Aetna
(formerly Aetna Health)
http://www.aetna.com/fed

Serving the following states: Arizona, California, Colorado, Georgia, Illinois, Indiana, Kansas, Kentucky, Missouri, Nevada, New Jersey,
New York, Ohio, Oklahoma, Pennsylvania, Tennessee, Texas and Washington.

Enrollment in this plan is limited. You must live or work in our Geographic service area to enroll. See pages 10-12 for requirements.

Please check the 2005 FEHB Guide for NCQA accreditation.

For changes in benefits see pages 13-14.

2005

A Health Maintenance Organization

Enrollment code for Phoenix & Tucson, AZ:

WQ1 Self Only

WQ2 Self and Family

Enrollment code for Columbus, OH:

ND1 Self Only

ND2 Self and Family

Enrollment code for Los Angeles & San Diego, CA:

2X1 Self Only

2X2 Self and Family

Enrollment code for Cleveland & Toledo, OH:

7D1 Self Only

7D2 Self and Family

Enrollment code for Denver, CO:

9E1 Self Only

9E2 Self and Family

Enrollment code for OklahomaCity&Tulsa, OK:

SL1 Self Only

SL2 Self and Family

Enrollment code for Athens & Atlanta, GA:

2U1 Self Only

2U2 Self and Family

Enrollment code for Pittsburgh, PA:

YE1 Self Only

YE2 Self and Family

Enrollment code for Chicago, IL & Northern IN:

IK1 Self Only

IK2 Self and Family

Enrollment code for Memphis, TN:

UB1 Self Only

UB2 Self and Family

Enrollment code for SE IN, NorthernKY & Cincinnati, OH:

RD1 Self Only

RD2 Self and Family

Enrollment code for Nashville, TN:

6J1 Self Only

6J2 Self and Family

Enrollment code for Kansas City, KS/MO:

KS1 Self Only

KS2 Self and Family

Enrollment code for Austin & San Antonio, TX:

P11 Self Only

P12 Self and Family

Enrollment code for NJ & Southeastern PA:

P31 Self Only

P32 Self and Family

Enrollment code for Dallas/Ft. Worth, TX:

PU1 Self Only

PU2 Self and Family

Enrollment code for Las Vegas, NV:

Y11 Self Only

Y12 Self and Family

Enrollment code for Houston, TX:

8G1 Self Only

8G2 Self and Family

Enrollment code for New York, NY:

JC1 Self Only

JC2 Self and Family

Enrollment code for Seattle&Puget Sound, WA:

8J1 Self Only

8J2 Self and Family

Special notice: The Service Area covered by Enrollment Code PU (Dallas/Ft. Worth & Houston, TX) has been split. Dallas/Ft. Worth will remain under Enrollment Code PU, but Houston has a new Enrollment Code of 8G. If you are currently covered by Enrollment Code PU, and you live in or work in the Houston area, your coverage will not be transferred automatically to Code 8G. You must enroll in Code 8G or elect another plan during Open Season.

RI 73-806

Dear Federal Employees Health Benefits Program Participant:

Welcome to the 2005 Open Season! By continuing to introduce pro-consumer health care ideas, the Office of Personnel Management (OPM) team has given you greater, cost effective choices. This year several national and local health plans are offering new options, strengthening the Federal Employees Health Benefits (FEHB) Program and highlighting once again its unique and distinctive market-oriented features. I remain firm in my belief that you, when fully informed as a Federal subscriber, are in the best position to make the decisions that meet your needs and those of your family. Plan brochures provide information to help subscribers make these fully informed decisions. Please take the time to review the plan’s benefits, particularly Section 2, which explains plan changes.

Exciting new features this year give you additional opportunities to save and better manage your hard-earned dollars. For 2005, I am very pleased and enthusiastic about the new High Deductible Health Plans (HDHP) with a Health Savings Account (HSA) or Health Reimbursement Arrangement (HRA) component. This combination of health plan and savings vehicle provides a new opportunity to save and better manage your money. If an HDHP/HSA is not for you and you are not retired, I encourage you to consider a Flexible Spending Account (FSA) for health care. FSAs allow you to reduce your out-of-pocket health care costs by 20 to more than 40 percent by paying for certain health care expenses with tax-free dollars, instead of after-tax dollars.

Since prevention remains a major factor in the cost of health care, last year OPM launched the HealthierFeds campaign. Through this effort we are encouraging Federal team members to take greater responsibility for living a healthier lifestyle. The positive effect of a healthier life style brings dividends for you and reduces the demands and costs within the health care system. This campaign embraces four key "actions" that can lead to a healthy America: be physically active every day, eat a nutritious diet, seek out preventative screenings, and make healthy lifestyle choices. Be sure to visit HealthierFeds at www.healthierfeds.opm.gov for more details on this important initiative. I also encourage you to visit the Department of Health and Human Services website on Wellness and Safety, www.hhs.gov/safety/index.shtml, which complements and broadens healthier lifestyle resources. The site provides extensive information from health care experts and organizations to support your personal interest in staying healthy.

The FEHB Program offers the Federal team the widest array of cost-effective health care options and the information needed to make the best choice for you and your family. You will find comprehensive health plan information in this brochure, in the 2005 Guide to FEHB Plans, and on the OPM Website at www.opm.gov/insure. I hope you find these resources useful, and thank you once again for your service to the nation.

Sincerely,

Kay Coles James

Director

Notice of the United States Office of Personnel Management’s

Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

By law, the United States Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB) Program, is required to protect the privacy of your personal medical information. OPM is also required to give you this notice to tell you how OPM may use and give out (“disclose”) your personal medical information held by OPM.

OPM will use and give out your personal medical information:

To you or someone who has the legal right to act for you (your personal representative),

To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected,

To law enforcement officials when investigating and/or prosecuting alleged or civil or criminal actions, and

Where required by law.

OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:

To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks for our assistance regarding a benefit or customer service issue.

To review, make a decision, or litigate your disputed claim.

For OPM and the General Accounting Office when conducting audits.

OPM may use or give out your personal medical information for the following purposes under limited circumstances:

For Government health care oversight activities (such as fraud and abuse investigations),

For research studies that meet all privacy law requirements (such as for medical research or education), and

To avoid a serious and imminent threat to health or safety.

By law, OPM must have your written permission (an “authorization”) to use or give out your personal medical information for any purpose that is not set out in this notice. You may take back (“revoke”) your written permission at any time, except if OPM has already acted based on your permission.

By law, you have the right to:

See and get a copy of your personal medical information held by OPM.

Amend any of your personal medical information created by OPM if you believe that it is wrong or if information is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal medical information.

Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any information that you authorized OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a disputed claim.

Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P.O. Box instead of your home address).

Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your request if the information is used to conduct operations in the manner described above.

Get a separate paper copy of this notice.

For more information on exercising your rights set out in this notice, look at www.opm.gov/insure on the Web. You may also call 202-606-0745 and ask for OPM’s FEHB Program privacy official for this purpose.

If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the following address:

Privacy Complaints

United States Office of Personnel Management

P.O. Box 707

Washington, DC 20004-0707

Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of the United States Department of Health and Human Services.

By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60 days of the change. The privacy practices listed in this notice are effective April 14, 2003.

Introduction

This brochure describes the benefits of Aetna* under our contract (CS 2867) with the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. The address for the Aetna administrative office is:

Aetna

920B Harvest Drive

Mail Stop U40A

Blue Bell, PA19422

This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in 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, 2005, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2005, and changes are summarized on pages 13-14. Rates are shown at the end of this brochure.

* "Aetna" is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. The Aetna companies that offer benefit coverage include Aetna Health Inc., Aetna Health of Illinois, Inc., and/or Aetna Health of California Inc.

Plain Language

All FEHB brochures are written in plain language to make them responsive, accessible, and understandable to the public. For instance,

Except for necessary technical terms, we use common words. For instance, “you” means the enrollee or family member; “we” means Aetna.

We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States 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 U.S. Office of Personnel Management, Insurance Services Programs, Program Planning & Evaluation Group, 1900 E Street, NW, Washington, DC 20415-3650.

Stop Health Care Fraud!

Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits Program premium.

OPM’s Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud — Here are some things that you can do to prevent fraud:

Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative.

Let only the appropriate medical professionals review your medical record or recommend services.

Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.

Carefully review explanations of benefits (EOBs) that you receive from us.

Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.

If you suspect that a provider 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:

United States Office of Personnel Management

Office of the Inspector General Fraud Hotline

1900 E Street NW Room 6400

Washington, DC20415-1100

Do not maintain as a family member on your policy:

Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or

Your child over age 22 (unless he/she is disabled and incapable of self support).

If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under Temporary Continuation of Coverage.

You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB benefits or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in the Plan.

Preventing medical mistakes

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.

Ask questions and make sure you understand the answers.

Choose a doctor with whom you feel comfortable talking.

Take a relative or friend with you to help you ask questions and understand answers.

2. Keep and bring a list of all the medicines you take.

Give your doctor and pharmacist a list of all the medicines that you take, including non-prescription medicines.

Tell them about any drug allergies you have.

Ask about side effects and what to avoid while taking the medicine.

Read the label when you get your medicine, including all warnings.

Make sure your medicine is what the doctor ordered and know how to use it.

Ask the pharmacist about your medicine if it looks different than you expected.

3. Get the results of any test or procedure.

Ask when and how you will get the results of tests or procedures.

Don’t assume the results are fine if you do not get them when expected, be it in person, by phone, or by mail.

Call your doctor and ask for your results.

Ask what the results mean for your care.

4. Talk to your doctor about which hospital is best for your health needs.

Ask your doctor about which hospital has the best care and results for your condition if you have more than one hospital to choose from to get the health care you need.

Be sure you understand the instructions you get about follow-up care when you leave the hospital.

5. Make sure you understand what will happen if you need surgery.

Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.

Ask your doctor, “Who will manage my care when I am in the hospital?”

Ask your surgeon:

Exactly what will you be doing?

About how long will it take?

What will happen after surgery?

How can I expect to feel during recovery?

Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reaction to anesthesia, and any medications you are taking.

Want more information on patient safety?

www.ahrq.gov/consumer/pathqpack.htm. The Agency for Healthcare Research and Quality makes available a wide-ranging list of topics not only to inform consumers about patient safety but to help choose quality health care providers and improve the quality of care you receive.

www.npsf.org. The National Patient Safety Foundation has information on how to ensure safer health care for you and your family.

www.talkaboutrx.org/consumer.html. The National Council on Patient Information and Education is dedicated to improving communication about the safe, appropriate use of medicines.

www.leapfroggroup.org. The Leapfrog Group is active in promoting safe practices in hospital care.

www.ahqa.org. The American Health Quality Association represents organizations and health care professionals working to improve patient safety.

www.quic.gov/report. Find out what federal agencies are doing to identify threats to patient safety and help prevent mistakes in the nation’s health care delivery system.

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. The Plan is solely responsible for the selection of these providers in your area. Contact the Plan for a copy of their most recent provider directory.

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 pay only 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

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 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; 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.

One of the purposes of managed care is to manage the cost of health care. Incentives in compensation arrangements with physicians and health care providers are one method by which Aetna attempts to achieve this goal. You are encouraged to ask your physicians and other providers how they are compensated for their services.

Your Rights

OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our networks, providers, and facilities. OPM’s FEHB Web site (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

To be medically necessary, the service or supply must:

Be care or treatment as likely to produce a significant positive outcome as, and no more likely to produce a negative outcome than, any alternative service or supply, both as to the disease or injury involved and the member's overall health condition;

Be a diagnostic procedure, indicated by the health status of the member and be as likely to result in information that could affect the course of treatment as, and no more likely to produce a negative outcome than, any alternative service or supply, both as to the disease or injury involved and the member's overall health condition; and

As to diagnosis, care and treatment be no more costly (taking into account all health expenses incurred in connection with the service or supply) than any equally effective service or supply in meeting the above tests.

In determining if a service or supply is medically necessary, the Plan will consider:

Information on the member's health status;

Reports in peer reviewed medical literature and guidelines published by nationally recognized health organizations;

Professional standards of safety and effectiveness which are generally recognized in the United States for diagnosis, care or treatment;

The opinion of health professionals in the generally recognized health specialty involved; and

Any other relevant information brought to the Plan’s attention.

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

All covered benefits will be covered in accordance with the guidelines determined by Aetna.

(See definition on Page 63)

Open Access HMO Plan – Does not apply to members in the states of California and Washington
(Enrollment Codes 2X or 8J)

Aetna offers an Open Access Plan to our members in our FEHBP service area. If you live or work in an Open Access HMO service area, you can go directly to any network specialist for covered services without a referral from your primary care physician. Note: This does not apply to mental health services and/or substance abuse services. Referrals must be obtained for those services. Please see Mental Health/Substance Abuse section below. Whether your covered services are provided by your selected primary care physician (for your PCP copay) or by another participating provider in the network (for the specialist copay), you will be responsible for payment which may be in the form of a copay (flat dollar amount) or coinsurance (a percentage of covered expenses). Members in the service areas, other than in the states of California and Washington, still must select a PCP and notify Member Services of their selection (1-800/537-9384). Members in the states of California and Washington will continue to obtain referrals from their PCPs to access specialist care. If you do not select a PCP, the specialist copay will apply. If you go directly to a specialist, you are responsible for verifying that the specialist is participating in our Plan.

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, one visit every 12 months from the last date of service. The program also allows female members to visit any participating gynecologist for gynecologic problems. Gynecologists may also refer a woman directly to other participating providers for specialized covered gynecologic services. All health plan preauthorization and coordination requirements continue to apply. If your Ob/Gyn is part of an Independent Practice Association (IPA), a Physician Medical Group (PMG), an Integrated Delivery System (IDS) or a similar organization, your care must be coordinated through the IPA, the PMG, the IDS, or similar organization and the organization may have different referral policies.

Mental Health/Substance Abuse

In most areas, certain behavioral health 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 these providers. As with other coverage determinations, you may appeal behavioral health care coverage decisions in accordance with the terms of your health 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 and payable under the health plan and the extent of such coverage and payment. The program assists members in receiving appropriate health care and maximizing coverage for those health care services.

Where such use is appropriate, our utilization review/patient management staff uses nationally recognized guidelines and resources, such as Milliman & Robertson Health Care Management Guidelines© and InterQual® ISD criteria, to guide the precertification, concurrent review and retrospective review processes. To the extent certain utilization review/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	Precertification is the process of collecting information prior to inpatient admissions and performance of selected ambulatory procedures and services. The process permits advance eligibility verification, determination of coverage, and communication with the physician and/or member. It also allows Aetna to coordinate the patient’s transition from the inpatient setting to the next level of care (discharge planning), or to register patients for specialized programs like disease management, case management, or our prenatal program. In some instances, precertification is used to inform physicians, members and other health care providers about cost-effective programs and alternative therapies and treatments. Certain health care services, such as hospitalization or outpatient surgery, require precertification with Aetna to ensure coverage for those services. When a member is to obtain services requiring precertification through a participating provider, this provider should precertify those services prior to treatment.
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 record 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 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 consider personal information to be confidential and have policies and procedures in place to protect it against unlawful use and disclosure. By “personal information,” we mean information that relates to a member’s physical or mental health or condition, the provision of health care to the member, or payment for the provision of health care to the member. Personal information does not include publicly available information or information that is available or reported in a summarized or aggregate fashion but does not identify the member.

When necessary or appropriate for your care or treatment, the operation of our health plans, or other related activities, we use personal information internally, share it with our affiliates, and disclose it to health care providers (doctors, dentists, pharmacies, hospitals and other caregivers), payors (health care provider organizations, employers who sponsor self-funded health plans or who share responsibility for the payment of benefits, and others who may be financially responsible for payment for the services or benefits you receive under your plan), other insurers, third party administrators, vendors, consultants, government authorities, and their respective agents. These parties are required to keep personal information confidential as provided by applicable law. Participating network providers are also required to give you access to your medical records within a reasonable amount of time after you make a request.

Some of the ways in which personal information is used include claims payment; utilization review and management; medical necessity reviews; coordination of care and benefits; preventive health, early detection, and disease and case management; quality assessment and improvement activities; auditing and anti-fraud activities; performance measurement and outcomes assessment; health claims analysis and reporting; health services research; data and information systems management; compliance with legal and regulatory requirements; formulary management; litigation proceedings; transfer of policies or contracts to and from other insurers, HMOs and third party administrators; underwriting activities; and due diligence activities in connection with the purchase or sale of some or all of our business. We consider these activities key for the operation of our health plans. To the extent permitted by law, we use and disclose personal information as provided above without member consent. However, we recognize that many members do not want to receive unsolicited marketing materials unrelated to their health benefits. We do not disclose personal information for these marketing purposes unless the member consents. We also have policies addressing circumstances in which members are unable to give consent.

Protecting the privacy of member health information is a top priority at Aetna. When contacting us about this FEHB Program brochure or for help with other questions, please be prepared to provide your or your family member’s name, member ID (or Social Security Number), and date of birth.

If you want more information about us, call 1-800/537-9384, or write to 920B Harvest Drive, Mail Stop U40A, Blue Bell, PA 19422. You may also contact us by fax at 215/775-5246 or visit our Web site at www.aetna.com/fed.

Aetna HMO Service Area

Please refer to the 2005 FEHB Guide for NCQA accreditations.

To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area is:

California, Los Angeles & San Diego – Enrollment code 2X – Los Angeles, Orange, San Diego, San Luis Obispo, Santa Barbara and Ventura counties, and portions of Kern, Riverside, and San Bernardino counties as defined below:

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

Riverside County: All towns except Blythe, Desert Center, Mesa Verde, Moreno Valley and Ripley

San Bernardino County: All towns except Amboy, Baker, Big River, Cadiz, Cima, Danby, Earp, Essex, Ivonpah, Kelso, Lake Havasu, Needles, Nipton, Parker Dam, Rice and Vidal.

Washington, Seattle & Puget Sound – Enrollment code8J – King, Kitsap, Pierce and Snohomish counties.

Aetna Open Access Service Area

Please refer to the 2005 FEHB Guide for NCQA accreditations.

The following service areas will be for our Aetna Open Access HMO. Under these plans, members may see network specialists without obtaining a referral from their primary care physician (PCP). To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area is:

Arizona, Phoenix and Tucson – Enrollment code WQ – Cochise, Maricopa, Pima and Santa Cruz counties and portions of the following county as defined by the below listed towns:

Pinal: Apache Junction and Casa Grande.

Colorado, Denver– Enrollment code 9E – Adams, Arapahoe, Boulder, Denver, Douglas, El Paso, Elbert, Fremont, Jefferson, Larimer, Mesa, Pueblo and Teller counties.

Georgia, Athens and Atlanta – Enrollment code 2U – 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.

Illinois, Chicago – Enrollment code IK –Cook, DuPage, Kane, Kankakee, Lake, McHenry and Will counties.

Indiana, Northern Indiana– Enrollment code IK – Lake county.

Indiana, Southeastern Indiana– Enrollment code RD – Dearborn, Franklin, Ohio and Switzerland counties.

Kansas, Kansas City – Enrollment code KS – Atchison, Douglas, Franklin, Johnson, Leavenworth, Miami and Wyandotte counties.

Kentucky, Northern Kentucky – Enrollment code RD – Boone, Campbell, Gallatin, Grant, Kenton and Pendleton counties.

Missouri, Kansas City – Enrollment code KS – Buchanan, Cass, Clay, Jackson, Lafayette, Platte and Ray counties.

Nevada, Las Vegas – Enrollment code Y1 – Clark county and a portion of the following county as defined by the below listed town:

Nye: Pahrump.

New Jersey – Enrollment code P3 – All of New Jersey.

New York, The Greater New York City area – Enrollment code JC – Bronx, Dutchess, Kings (Brooklyn), Nassau, New York (Manhattan), Orange, Putnam, Queens, Richmond (Staten Island), Rockland, Suffolk, Sullivan, Ulster and Westchester counties.

Ohio, Greater Cincinnati area – Enrollment code RD – Adams, Brown, Butler, Champaign, Clark, Clermont, Clinton, Greene, Hamilton, Highland, Logan, Miami, Montgomery, Preble, Shelby and Warren counties.

Ohio, Columbus – Enrollment code ND – Coshocton, Delaware, Fairfield, Fayette, Guernsey, Hocking, Knox, Licking, Madison, Marion, Morgan, Morrow, Muskingum, Noble, Perry, Pickaway, Pike, Ross, Scioto and Union counties and portions of the following counties as defined by the below listed towns:

Adams: Bentonville, Blue Creek, Cherry Fork, Lynx, Manchester, Peebles, Seaman, Stout, West Union and Winchester

Franklin: Amlin, Blacklick, Brice, Canal Winchester, Columbus, Dublin, Galloway, Grove City, Groveport, Harrisburg, Hilliard, Lockbourne, New Albany, Reynoldsburg and Westerville.

Ohio, Cleveland & Toledo – Enrollment code 7D – Allen, Ashland, Ashtabula, Carroll, Cuyahoga, Geauga, Hancock, Hardin, Henry, Holmes, Lake, Lorain, Lucas, Mahoning, Medina, Portage, Putnam, Richland, Sandusky, Seneca, Stark, Summit, Trumbull, Tuscarawas and Wayne counties and portions of the following counties as defined by the below listed towns:

Auglaize: Buckland and Lima

Columbiana: Beloit, Columbiana, East Palestine, East Rochester, Elkton, Hanoverton, Homeworth, Kensington, Leetonia, Lisbon, Minerva, Negley, New Waterford, North Georgetown, Rogers, Salem, Salineville, Washingtonville, West Point and Winona

Erie: Berlin Heights, Birmingham, Castalia, Huron, Kelleys Island, Milan, Sandusky and Vermilion

Fulton: Metamora and Swanton

Huron: Collins, Greenwich, New London and Wakeman

Wood: Grand Rapids, Haskins, Millbury, Northwood, Perrysburg, Rossford, Stony Ridge and Walbridge.

Oklahoma, Oklahoma City and Tulsa – Enrollment code SL – Cleveland, Oklahoma, Pottawatomie, Rogers, Tulsa and portions of the following counties as defined by the below listed towns:

Canadian: Concho, El Reno, Mustang, Piedmont, Union City and Yukon

Creek: Kellyville, Kiefer, Mounds, and Sapulpa

Grady: Amber, Minco, and Tuttle

Lincoln: Fallis, Jacktown, Meeker, Midway, Payson, Sparks and Wellston

Logan: Cedar Valley, Coyle, Guthrie, Meridian, Mulhall, Navina, and Seward

McClain: Blanchard, Byars, Cole, Criner, Dibble, Goldsby, Newcastle, Purcell, Rosedale, and Washington

Osage: Osage, Prue, and Skiatook

Wagoner: Choska, Coweta, Fair Oaks, New Tulsa, and Oneta.

Pennsylvania, Philadelphia and Southeastern PA – Enrollment code P3 – Berks, Bucks, Chester, Delaware, Lehigh, Monroe, Montgomery, Northampton, and Philadelphia counties.

Pennsylvania, Pittsburgh – Enrollment code YE - Allegheny, Armstrong, Beaver, Blair, Butler, Cambria, Clarion, Fayette, Greene, Lawrence, Somerset, Washington and Westmoreland counties.

Tennessee, Memphis – Enrollment code UB – Crockett, Dyer, Fayette, Haywood, Lauderdale, Shelby and Tipton counties.

Tennessee, Nashville – Enrollment code 6J – Bedford, Cannon, Cheatham, Coffee, Davidson, DeKalb, Dickson, Franklin, Giles, Lewis, Macon, Montgomery,Moore, Robertson, Rutherford, Smith, Sumner, Trousdale, Williamson and Wilson counties.

Texas, Austin & San Antonio – Enrollment code P1 – Atascosa, Bexar, Medina, Travis, Williamson and Wilson counties and portions of the following counties as defined by the below listed towns:

Bastrop: Bastrop

Comal: Bulverde, Canyon Lake, New Braunfels and Spring Branch

Hays: Buda, Driftwood, Dripping Springs, Kyle, San Marcos and Wimberly

Guadalupe: Cibolo, Geronimo, Marion, McQueeney, Schertz, Seguin and Staples

Kendall: Boerne and Waring.

Texas, Dallas/Ft. Worth – Enrollment code PU – Collin, Cooke, Dallas, Delta, Denton, Ellis, Erath, Fannin, Grayson, Hood, Hopkins, Hunt, Johnson, Kaufman, Navarro, Palo Pinto, Parker, Rains, Rockwall, Somervell, Tarrant and Wise counties and portions of the following counties as defined by the below listed towns:

Henderson: Mabank

Hill: Covington and Itasca

Van Zandt: Canton, Edgewood, Fruitvale, Grand Saline, and Wills Point.

Texas, Houston – Enrollment code 8G – Austin, Brazoria, Chambers, Colorado, Fort Bend, Galveston, Grimes, Hardin, Harris, Jefferson, Liberty, Matagorda, Montgomery, Orange, San Jacinto, Walker, Waller and Wharton 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 or urgent care benefits. We will not pay for any other health care services out of our service 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 the area (for example, if your child goes to college in another state), they will be able to access full HMO benefits if they reside in any Aetna HMO service area by selecting a PCP in that service area. If not, 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.

Section 2. How we change for 2005

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.

Program-wide changes

In Section 9, we revised the Medicare Primary Payer Chart and updated the language regarding Medicare Advantage plans (formerly called Medicare + Choice plans).

In Section 12, we revised the language regarding the Flexible Spending Account Program - FSAFEDS and the Federal Long Term Care Insurance Program.

Changes to this Plan

Enrollment Code 2U. Your share of the non-Postal premium will increase by 14.3% for Self Only and increase by 14.3% for Self and Family.

Enrollment Code 2X. Your share of the non-Postal premium will increase by 6.2% for Self Only and increase by 7.3% for Self and Family.

Enrollment Code 6J. Your share of the non-Postal premium will increase by 35.5% for Self Only and increase by 28.9% for Self and Family.

Enrollment Code 7D. Your share of the non-Postal premium will increase by 5.2% for Self Only and increase by 3.9% for Self and Family.

Enrollment Code 8J. Your share of the non-Postal premium will increase by 17.0% for Self Only and increase by 17.0% for Self and Family.

Enrollment Code JC. Your share of the non-Postal premium will increase by 15.4% for Self Only and increase by 15.4% for Self and Family.

Enrollment Code PU. Your share of the non-Postal premium will increase by 22.6% for Self Only and increase by 30.6% for Self and Family.

Enrollment Code P1. Your share of the non-Postal premium will increase by 21.0% for Self Only and increase by 21.0% for Self and Family.

Enrollment Code P3. Your share of the non-Postal premium will increase by 36.1% for Self Only and increase by 39.7% for Self and Family.

Enrollment Code RD. Your share of the non-Postal premium will increase by 7.3% for Self Only and increase by 4.7% for Self and Family.

Enrollment Code SL. Your share of the non-Postal premium will increase by 9.1% for Self Only and decrease by 6.2% for Self and Family.

Enrollment Code UB. Your share of the non-Postal premium will increase by 12.2% for Self Only and increase by 6.9% for Self and Family.

Enrollment Code WQ. Your share of the non-Postal premium will increase by 22.0% for Self Only and increase by 11.0% for Self and Family.

Enrollment Code YE. Your share of the non-Postal premium will increase by 8.3% for Self Only and increase by 8.2% for Self and Family.

Enrollment Code Y1. Your share of the non-Postal premium will increase by 15.0% for Self Only and increase by 15.0% for Self and Family.

We are now an “Open Access HMO.” Members in the FEHBP service areas, with the exception of those members in the States of California or Washington (Enrollment Codes 2X or 8J), can go directly to any network specialist for covered services without a referral from their primary care physician (PCP). This does not apply to covered mental health services and/or substance abuse services -- you still must obtain referrals. (See Section 1 for details)

A specialist visit is now subject to a $30 copay. (Section 5(a))

The inpatient hospital copay is $150 per day up to a maximum copay of $750 per admission. (Section 5(c))

Bony impacted wisdom teeth extractions previously covered under either the Medical or Dental benefits section of the Plan, now are covered only under the Dental benefits section. (Section 5(h))

The extraction of a surgical, soft tissue, or bony impacted tooth is covered under the Dental benefits section based on a reduced fee schedule. You pay up to a maximum fee of $482 per tooth. (Section 5(h))

Deep sedation/general anesthesia for oral surgery performed in the office is covered under the Dental benefits section based on a reduced fee schedule. You pay up to a maximum fee of $267. (Section 5(h))

We now provide HMO benefits to out-of-area dependents if the dependents reside in any service area where we operate an HMO. The dependent should select a PCP in that service area. (Section 1)

The Service Area covered by Enrollment Code PU (Dallas/Ft.Worth & Houston, TX) has been split. Dallas/Ft. Worth will remain under Enrollment Code PU, but Houston has a new Enrollment Code of 8G. If you are currently covered by Enrollment Code PU, and you live in or work in the Houston area, your coverage will not be transferred automatically to Code 8G. You must enroll in Code 8G or elect another plan during Open Season. (See page 11 for a detailed description of the Service Area)

We added the following to the Service Area in the State of Ohio: the city of Toledo and various surrounding full and partial counties (Enrollment Code 7D). (See page 11 for a detailed description of the Service Area)

We added the following to the Service Area in the State of Kentucky: The Northern counties of Boone, Campbell, Gallatin, Grant, Kenton, and Pendleton (Enrollment Code RD). (See page 10)

We added a new Service Area in the State of Ohio: the city of Columbus and various surrounding full and partial counties (Enrollment Code ND). (See pages 10-11 for a detailed description of the Service Area)

We added a new Service Area in the State of Illinois: the city of Chicago and the entire counties of Cook, DuPage, Kane, Kankakee, Lake, McHenry, and Will (Enrollment Code IK). (See page 10)

We added a new Service Area in the State of Indiana: the Northern county of Lake (Enrollment Code IK).
(See page 10)

We added a new Service Area in the State of Kansas: Kansas City and the entire counties of Atchison, Douglas, Franklin, Johnson, Leavenworth, Miami, and Wyandotte (Enrollment Code KS). (See page 10)

We added a new Service Area in the State of Missouri: Kansas City and the entire counties of Buchanan, Cass, Clay, Jackson, Lafayette, Platte, and Ray (Enrollment Code KS). (See page 10)

We added a new Service Area in the State of Colorado: the city of Denver and the entire counties of Adams, Arapahoe, Boulder, Denver, Douglas, El Paso, Elbert, Fremont, Jefferson, Larimer, Mesa, Pueblo, and Teller (Enrollment Code 9E). (See page 10)

Section 3. How you get care

Open Access HMO	This does not apply to members in Enrollment Codes 2X or 8J. Aetna offers Open Access to our members in those FEHBP service areas identified starting on page 10. You can go directly to any network specialist for covered services without a referral from your primary care physician. Note: This does not apply to mental health services and/or substance abuse services. Referrals must be obtained for those services. Please see the Mental Health/Substance Abuse section on page 42. Whether your covered services are provided by your selected primary care physician (for your PCP copay) or by any other participating provider in the network (for the specialist copay), you will be responsible for payment which may be in the form of a copay (flat dollar amount) or coinsurance (a percentage of covered expenses). You still must select a PCP and notify Member Services of your selection (1-800/537-9384). If you do not select a PCP, the specialist copay will apply. If you go directly to a specialist, you are responsible for verifying that the specialist is participating in our Plan.
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 or write to us at Aetna, 1425 Union Meeting Road, P.O. Box 1125, Blue Bell, PA 19422. You may also request replacement cards through our Web site at www.aetna.com/fed.
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 Web site at www.aetna.com/fed under DocFind. To ensure covered services, you must notify Member Services at 1-800/537-9384 of your primary care physician selection.
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 in the provider directory, which we update periodically. The most current information on our Plan facilities is also on our Web site at www.aetna.com/fed.
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.
	If you want to change primary care physicians or if your primary care physician leaves the Plan, call us or visit our Web site. We will help you select a new one.
Specialty care	If you are enrolled in Enrollment Codes 2X or 8J, 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. If you need mental health or substance abuse care, you may call your primary care physician or the behavioral health vendor number on the front of your ID card. 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 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 some 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 and 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 program 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 your 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 Member Services 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. If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such case, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment.
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 for covered follow-up care with non-participating providers; You must contact Member Services at 1-800/537-9384 or call the behavioral health contractor 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 select outpatient surgery; For air ambulance; For surgical correction of congenital defects, such as cleft lip and cleft palate; For home IV and antibiotic therapy; For limb and torso prosthetics; For orthognathic surgery and TMJ surgery; For inpatient confinements, skilled nursing facilities, rehabilitation facilities, and inpatient hospice; For covered transplant surgery; When full-time skilled nursing care is necessary in an extended care facility; For non-emergent ambulance transportation service; For certain drugs before they can be prescribed; For growth hormone therapy treatment; For intravenous immunoglobulin (IVIG) therapy treatment; For penile implants; For all home health care services; and For certain outpatient imaging studies such as CT scans, MRIs, and MRAs. You or your physician must obtain an approval for certain durable medical equipment. Members must call 1-800/537-9384 for authorization.

Section 5(a) Medical services and supplies provided by physicians and other health care professionals

Benefit Description			You pay
	I M P O R T A N T	Here are some important things you should 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 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. If you live or work in an Open Access HMO service area, you should select a PCP by calling Member Services at 1-800/537-9384. If you do not select a PCP and you self-refer to a participating PCP for care, you will pay a specialist copay. If you live or work in an Open Access HMO service area, you do not have to obtain a referral from your PCP to see a specialist (does not apply to enrollment codes 2X or 8J).		I M P O R T A N T
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 In an urgent care center for a routine service During a hospital stay In a skilled nursing facility			$20 per primary care physician (PCP) visit $30 per specialist visit
At home			$25 per PCP visit $30 per specialist visit
At home visits by nurses and health aides			Nothing
Lab, X-ray and other diagnostic tests
Tests, such as: Blood tests Urinalysis Non-routine pap tests Pathology X-rays Non-routine Mammograms CAT Scans/MRI Ultrasound			Nothing if you receive these services during your office visit; otherwise, $20 per PCP visit or $30 per specialist visit
Lab, X-ray and other diagnostic tests (continued)			You pay
Electrocardiogram and EEG			Nothing if you receive these services during your office visit; otherwise, $20 per PCP visit or $30 per specialist visit
Preventive care, adult
Routine screenings, such as: Blood Total Blood Cholesterol Routine Prostate Specific Antigen (PSA) test – one annually for men age 50 and older Colorectal Cancer Screening, including Fecal occult blood test yearly starting at age 50; Sigmoidoscopy, screening – every five years starting at age 50; Double contrast barium enema – every five years starting at age 50; Colonoscopy screening – every ten years starting at age 50 Note: You may pay either a specialist copay or an outpatient hospital copay depending on where the procedure is performed.			$20 per PCP visit $30 per specialist visit Nothing if provided during the office visit
Routine Pap test Note: No copay for the Pap test if performed on the same day as the office visit.			$20 per PCP visit $30 per specialist visit Nothing if provided during 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			$20 per PCP visit $30 per specialist visit Nothing if provided during the office visit
Routine physicals: One exam every 24 months up to age 65 One exam every 12 months age 65 or older			$20 per PCP visit $30 per specialist visit
Routine immunizations, limited to: Tetanus-diphtheria (Td) booster – once every 10 years, ages19 and over (except as provided for under Childhood immunizations) Influenza vaccine, annually Pneumococcal vaccine, age 65 and older			$20 per PCP visit $30 per specialist visit Nothing if provided during the office visit
Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel. *Immunizations and boosters for travel or work-related exposure.*			All charges.

Preventive care, children	You pay
Childhood immunizations recommended by the American Academy of Pediatrics	Nothing
Well-child care charges for routine examinations, immunizations and care (up to age 22) Examinations, such as: Eye exams through age 17 to determine the need for vision correction Ear exams through age 17 to determine the need for hearing correction Examinations done on the day of immunizations (up to age 22)	$20 per PCP visit $30 per specialist visit
Not covered: *Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.* *Immunizations and boosters for travel or work-related exposure.*	All charges.
Maternity care
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 extend your inpatient stay if medically necessary , but you, your representative, your participating doctor, or your hospital must precertify the extended stay. 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. Surgical benefits, not maternity benefits, apply to circumcision. We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and Surgery benefits (Section 5b).	$20 for the first PCP visit only or $30 for the first specialist visit only Note: If your PCP or specialist refers you to another provider or facility for additional services, you pay the applicable copay for the service rendered
Not covered: Routine sonograms to determine fetal age, size or sex.	All charges.
Family planning	You pay
A range of voluntary family planning services, limited to: Voluntary sterilization (See Surgical procedures Section 5 (b)) Surgically implanted contraceptives Injectable contraceptive drugs (such as Depo provera) Intrauterine devices (IUDs) Diaphragms Note: We cover oral contraceptives and Depo provera under the prescription drug benefit.	$20 per PCP visit $30 per specialist visit
Not covered: 1) *Reversal of voluntary surgical sterilization* 2) *Genetic counseling.*	All charges.
Infertility services
Infertility is defined as the inability to conceive after 12 months of unprotected intravaginal sexual relations (or 12 cycles of artificial insemination) for women under age 35 and 6 months of unprotected intravaginal sexual relations (or 6 cycles of artificial insemination) for women age 35 and over. Diagnosis and treatment of infertility such as: Artificial insemination: intravaginal insemination (IVI) intracervical insemination (ICI) intrauterine insemination (IUI) Infertility surgery Note: Coverage is only for 3 cycles (per lifetime). Artificial insemination must be authorized. You must use our select network of Plan infertility providers. You must contact the Infertility Case Manager at 1-800/575-5999. Fertility drugs except injectables Note: We cover oral fertility drugs under the prescription drug benefit.	$30 per specialist visit

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 Infertility treatment when the FSH level is 19 mIU/ml or greater on day 3 of menstrual cycle. The purchase, freezing and storage of donor sperm and donor embryos. Assisted reproductive technology (ART) procedures, such as: in vitro fertilization *embryo transfer, including but not limited to gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)*	All charges.
Allergy care
Testing and treatment Allergy injections Note: You pay the applicable copay for each visit to a doctor’s office including each visit to a nurse for an injection.	$20 per PCP visit $30 per specialist visit
Allergy serum	Nothing
Not covered: Provocative food testing and sublingual allergy desensitization	All charges.
Treatment therapies	You pay
Chemotherapy and radiation therapy Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 34. Respiratory and inhalation therapy Dialysis – hemodialysis and peritoneal dialysis Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy must be precertified by your Plan physician Growth hormone therapy (GHT) Note: Growth hormone therapy 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 and it is authorized by Aetna. 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	$30 per specialist visit
Physical and occupational therapies
Two consecutive months per condition per member per calendar year, beginning with the first day of treatment for the services of each of the following: qualified physical therapists and occupational therapists Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury. 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. Physical therapy to treat temporomandibular joint (TMJ) pain dysfunction syndrome	$30 per visit Nothing during a covered inpatient admission
Not covered: Long-term rehabilitative therapy	All charges.
Pulmonary and cardiac rehabilitation
Two consecutive months per condition per member per calendar year for pulmonary rehabilitation to treat functional pulmonary disability. Cardiac rehabilitation following angioplasty, cardiovascular surgery, chronic heart failure or a myocardial infarction is provided for up to 3 visits a week for a total of 18 visits.	$30 per visit Nothing during a covered inpatient admission
Not covered: Long-term rehabilitative therapy	All charges.
Speech therapy	You pay
Two consecutive months per condition per member per calendar year, beginning with the first day of treatment	$30 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	$20 per PCP visit $30 per specialist visit
Not covered: Hearing aids, testing and examinations for them	All charges.
Vision services (testing, treatment, and supplies)
Treatment of eye diseases and injury	$20 per PCP visit $30 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 *Note: See Preventive Care, Children* for eye exams for children**	$30 per specialist visit
Not covered:

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 $20 per office visit or $30 when you see a participating specialist.
Deductible	We do not have a deductible. Note: If you change plans during open season, you do not have to start a new deductible under your old plan between January 1 and the effective date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan.
Coinsurance	Coinsurance is the percentage of our allowance that you must pay for your care Example: In our Plan, you pay 50% of our allowance for drugs to treat sexual dysfunction.
Your catastrophic protection out-of-pocket maximum	After your copayments and coinsurance total $1,500/Self Only enrollment or $3,000/Self and 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 catastrophic protection 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.