excellent - Levels of service and clinical quality that meet or exceed NCQA's requirements for consumer protection and quality improvement AND achieve health plan performance results that are in the highest range of national or regional performance. Code N1 | Commendable - Meets or exceeds NCQA's requirements for consumer protection and quality improvement. Code N2 |
Accredited - Meets most of NCQA's requirements for consumer protection and quality improvement. Code N3 |
Provisional - Meets some but not all of NCQA's requirements for consumer protection and quality improvement. Code N4 | New Health Plan - Applies to health plans that are less than two years old. Code N6 |
Joint Commission on Accreditation of Healthcare Organizations (www.jcaho.org) |
Accreditation with Full Compliance - Demonstrates satisfactory compliance with JCAHO standards in all performance areas. Code J1 |
Accreditation with Requirements for Improvement - |
Provisional - Demonstrates a previously unaccredited plan's satisfactory compliance with a subset of standards. Code J3 |
Conditional - Demonstrates failure to meet standard (s) or specific policy requirement(s) but is believed capable to do so in a specified time period. Code J4 |
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URAC (www.urac.org) |
Full Accreditation - Demonstrates full compliance with standards. Code U1 |
Conditional - Meets most of the standards but needs some improvement before achieving full compliance. Code U2 |
Provisional -A plan that has otherwise complied with all standards but has been in operation for less than 6 months. Code U3 |
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Note. This chart shows the accreditation levels available under each accrediting organization listed. It is not intended to draw comparisons among the different accrediting organizations.
Member Survey results, shown in the plan comparison sections, are collected, scored, and reported by an independent organization - not by the health plans. Here is a brief explanation of each survey category.
Overall Plan Satisfaction |
How would you rate your overall experience with your health plan? |
Getting Needed Care |
Were you satisfied with the choices your health plan gave you to select a personal doctor? |
Getting Care Quickly |
Did you get the advice or help you needed when you called your doctor during regular office hours? Could you get an appointment for regular or routine care when you wanted? |
| How Well Doctors Communicate | Did your doctor listen carefully to you and explain things in a way you could understand? |
Customer Service |
Was your plan helpful when you called its customer service department? Did you have paperwork problems? Were the plan's written materials understandable? |
Claims Processing |
Did your plan pay your claims correctly and in a reasonable time? |
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An influential report from the Institute of Medicine estimates that up to 98,000 Americans die every year from medical mistakes in hospitals alone. That's about 3,230 preventable deaths in the FEHB Program a year. While death is the most tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and even additional treatments. By asking questions, learning more and understanding your risks, you can improve the safety of your own health care, and that of your family members. Take these simple steps:
1. Ask questions if you have doubts or concerns.
Want more information on patient safety?
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The FEHB web site at www.opm.gov/insure/health can help you to choose your health plan and enroll. In addition to the information found in this Guide you will find:
Program Features
Consumer Protections. Go to www.opm.gov/insure/health/consumers to see your appeal rights to OPM if you and your plan have a dispute over a claim; to read the Patients' Bill of Rights and the FEHB Program; and to learn about your privacy protections when it comes to your medical information.
Accreditation - The status granted to a health care organization following a rigorous and comprehensive evaluation performed by independent organizations. The evaluation also includes an assessment of the care and service plans are delivering in important areas of public concern such as immunization rates, mammography rates, and member satisfaction.
Brand name drug - A prescription drug that is protected by a patent, supplied by a single company, and marketed under the manufacturer's brand name.
Coinsurance - The amount you pay as your share of the medical services you receive, like for a doctor's visit. Coinsurance is a percentage of the cost of the service (e.g., you pay 20%).
Consumer-Driven Plans - Describes a wide range of approaches to give you more incentive to control the cost of either your health benefits or health care. You have greater freedom in spending health care dollars up to a designated amount, and you receive full coverage for in-network preventive care. In return, you assume significantly higher cost sharing expenses after you have used up the designated amount. The catastrophic limit is usually higher than those common in other plans. Common features include full or partial employee responsibility for several thousand dollars in expenses, and catastrophic coverage covering costs above a certain level, usually higher than those common in other plans.
Copayment - The amount you pay as your share of the medical services you receive, like for a doctor's visit. Copayment is a fixed dollar amount (e.g., you pay $15).
Fee-For-Service (FFS) - Health coverage in which doctors and other providers receive a fee for each service such as an office visit, test, procedure, or other health care service. The health plan will either pay the medical provider directly or reimburse you for covered services after you have paid the bill and filed an insurance claim. When you need medical attention, you visit the doctor or hospital of your choice.
Formulary - A list of both generic and brand name drugs that are preferred by your health plan. Many prescription drugs produce the same results. Health plans choose formulary drugs that are medically safe and cost effective. A team including pharmacists and physicians meet to review the formulary and make changes as necessary.
Generic drug - A prescription that is not protected by a drug patent. A generic medication is basically a copy of the brand name drug. A generic drug may have a different color or shape than its brand name counterpart, but it must have the same active ingredients, strength, and dosage form (i.e., pill, liquid, or injection), and provide the same effectiveness and safety. Generics generally cost less than brand name drugs.
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Health Maintenance Organization (HMO) - A health plan that provides care through contracted or employed physicians and hospitals located in particular geographic or service areas. HMOs emphasize prevention and early detection of illness. Your eligibility to enroll in an HMO is determined by where you live or, in some plans, where you work.
In-Network - You receive treatment from the doctors, clinics, health centers, hospitals, medical practices, and other providers with whom your plan has an agreement to care for its members. Examples include a Fee-For-Service plan's PPO or a Health Maintenance Organization. Members have fewer out-of-pocket costs when they use in-network providers.
Out-of-Network - You receive treatment from doctors, hospitals, and medical practitioners other than those with whom the plan has an agreement, and pay more to do so. Members in a PPO-only option who receive services outside the PPO network generally pay all charges.
Point of Service (POS) - A product offered by an HMO or FFS plan that has both in-network and out-of-network features. In a POS you don't have to use the plan's network of providers for every service, but you generally pay more out of network.
Preferred Provider Organization (PPO) - The PPO is similar to FFS insurance except it uses a network of providers. PPOs give you the choice of using doctors and other providers in the network or using non-network providers. You don't have to use the PPO, but there are advantages if you do. (Be aware, however, that some of the services provided in a PPO hospital may not be covered by PPO arrangements. Room and board will be covered, but anesthesia and radiology, for instance, may be covered under non-PPO benefits.) Note that some FFS plans may offer an enrollment option that is "PPO-only." You must use network providers to receive benefits from a PPO-only plan.
Provider - A doctor, hospital, health care practitioner, pharmacy, or health care facility.
OPM wants to be sure you know about two new Federal programs that complement the FEHB Program. First, the Flexible Spending Account (FSA) Program, also known as FSAFeds, lets you set aside tax-free money to pay for health and dependent care expenses. The result can be a discount of 20 to more than 40 percent on services you routinely pay for out-of-pocket. Second, the Federal Long Term Care Insurance Program (FLTCIP) covers long term care costs not covered under the FEHB Program.
What is an FSA?
It is a tax-favored benefit that allows you to set aside pre-tax money from your paychecks to pay for a variety of eligible expenses. By using an FSA, you can reduce your taxes while paying for services you would have to pay for anyway, producing a discount that can be over 40%.
There are two types of FSAs offered by the FSAFeds Program:
Health Care Flexible Spending Accounts (HCFSA)
Dependent Care Flexible Spending Account (DCFSA)
Enroll during Open Season
You must make an election to enroll in an FSA during the FEHB Open Season. Even if you enrolled during the initial Open Season for 2003, you must make a new election to continue participating in 2004. Enrollment is easy.
What is SHPS?
SHPS is a third-party administrator hired by OPM to manage the FSAFeds Program. SHPS is the largest FSA administrator in the nation and will be responsible for enrollment, claims processing, customer service, and day-to-day operations of FSAFeds.
Who is eligible to enroll?
If you are a Federal employee eligible for FEHB - even if you're not enrolled in FEHB - you can choose to participate in either, or both, of the flexible spending accounts. If you are not eligible for FEHB, you are not eligible to enroll for a Health Care FSA. However, almost all Federal
employees are eligible to enroll for the Dependent Care FSA. The only exception is intermittent (also called when actually employed [WAE]) employees expected to work less than 180 days during the year.
NOTE: FSAFeds is the FSA Program established for all Executive Branch employees and Legislative Branch employees whose employers signed on. Under IRS law, FSAs are not available to annuitants. In addition, the U.S. Postal Service and the Judicial Branch, among others, are Federal agencies that have their own plans with slightly different rules, but the advantages of having an FSA are the same no matter what agency you work for.
How much should I contribute to my FSA?
Plan carefully when deciding how much to contribute to an FSA. Because of the tax benefits of an FSA, the IRS places strict guidelines on them. You need to estimate how much you want to allocate to an FSA because current IRS regulations require you forfeit any funds remaining in your account(s) at the end of the FSA plan year. This is referred to as the "use-it-or-lose-it" rule. You will have until April 29, 2004 to submit claims for your eligible expenses incurred during 2003 if you enrolled in FSAFeds when it was initially offered. You will have until April 30, 2005 to submit claims for your eligible expenses incurred from January 1 through December 31, 2004 if you elect FSAFeds during this Open Season.
The FSAFeds Calculator at www.FSAFeds.com will help you plan your FSA allocations and provide an estimate of your tax savings based on your individual situation.
What can my HCFSA pay for?
Every FEHB health plan includes cost sharing features, such as deductibles you must meet before the Plan provides benefits, coinsurance or copayments that you pay when you and the Plan share costs, and medical services and supplies that are not covered by the Plan and for which you must pay. Your HCFSA will reimburse you for such costs when they are for tax deductible medical care for you and your dependents that is NOT covered by this FEHB Plan or any other coverage that you have.
The IRS governs expenses reimbursable by a HCFSA. See Publication 502 for a comprehensive list of tax-deductible medical expenses. Note: While you will see insurance premiums listed in Publication 502, they are NOT a reimbursable expense for FSA purposes. Publication 502 can be found on the IRS Web site at http://www.irs.gov/pub/irs-pdf/p502.pdf. If you do not see your service or expense listed in Publication 502, please call an FSAFeds Benefit Counselor at 1-877-FSAFeds (372-3337), who will be able to answer your specific questions.
Tax savings with an FSA
An FSA lets you allot money for eligible expenses before your agency deducts taxes from your paycheck. This means the amount of income that your taxes are based on will be lower, so your tax liability will also be lower. Without an FSA, you would still pay for these expenses, but you would do so using money remaining in your paycheck after Federal (and often state and local) taxes are deducted. The following chart illustrates a typical tax savings example:
Annual Tax Savings Example | With FSA | Without FSA |
|---|---|---|
If your taxable income is: | $50,000 | $50,000 |
And you deposit this amount into an FSA: | $ 2,000 | -$0- |
Your taxable income is now: | $48,000 | $50,000 |
Subtract Federal & Social Security taxes: | $13,807 | $14,383 |
If you spend after-tax dollars for expenses: | - $0- | $ 2,000 |
Your real spendable income is: | $34,193 | $33,617 |
Your tax savings: | $576 | -$0- |
Note: This example is intended to demonstrate a typical tax savings based on 27% Federal and 7.65% FICA taxes. Actual savings will vary based upon in which retirement system you are enrolled (CSRS or FERS), as well as your individual tax situation. In this example, the individual received $2,000 in services for $1,424, a discount of almost 36%. You may also wish to consult a tax professional for more information on the tax implications of an FSA.
Tax Credits and Deductions
You cannot claim expenses on your Federal income tax return if you receive reimbursement for them from your HCFSA or DCFSA. Below are some guidelines that may help you decide whether to participate in FSAFeds.
Health Care Expenses
The HCFSA is tax-free from the first dollar. In addition, you may be reimbursed from the HCFSA at any time during the year for expenses up to the annual amount you've elected to contribute.
Only health care expenses exceeding 7.5% of your adjusted gross income are eligible to be deducted on your Federal income tax return. Using the example listed in the above chart, only health care expenses exceeding $3,750 (7.5% of $50,000) would be eligible to be deducted on your Federal income tax return. In addition, money set aside through a HCFSA is also exempt from FICA taxes. This exception is not available on your Federal income tax return.
Dependent Care Expenses
The DCFSA generally allows many families to save more than they would with the Federal tax credit for dependent care expenses. Note that you may only be reimbursed from the DCFSA up to your current account balance. If you file a claim for more than your current balance, it will be held until additional payroll allotments have been added to your account.
Visit www.FSAFeds.com and download the Dependent Care Tax Credit Worksheet from the Quick Links box to help you determine what is best for your situation. You may also wish to consult a tax professional for more details.
Does it cost me anything to participate in FSAFeds?
Probably not. While there is an administrative fee of $4.00 per month for an HCFSA and 1.5% of the annual election for a DCFSA, most agencies have elected to pay these fees out of their share of employment tax savings. To be sure, check the FSAFeds.com web site or call 1-877-FSAFeds (372-3337). Also, remember that participating in FSAFeds can cost you money if you don't spend your entire account balance by the end of the plan year and wind up forfeiting your end of year account balance, per the IRS "use-it-or-lose-it" rule.
Contact us
To find out more or to enroll, please visit the FSAFeds web site at www.FSAFeds.com, or contact SHPS by email or by phone. SHPS Benefit Counselors are available from 9:00 a.m. until 9:00 p.m. eastern time, Monday through Friday.
Here's why you should consider enrolling in the Federal Long Term Care Insurance Program:
To find out more or to request an application
Call 1-800-LTC-FEDS (1-800-582-3337) (TTY 1-800-843-3557) or visit www.ltcfeds.com.
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits Program (FEHBP) premium. OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHBP regardless of the agency that employs you or from which you retired.
Protect Yourself From Fraud - Here are some things you can do to prevent fraud:
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
(Pages 16 through 19)
Fee-For-Service (FFS) Plans with a Preferred Provider Organization (PPO) — A FFS option that allows you to see medical providers who reduce their charges to the plan; you pay less money out-of-pocket when you use a PPO provider. When you visit a PPO you usually won't have to file claims or paperwork. However, going to a PPO hospital does not guarantee PPO benefits for all services received within that hospital. For instance, lab work and radiology services from independent practitioners within the hospital may not be covered by the PPO agreement.
Fee-For-Service (FFS) Plans (non-PPO) — An FFS plan that either pays the medical provider directly or reimburses you for covered medical expenses. When you need medical attention, you visit the doctor or hospital of your choice.
In PPO-only options, you must use PPO providers to receive benefits.
Consumer-Driven Plans — Describes a wide range of approaches to give you more incentive to control the cost of either your health benefits or health care. You have greater freedom in spending health care dollars up to a designated amount, and you receive full coverage for in-network preventive care. In return, you assume significantly higher cost sharing expenses after you have used up the designated amount. The catastrophic limit is usually higher than those common in other plans.
Nationwide Fee-for-Service Plans Open to All
How to read this chart:
The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures before making your final decision. The chart does not show all of your possible out-of-pocket costs.
The Deductibles shown are the amount of covered expenses that you pay before your health plan begins to pay.
Calendar Year deductibles for families are two or more times the per person amount shown.
In some plans your combined Prescription Drug purchases from Mail Order and local pharmacies count toward the deductible. In other plans only purchases from local pharmacies count. Some plans require each family member to meet a per person deductible.
The Hospital Inpatient deductible is what you pay each time you are admitted to a hospital.
Your share of Hospital Inpatient Room and Board covered charges is shown.
The Generic drug figure is the copayment or coinsurance most commonly paid by members of this health plan for a Generic formulary drug.
Plan name |
Telephone number |
Enrollment code |
Total Monthly Premium |
102% of Total Monthly Premium |
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|---|---|---|---|---|---|---|---|
Self only |
Self & family |
Self only |
Self & family |
Self only |
Self & family |
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APWU Health Plan-High |
800/222-2798 |
471 |
472 |
386.36 |
847.90 |
394.09 |
864.86 |
APWU Health Plan-Std |
800/222-2798 |
474 |
475 |
337.55 |
786.05 |
344.30 |
801.77 |
Blue Cross and Blue Shield Service Benefit Plan-Std |
Local phone # |
104 |
105 |
368.98 |
844.94 |
376.36 |
861.84 |
Blue Cross and Blue Shield Service Benefit Plan-Basic |
Local phone # |
111 |
112 |
329.29 |
771.29 |
335.88 |
786.72 |
GEHA Benefit Plan-High |
800/821-6136 |
311 |
312 |
428.22 |
931.97 |
436.78 |
950.61 |
GEHA Benefit Plan-Std |
800/821-6136 |
314 |
315 |
262.17 |
595.83 |
267.41 |
607.75 |
Mail Handlers-High |
800/410-7778 |
451 |
452 |
470.15 |
991.68 |
479.55 |
1011.51 |
Mail Handlers-Std |
800/410-7778 |
454 |
455 |
278.72 |
605.04 |
284.29 |
617.14 |
NALC |
888/636-6252 |
321 |
322 |
375.01 |
801.39 |
382.51 |
817.42 |
PBP Health Plan-High |
800-544-7111 |
361 |
362 |
659.66 |
1423.22 |
672.85 |
1451.68 |
PBP Health Plan-Std |
800-544-7111 |
364 |
365 |
410.15 |
929.05 |
418.35 |
947.63 |
Brand Name/Non-formulary is what you pay for a manufacturer's Brand name drug on this health plan's formulary. You pay the Brand name amount if you or your doctor requests the Brand name or if a Generic is not available. The figure in this column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a Non-formulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed.
Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan's response is "yes." If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan's response is "no."
The prescription drug copayments or coinsurances described in this chart do not represent the complete range of cost-sharing under these plans. Many plans have variations in their prescription drug benefits (e.g., you pay the greater of a dollar amount or a percentage, or you pay one amount for your first prescription and then a different amount for refills). The prescription drug figures in this chart show what most plan members pay for their medications under each plan. You must read the plan brochure for a complete description of prescription drug and all other benefits.
| Plan | Benefit type |
Medical Surgical - You Pay |
|||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
Deductible |
Copay ($)/Coinsurance (%) |
||||||||||
Per Person |
Hospital inpatient |
Doctors |
Hospital Inpatient Room & Board |
Prescription Drugs |
|||||||
Calendar Year |
Prescription Drug |
Office Visits |
Inpatient Surgical Services |
Generic |
Brand Name/Non-Formulary |
Mail Order Discounts |
|||||
APWU-High |
PPO |
$275 |
None |
None |
$18 |
10% |
10% |
$8 |
25% |
No |
|
Non-PPO |
$500 |
None |
$300 |
30% |
30% |
30% |
50% |
50% |
No |
||
APWU |
PPO |
$600 |
None |
None |
15% |
15% |
15% |
25% |
25%/25% |
No |
|
Non-PPO |
$600 |
None |
None |
40% |
40% |
40% |
N/A |
N/A |
No |
||
BCBS -Std |
PPO |
$250 |
None |
$100 |
$15 |
10% |
Nothing |
25% |
25% |
Yes |
|
Non-PPO |
$250 |
None |
$300 |
25% |
25% |
30% |
45%+ |
45%+ |
No |
||
BCBS -Basic |
PPO |
None |
None |
$100/day x 5 |
$20/$30 |
$100 |
Nothing |
$10 |
$25/$35 or 50% |
No |
|
GEHA -High |
PPO |
$350 |
None |
$100 |
$20 |
10% |
Nothing |
$5 |
$25 |
Yes |
|
Non-PPO |
$350 |
None |
$300 |
25% |
25% |
Nothing |
$5 |
$25 |
Yes |
||
GEHA -Std |
PPO |
$450 |
None |
None |
$10 |
15% |
15% |
$5 |
50% |
Yes |
|
Non-PPO |
$450 |
None |
None |
35% |
35% |
35% |
$5 |
50% |
Yes |
||
MH -High |
PPO |
$250 |
$200 |
$100 |
$20/$10 |
10% |
Nothing |
$10 |
$25/$40 |
Yes |
|
Non-PPO |
$300 |
$200 |
$300 |
30% |
30% |
30% |
50% |
50% |
Yes |
||
MH -Std |
PPO |
$300 |
$400 |
$200 |
$20/$10 |
10% |
Nothing |
$10 |
$30/$45 |
Yes |
|
Non-PPO |
$350 |
$400 |
$400 |
30% |
30% |
30% |
50% |
50% |
Yes |
||
NALC |
PPO |
$250 |
$25 |
None |
$20 |
10% |
10% |
25% |
25% |
Yes |
|
Non-PPO |
$300 |
$25 |
$100 |
30% |
30% |
30% |
50% |
50%+ |
Yes |
||
PBP -High |
PPO |
$200 |
$90 |
None |
10% |
10% |
10% |
$3 |
$25 or 20%/$40 or 20% |
Yes |
|
Non-PPO |
$500 |
$90 |
$150 |
20% |
25% |
25% |
20%+ |
20%+ |
Yes |
||
PBP -Std |
PPO |
$250 |
$90 |
None |
$8 |
9% |
9% |
$4 |
$30 or 20%/$40 or 20% |
Yes |
|
Non-PPO |
$600 |
$90 |
$250 |
30% |
30% |
30% |
30%+ |
30%+ |
Yes |
||
Nationwide Fee-for-Service Plans Open to All
Member Survey results, shown in the plan comparison sections, are collected, scored, and reported by an independent organization - not by the health plans. Here is a brief explanation of each survey category.
Overall Plan Satisfaction |
How would you rate your overall experience with your health plan? |
Getting Needed Care |
Were you satisfied with the choices your health plan gave you to select a personal doctor? |
Getting Care Quickly |
Did you get the advice or help you needed when you called your doctor during regular office hours? Could you get an appointment for regular or routine care when you wanted? |
| How Well Doctors Communicate | Did your doctor listen carefully to you and explain things in a way you could understand? |
Customer Service |
Was your plan helpful when you called its customer service department? Did you have paperwork problems? Were the plan's written materials understandable? |
Claims Processing |
Did your plan pay your claims correctly and in a reasonable time? |
Plan name |
Member Survey Results |
||||||
|---|---|---|---|---|---|---|---|
Plan code |
Overall plan satisfaction |
Getting needed care |
Getting care quickly |
How well doctors communicate |
Customer service |
Claims processing |
|
APWU Health Plan-High |
47 |
Above Average |
Average |
Above Average |
Above Average |
Above Average |
Above Average |
APWU Health Plan-Consumer driven |
47 |
Above Average |
Average |
Above Average |
Above Average |
Above Average |
Above Average |
Blue Cross and Blue Shield Service Benefit Plan-Std |
10 |
Average |
Average |
Average |
Average |
Below Average |
Average |
Blue Cross and Blue Shield Service Benefit Plan-Basic |
11 |
Below Average |
Below Average |
Below Average |
Below Average |
Below Average |
Below Average |
GEHA Benefit Plan-High |
31 |
Above Average |
Average |
Average |
Average |
Above Average |
Above Average |
GEHA Benefit Plan-Std |
31 |
Above Average |
Average |
Average |
Average |
Above Average |
Above Average |
Mail Handlers-High |
45 |
Below Average |
Average |
Below Average |
Average |
Average |
Average |
Mail Handlers-Std |
45 |
Below Average |
Average |
Below Average |
Average |
Average |
Average |
NALC |
32 |
Above Average |
Above Average |
Above Average |
Above Average |
Above Average |
Above Average |
PBP Health Plan-High |
36 |
Average |
Average |
Above Average |
Above Average |
Below Average |
Below Average |
PBP Health Plan-Std |
36 |
Average |
Average |
Above Average |
Above Average |
Below Average |
Below Average |
Page 19 To Next Page To Previous Page
Fee-For-Service Plans Blue Cross and Blue Shield Service Benefit Plan Member Survey Results for Select States
This year we are providing more detailed information regarding the quality of services provided by our health plans. We are including the results of the Member Satisfaction survey at the state level for eight local Blue Cross Blue Shield (BCBS) Plans. In the past, BCBS has conducted a single survey representing all of its members nation-wide. This year, however, we are able to provide local member satisfaction results for both the Standard Option plan and the Basic Option plan.
In the future, we expect to increase the number of plans conducting local or regional Member Satisfaction surveys. We look forward to making those results available to help you select quality health plans.
Below are Member Survey ratings for local BCBS plans by location:
Plan Name |
Location |
Member Survey Results |
|||||||
|---|---|---|---|---|---|---|---|---|---|
Plan Code |
Overall plan satisfaction |
Getting needed care |
Getting care quickly |
How well doctors communicate |
Customer service |
Claims processing |
|||
Blue Cross and Blue Shield Service Benefit Plan |
Standard |
Arizona |
10 |
Above |
Below |
Below |
Below |
Average |
Above |
Basic |
11 |
Below |
Below |
Below |
Below |
Below |
Below |
||
Blue Cross and Blue Shield Service Benefit Plan |
Standard |
California |
10 |
Above |
Below |
Average |
Average |
Average |
Above |
Basic |
11 |
Below |
Below |
Below |
Below |
Below |
Below |
||
Blue Cross and Blue Shield Service Benefit Plan |
Standard |
District of Columbia |
10 |
Average |
Average |
Below |
Average |
Average |
Average |
Basic |
11 |
Below |
Below |
Below |
Below |
Below |
Average |
||
Blue Cross and Blue Shield Service Benefit Plan |
Standard |
Florida |
10 |
Above |
Average |
Below |
Below |
Average |
Above |
Basic |
11 |
Below |
Below |
Below |
Below |
Below |
Average |
||
Blue Cross and Blue Shield Service Benefit Plan |
Standard |
Illinois |
10 |
Average |
Above |
Average |
Average |
Average |
Average |
Basic |
11 |
Below |
Below |
Below |
Below |
Below |
Below |
||
Blue Cross and Blue Shield Service Benefit Plan |
Standard |
Maryland |
10 |
Average |
Average |
Average |
Average |
Below |
Average |
Basic |
11 |
Below |
Below |
Below |
Below |
Below |
Below |
||
Blue Cross and Blue Shield Service Benefit Plan |
Standard |
Texas |
10 |
Above |
Average |
Average |
Above |
Average |
Average |
Basic |
11 |
Below |
Below |
Below |
Below |
Below |
Below |
||
Blue Cross and Blue Shield Service Benefit Plan |
Standard |
Virginia |
10 |
Above |
Average |
Average |
Average |
Above |
Above |
Basic |
11 |
Below |
Below |
Below |
Below |
Average |
Above |
||
Page 20 To Next Page To Previous Page
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Page 21 To Next Page To Previous Page
Fee-For-Service (FFS) Plans with a Preferred Provider Organization (PPO) — An FFS plan that allows you to see medical providers who reduce their charges to the plan; you pay less money out-of-pocket when you use a PPO provider. When you visit a PPO you usually won't have to file claims or paperwork. However, going to a PPO hospital does not guarantee PPO benefits for all services received within that hospital. For instance, lab work and radiology services from independent practitioners within the hospital are frequently not covered by the PPO agreement.
Fee-For-Service (FFS) Plans (non-PPO) — An FFS plan that either pays the medical provider directly or reimburses you for covered medical expenses. When you need medical attention, you visit the doctor or hospital of your choice.
Page 22 To Next Page To Previous Page
Nationwide Fee-for-Service Plans Open Only to Specific Groups
How to read this chart:
The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures before making your final decision. The chart does not show all of your possible out-of-pocket costs.
The Deductibles shown are the amount of covered expenses that you pay before your health plan begins to pay.
Calendar Year deductibles for families are two or more times the per person amount shown.
In some plans your combined Prescription Drug purchases from Mail Order and local pharmacies count toward the deductible. In other plans, only purchases from local pharmacies count. Some plans require each family member to meet a per person deductible.
The Hospital Inpatient deductible is what you pay each time you are admitted to a hospital.
Doctors shows what you pay for inpatient surgical services and for office visits.
Your share of Hospital Inpatient Room and Board covered charges is shown.
The Generic drug figure is the copayment or coinsurance most commonly paid by members of this health plan for a Generic formulary drug.
Plan name |
Telephone number |
Enrollment code |
Total Monthly Premium |
102% of Total Monthly Premium |
|||
|---|---|---|---|---|---|---|---|
Self only |
Self & family |
Self only |
Self & family |
Self only |
Self & family |
||
Association Benefit Plan |
800/634-0069 |
421 |
422 |
390.35 |
899.19 |
398.16 |
917.17 |
Foreign Service Benefit Plan |
202/833-4910 |
401 |
402 |
352.47 |
853.67 |
359.52 |
870.74 |
Panama Canal Area Benefit Plan |
800/548-8969 |
431 |
432 |
329.79 |
688.39 |
336.39 |
702.16 |
Rural Carrier Benefit Plan |
800/638-8432 |
381 |
382 |
433.20 |
881.44 |
441.86 |
899.07 |
SAMBA |
800/638-6589 |
441 |
442 |
416.24 |
980.24 |
424.56 |
999.84 |
Secret Service Employees Health Association |
800/424-7474 |
Y71 |
Y72 |
380.77 |
902.42 |
388.39 |
920.47 |
Page 23 To Next Page To Previous Page
Brand Name/Non-formulary is what you pay for a manufacturer's Brand name drug on this health plan's formulary. You pay the Brand name amount if you or your doctor requests the Brand name or if a Generic is not available. The figure in this column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a Non-formulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed.
Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan's response is "yes." If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan's response is "no."
The prescription drug copayments or coinsurances described in this chart do not represent the complete range of cost-sharing under these plans. Many plans have variations in their prescription drug benefits (e.g., you pay the greater of a dollar amount or a percentage, or you pay one amount for your first prescription and then a different amount for refills). The prescription drug figures in this chart show what most plan members pay for their medications under each plan. You must read the plan brochure for a complete description of prescription drug and all other benefits.
| Plan | Benefit type |
Medical Surgical - You Pay |
|||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
Deductible |
Copay ($)/Coinsurance (%) |
||||||||||
Per Person |
Hospital inpatient |
Doctors |
Hospital Inpatient Room & Board |
Prescription Drugs |
|||||||
Calendar Year |
Prescription Drug |
Office Visits |
Inpatient Surgical Services |
Generic |
Brand Name/Non-Formulary |
Mail Order Discounts |
|||||
ABP |
PPO |
$300 |
None |
$100 |
$10 |
10% |
Nothing |
$5 |
$25/$40 |
No |
|
Non-PPO |
$300 |
None |
$300 |
30% |
30% |
30% |
$5 |
$25/$40 |
No |
||
FS |
PPO |
$300 |
None |
Nothing |
10% |
10% |
Nothing |
$10/25% |
$20/25%/N/A |
Yes |
|
Non-PPO |
$300 |
None |
$200 |
30% |
30% |
20% |
$10/25% |
$20/25%/N/A |
Yes |
||
PCA |
POS |
None |
$400 |
$50 |
$10 |
Nothing |
Nothing |
50% |
50%/50% |
N/A |
|
FFS |
None |
$400 |
$125 |
50% |
50% |
50% |
50% |
50%/50% |
N/A |
||
Rural |
PPO |
$350 |
$200 |
$100 |
$20 |
10% |
Nothing |
30% |
30%/30% |
Yes |
|
Non-PPO |
$400 |
$200 |
$300 |
25% |
20% |
20% |
30% |
30%/30% |
Yes |
||
SAMBA |
PPO |
$350 |
None |
$200 |
$20 |
10% |
Nothing |
$10 |
$25/$40 |
Yes |
|
Non-PPO |
$350 |
None |
$300 |
30% |
30% |
30% |
$10 |
$25/$40 |
Yes |
||
SSEHA |
Par |
$200 |
None |
$100 |
20% |
20% |
Nothing |
$10 |
$20/$20 |
Yes |
|
Non-Par |
$200 |
None |
$100+any diff. |
20%+diff. |
20%+diff. |
20%+diff. |
All chgs. |
All chgs./All chgs. |
No |
||
*The Panama Canal Area Plan provides a point-of-service product within the Republic of Panama.
Page 24 To Next Page To Previous Page
Nationwide Fee-for-Service Plans Open Only to Specific Groups
Member Survey results, shown in the plan comparison sections, are collected, scored, and reported by an independent organization - not by the health plans. Here is a brief explanation of each survey category.
Overall Plan Satisfaction |
How would you rate your overall experience with your health plan? |
Getting Needed Care |
Were you satisfied with the choices your health plan gave you to select a personal doctor? |
Getting Care Quickly |
Did you get the advice or help you needed when you called your doctor during regular office hours? Could you get an appointment for regular or routine care when you wanted? |
| How Well Doctors Communicate | Did your doctor listen carefully to you and explain things in a way you could understand? |
Customer Service |
Was your plan helpful when you called its customer service department? Did you have paperwork problems? Were the plan's written materials understandable? |
Claims Processing |
Did your plan pay your claims correctly and in a reasonable time? |
Plan name |
Member Survey Results |
||||||
|---|---|---|---|---|---|---|---|
Plan code |
Overall plan satisfaction |
Getting needed care |
Getting care quickly |
How well doctors communicate |
Customer service |
Claims processing |
|
Association Benefit Plan |
42 |
Above Average |
Average |
Above Average |
Average |
Above Average |
Above Average |
Foreign Service Benefit Plan |
40 |
Average |
Below Average |
Below Average |
Below Average |
Below Average |
Below Average |
Panama Canal Area Benefit Plan |
43 |
Below Average |
Above Average |
Average |
Above Average |
Above Average |
Below Average |
Rural Carrier Benefit Plan |
38 |
Above Average |
Above Average |
Above Average |
Average |
Above Average |
Above Average |
SAMBA |
44 |
Above Average |
Below Average |
Average |
Average |
Average |
Above Average |
Secret Service Employees Health Association |
Y7 |
Below Average |
Average |
Below Average |
Below Average |
Below Average |
Below Average |
Page 25 To Next Page To Previous Page
Health Maintenance Organization Plans, Plans Offering a Point of Service Product, and Local Consumer-Driven Plans
(Pages 26 through 55)
Health Maintenance Organization (HMO) - A health plan that provides care through a network of physicians and hospitals in particular geographic or service areas. HMOs coordinate the health care service you receive and free you from completing paperwork or being billed for covered services. Your eligibility to enroll in an HMO is determined by where you live or, for some plans, where you work. Some HMOs are affiliated with or have arrangements with HMOs in other service areas for non-emergency care if you travel or are away from home for extended periods (reciprocity). Plans that offer reciprocity discuss it in their brochure.
Plans Offering a Point of Service (POS) Product - A product similar to an HMO and FFS plan.
The POS product lets you use providers who are not part of the HMO network. However, you pay more for using these non-network providers. You usually pay higher deductibles and coinsurances than you pay with a plan provider. You will also need to file a claim for reimbursement, like in a FFS plan. The HMO plan wants you to use its network of providers, but recognizes that sometimes enrollees want to choose their own provider.
The POS plans have two rows for In Network and Out of Network benefits. In Network shows what you pay if you go to the plan's providers; Out of Network shows what you pay if you decide not to go to the plan's providers.
Consumer-Driven Plans - Describes a wide range of approaches to give you more incentive to control the cost of either your health benefits or health care. You have greater freedom in spending health care dollars up to a designated amount and you receive full coverage for in-network preventive care. In return, you assume significantly higher cost sharing expenses after you have used up the designated amount. The catastrophic limit is usually higher than those common in other plans.Page 26 To Next Page To Previous Page
Health Maintenance Organization (HMO) and Point of Service (POS) Plans
How to read this chart: The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures before making your final decision. This chart does not show all of your possible out-of-pocket costs.
Primary Care Specialist/Office Copay shows what you pay for each office visit to your primary care doctor and specialist. Contact your plan to find out what providers it considers specialists.Hospital per Stay Deductible is the amount you pay when you are admitted into a hospital.
Plan name - Location |
Telephone Number |
Enrollment Code |
Total Monthly Premium |
102% of Total Monthly Premiuim |
Accredited |
|||
|---|---|---|---|---|---|---|---|---|
Self only |
Self & family |
Self only |
Self & family |
Self only |
Self & family |
|||
Alabama |
||||||||
HealthSpring of Alabama, Inc. - Birmingham/Other areas |
800/947-5093 |
DF1 |
DF2 |
374.12 |
957.73 |
381.60 |
976.88 |
|
Arizona |
||||||||
Aetna Health Inc. - Phoenix/Tucson Areas |
800/537-9384 |
WQ1 |
WQ2 |
250.23 |
687.33 |
255.23 |
701.08 |
NCQA 2 |
Health Net of Arizona, Inc. - Maricopa/Pima/Other AZ counties |
800/289-2818 |
A71 |
A72 |
306.87 |
777.51 |
313.01 |
793.06 |
NCQA 2 |
Humana CoverageFirst (Consumer Driven Plan) - Phoenix |
888/393-6765 |
DB1 |
DB2 |
197.75 |
454.81 |
201.71 |
463.91 |
|
PacifiCare Desert Region (AZ & NV) - Maricopa, Pima County & Apache Junction |
800-531-3341 |
A31 |
A32 |
278.16 |
692.64 |
283.72 |
706.49 |
|