RI 73-828

2005

Aetna HealthFund®

http://www.aetna.com/fed

An individual practice plan with a consumer driven health plan option and a high deductible health plan option

Serving the following states: Alabama, Alaska, Arizona, Arkansas,
California, Colorado, Connecticut, Delaware, District of Columbia,
Florida, Georgia, Illinois, Indiana, Kansas, Kentucky, Maryland,
Massachusetts, Michigan, Mississippi, Missouri, Nevada,
New Hampshire, New Jersey, New York, North Carolina, Ohio,
Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas,
Virginia and Washington

Underwritten and administered by: Aetna Life Insurance Company

Enrollment in this Plan is limited: You must live or work in our geographic service area to enroll. See pages 11 - 13 for requirements.

For changes in benefits see page 14.

Enrollment codes for this Plan:

221 Consumer Driven Health Plan (CDHP) Option – Self Only

222 Consumer Driven Health Plan (CDHP) Option – Self and Family

224 High Deductible Health Plan (HDHP) Option – Self Only

225 High Deductible Health Plan (HDHP) Option – Self and Family

Special notice: This Plan is offering a High Deductible Health Plan (HDHP) option for the first time under the Federal Employees Health Benefits Program during the 2004 Open Season.

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 you can receive of Aetna Life Insurance Company under our contract (CS 2900) 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 Life Insurance Company

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 CDHP benefits that were available before January 1, 2005, unless those CDHP benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefits are effective January 1, 2005, and CDHP changes are summarized on page 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 subsidiary companies. Plan benefits are provided by Aetna Life Insurance Company.

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 United States 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 (FEHB) 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 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 ¾ 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?

Ø 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.

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

Ø 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.

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

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

Ø 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 the Consumer Driven Health Plan (CDHP)
and High Deductible Health Plan (HDHP)

This Plan is an individual practice plan offering you a choice of a consumer driven health plan (CDHP) or a high deductible health plan (HDHP) with a Health Savings Account (HSA) or Health Reimbursement Arrangement (HRA) component.

Our CDHP is a comprehensive consumer driven health plan that combines a traditional health plan with separate medical and dental funds that help you pay for covered medical and dental expenses. Aetna’s CDHP puts you first, can save you time and money, and gives you flexibility, choice and control.

For 2005, CDHP offers lower out-of-pocket maximums and 100% in-network preventive care coverage, including dental. You have:

- A consumer-controlled Fund to help you pay for eligible expenses

- Opportunity to use your Fund toward medical expenses in future years

- Online tools to help you manage your money and your health

- Freedom to choose the providers you wish to see – with no referrals

- A cap that limits the total amount you pay annually for eligible expenses

CDHP delivers the best of both worlds by blending traditional health coverage with a unique Fund benefit to help you pay for covered expenses.

An HDHP is a new health plan product that provides traditional health care coverage and a tax-advantaged way to help you build savings for future medical needs. An HDHP with an HSA or HRA is designed to give greater flexibility and discretion over how you use your health care benefits. As an informed consumer, you decide how to utilize your plan coverage with a high deductible and out-of-pocket expenses limited by catastrophic protection. And you decide how to spend the dollars in your HSA or HRA. You may consider:

- Using the most cost effective provider

- Actively pursuing a healthier lifestyle and utilizing your preventive care benefit

- Becoming an informed health care consumer so you can be more involved in the treatment of any medical condition or chronic illness.

The type and extent of covered services, and the amount we allow, may be different from other plans. Read our brochure carefully to understand the benefits and features of this HDHP. Internal Revenue Service (IRS) rules govern the administration of all HDHPs. The IRS Website at http://www.ustreas.gov/offices/public-affairs/hsa/faq1.html has additional information about HDHPs.

General features of an HDHP:

HDHPs have higher annual deductibles and annual out-of-pocket maximum limits than other types of FEHB plans.

Preventive care services are generally paid as first dollar coverage or after a small deductible or copayment. First dollar coverage may be limited to a maximum dollar amount each year.

The annual deductible must be met before Plan benefits are paid for care other than preventive care services.

You are eligible for a Health Savings Account (HSA) if you are enrolled in an HDHP, not covered by any other health plan that is not an HDHP (including a spouse’s health plan, but does not include specific injury insurance and accident, disability, dental care, vision care, or long-term care coverage), not enrolled in Medicare, have not received VA benefits within the previous three months, and are not claimed as a dependent on someone else’s tax return.

· You may use the money in your HSA to pay all or a portion of the annual deductible, copayments, coinsurance, or other out-of-pocket costs that meet the IRS definition of a qualified medical expense. Distributions from your HSA are tax-free for qualified medical expenses for you, your spouse, and your dependents, even if they are not covered by an HDHP. You may withdraw money from your HSA for items other than qualified medical expenses, but it will be subject to income tax and, if you are under 65 years old, an additional 10% penalty tax on the amount withdrawn.

· For each month that you are enrolled in an HDHP and eligible for an HSA, the HDHP will pass through (contribute) a portion of the health plan premium to your HSA. In addition, you (the account holder) may contribute your own money to your HSA up to an allowable amount determined by IRS rules. In addition, your HSA dollars earn tax-free interest.

· You may allow the contributions in your HSA to grow over time, like a savings account. The HSA is portable – you may take the HSA with you if you leave the Federal government or switch to another plan.

If you are not eligible for an HSA, or become ineligible to continue contributing to an HSA, you are eligible for a Health Reimbursement Arrangement (HRA). Although an HRA is similar to an HSA, there are major differences.

· An HRA does not earn interest.

· An HRA is not portable if you leave the Federal government or switch to another plan.

We protect you against catastrophic out-of-pocket expenses for covered services. Your annual out-of-pocket expenses for covered services, including deductibles and copayments, are limited to $4,000 for Self Only enrollment, or $8,000 for Self and Family enrollment.

We reimburse you or your provider for your covered services, usually based on a percentage of our Plan allowance. The type and extent of covered services, and the amount we allow, may be different from other plans. Read brochures carefully.

We have Network Providers:

Our network providers offer services through our Plan. When you use our network providers, you will receive covered services at reduced costs. In-network benefits apply only when you use a network provider. Provider networks may be more extensive in some areas than others. We cannot guarantee the availability of every specialty in all areas. Aetna is solely responsible for the selection of network providers in your area. You can access network providers on DocFind by visiting our Web site at www.aetna.com/fed, or contact us for a directory or the names of network providers by calling
1-800/537-9384.

Out-of-network benefits apply when you use a non-network provider.

How we pay providers

Network Providers

Aetna negotiates with network participating providers to provide care for a discounted fee. Members are only responsible for their coinsurance based off this discounted fee.

Non-Network Providers

Because they do not participate in our networks, non-network providers are paid by Aetna a percentage of our Plan allowance for a service. Our Plan allowance is essentially a limit on fees based on what the medical care providers typically charge for a particular service in your geographic area. Members are responsible for their coinsurance portion of our Plan allowance, as well as any expense over that limit.

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 104)

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.

1) 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.

Note: Since this Plan pays out-of-network benefits and you may self-refer for covered services, it is your responsibility to contact Aetna to precertify those services which require precertification. You must obtain precertification for certain types of care rendered by non- network providers to avoid a reduction in benefits paid for that care.

2) 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.

3) 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.

4) 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.

- 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.

Service Area

To enroll in this Plan, you must live or work in our Service Area. This is where our network providers practice. The enrollment code for all service areas is 22. Our Service Areas are:

Alabama (part of Memphis, TN network) – Lamar and Pickens counties.

Alaska, Anchorage and Fairbanks – Aleutians East, Aleutians West, Anchorage, Bethel, Bristol Bay, Denali, Dillingham, Juneau, Kenai Peninsula, Ketchikan Gateway, Kodiak Island, Lake and Peninsula, Matanuska Susitna, Nome, North Slope, Skagway Yakutat Angoon, Southeast Fairbanks, Valdez Cordova and Yukon Koyukuk.

Arizona, Phoenix & Tucson – Apache, Cochise, Coconino, Gila, Graham, Greenlee, La Paz, Maricopa, Mohave, Navajo, Pima, Pinal, Santa Cruz, Yavapai, and Yuma counties.

Arkansas (part of Memphis, TN network) – Crittenden, Cross, Lee, Mississippi, Phillips and St. Francis counties.

California, Northern California – Alameda, Contra Costa, Marin, Monterey, Napa, San Francisco, Santa Clara, Santa Cruz, San Mateo, Solano, and Sonoma counties.

California, Central Valley – Amador, El Dorado, Fresno, Kings, Madera, Merced, Nevada, Placer, Sacramento, San Joaquin, Stanislaus, Sutter, Tulare, Tuolumne, Yolo, and Yuba counties.

California, Los Angeles – Kern, Los Angeles, Orange, Riverside, San Bernardino, San Luis Obispo, Santa Barbara, and Ventura counties.

California, San Diego – San Diego county.

Colorado, Denver – Adams, Arapahoe, Boulder, Broomfield, Clear Creek, Denver, Douglas, El Paso, Elbert, Fremont, Gilpin, Jefferson, Larimer, Mesa, Pueblo, Teller and Weld counties.

Connecticut – All of Connecticut.

Delaware – All of Delaware.

District of Columbia – All of Washington, DC

Florida, Jacksonville – Baker, Clay, Duval, Flagler, Nassau and St. Johns counties.

Florida, Miami – Broward and Miami-Dade counties.

Florida, Orlando – Lake, Orange, Osceola, Seminole and Sumter counties.

Florida, Tampa – Charlotte, Hillsborough, Manatee, Pasco, Pinellas, Polk and Sarasota counties.

Georgia, Atlanta – Banks, Barrow, Bartow, Butts, Carroll, Chattooga, Cherokee, Clarke, Clayton, Cobb, Coweta, Dawson, DeKalb, Douglas, Fayette, Floyd, Forsyth, Fulton, Gordon, Gwinnett, Hall, Haralson, Henry, Jackson, Jasper, Lamar, Madison, Newton, Oconee, Oglethorpe, Paulding, Pickens, Pike, Polk, Rockdale, Spalding, and Walton.

Illinois, Chicago – Cook, DuPage, Ford, Grundy, Iroquois, Kane, Kankakee, Kendall, Lake, McHenry, and Will counties.

Illinois (part of St. Louis, MO network) – Alexander, Bond, Calhoun, Clinton, Fayette, Jersey, Macoupin, Madison, Monroe, Montgomery, Randolph and St. Clair counties.

Indiana (part of Chicago, IL network) – Lake and Porter counties.

Indiana (part of Cincinnati, OH network) – Dearborn, Franklin, Ohio and Switzerland counties.

Kansas, Kansas City – Allen, Anderson, Atchison, Douglas, Franklin, Johnson, Leavenworth, Miami and Wyandotte counties.

Kansas (part of Northeast OK network) – Chautauqua and Montgomery counties.

Kentucky (part of Central OH network) – Lewis county.

Kentucky (part of Cincinnati, OH network) – Boone, Boyd, Campbell, Carter, Gallatin, Grant, Greenup, Kenton, Lawrence, Mason and Pendleton counties.

Kentucky (part of Memphis, TN network) – Fulton county.

Maryland – All of Maryland

Massachusetts, Boston – Barnstable, Berkshire, Bristol, Essex, Franklin, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, Suffolk and Worcester counties.

Michigan, Detroit– Livingston, Macomb, Monroe, Oakland, Washtenaw and Wayne counties.

Mississippi (part of Memphis, TN network) –Alcorn, Benton, Bolivar, Calhoun, Chickasaw, Coahoma, De Soto, Grenada, Itawamba, Lafayette, Lee, Lowndes, Marshall, Monroe, Panola, Pontotoc, Prentiss, Quitman, Tate, Tippah, Tunica and Union counties.

Missouri, Kansas City – Buchanan, Cass, Clay, Clinton, Henry, Jackson, Lafayette, Platte and Ray counties.

Missouri, St. Louis – Crawford, Franklin, Jefferson, Lincoln, St. Charles, St. Francois, St. Louis, St. Louis City,
Ste. Genevieve and Warren counties.

Nevada, Las Vegas – Clark and Nye counties.

New Hampshire (part of Northeast New England network) – Belknap, Carroll, Cheshire, Coos, Hillsborough, Merrimack, Rockingham and Strafford counties.

New Jersey – All of New Jersey

New York, New York City – Bronx, Dutchess, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk, Sullivan, Ulster and Westchester counties.

New York, Upstate New York – Albany, Broome, Cayuga, Chemung, Chenango, Columbia, Cortland, Delaware, Fulton, Genesee, Greene, Herkimer, Livingston, Madison, Monroe, Montgomery, Oneida, Onondaga, Ontario, Orleans, Oswego, Rensselaer, Saratoga, Schenectady, Schuyler, Seneca, Steuben, Tioga, Tompkins, Warren, Washington, Wayne and Yates counties.

North Carolina, Charlotte and Central North Carolina – Anson, Cabarrus, Cleveland, Gaston, Iredell, Lincoln, Mecklenburg, Rowan, Rutherford, Stanly and Union counties.

North Carolina, Raleigh/Durham – Alamance, Bladen, Caswell, Chatham, Cumberland, Durham, Franklin, Granville, Greene, Harnett, Johnston, Lee, Lenoir, Nash, Orange, Person, Robeson, Sampson and Wake counties.

Ohio, Cincinnati – Adams, Brown, Butler, Champaign, Clark, Clermont, Clinton, Darke, Greene, Hamilton, Highland, Logan, Miami, Montgomery, Preble, Shelby and Warren counties.

Ohio, Cleveland – Ashland, Ashtabula, Carroll, Columbiana, Cuyahoga, Geauga, Harrison, Holmes, Jefferson, Lake, Lorain, Mahoning, Medina, Portage, Richland, Stark, Summit, Trumbull, Tuscarawas and Wayne counties.

Ohio, Columbus and Central Ohio – Adams, Athens, Belmont, Coshocton, Delaware, Fairfield, Fayette, Franklin, Gallia, Guernsey, Hocking, Jackson, Knox, Lawrence, Licking, Madison, Marion, Meigs, Monroe, Morgan, Morrow, Muskingum, Noble, Perry, Pickaway, Pike, Ross, Scioto, Union, Vinton and Washington counties.

Ohio, Toledo – Allen, Auglaize, Crawford, Defiance, Erie, Fulton, Hancock, Hardin, Henry, Huron, Lucas, Mercer, Ottawa, Paulding, Putnam, Sandusky, Seneca, Van Wert, Williams, Wood and Wyandot counties.

Oklahoma, Oklahoma City and Tulsa – Adair, Atoka, Beaver, Beckham, Blaine, Bryan, Caddo, Canadian, Carter, Cherokee, Choctaw, Cimarron, Cleveland, Coal, Comanche, Craig, Creek, Delaware, Dewey, Ellis, Garfield, Garvin, Grady, Grant, Greer, Harper, Haskell, Jackson, Johnston, Kay, Kingfisher, Kiowa, Latimer, Le Flore, Lincoln, Logan, Major, McClain, Mayes, Muskogee, Noble, Nowata, Oklahoma, Okmulgee, Osage, Ottawa, Pawnee, Payne, Pittsburg, Pontotoc, Pottawatomie, Pushmataha, Roger Mills, Rogers, Seminole, Tulsa, Wagoner ,Washington, Washita and Woods counties.

Pennsylvania, Philadelphia and Southeastern PA– Berks, Bucks, Chester, Delaware, Monroe, Montgomery, and Philadelphia counties.

Pennsylvania, Pittsburgh – Allegheny, Armstrong, Beaver, Blair, Butler, Cambria, Clarion, Erie, Fayette, Greene, Indiana, Jefferson, Lawrence, Mercer, Somerset, Washington, and Westmoreland counties.

South Carolina (part of Central NC network) – York county.

Tennessee, Memphis – Carroll, Dyer, Fayette, Gibson, Lake, Lauderdale, Obion, Shelby, Tipton and Weakley counties.

Tennessee, Nashville – Bedford, Cannon, Cheatham, Coffee, Davidson, DeKalb, Dickson, Franklin, Giles, Lawrence, Lewis, Lincoln, Macon, Maury, Montgomery, Moore, Robertson, Rutherford, Smith, Sumner, Trousdale, Williamson and Wilson counties.

Texas, Austin – Bastrop, Bell, Blanco, Burnet, Caldwell, Fayette, Hays, Lee, Travis and Williamson counties.

Texas, Dallas – Camp, Cherokee, Collin, Cooke, Dallas, Delta, Denton, Ellis, Erath, Fannin, Franklin, Freestone, Grayson, Gregg, Harrison, Henderson, Hill, Hood, Hopkins, Hunt, Johnson, Kaufman, Lamar, Marion, Montague, Morris, Navarro, Palo Pinto, Parker, Rains, Red River, Rockwall, Smith, Somervell, Tarrant, Titus, Upshur, Van Zandt, Wise and Wood counties.

Texas, Houston – Austin, Brazoria, Chambers, Colorado, Fort Bend, Galveston, Grimes, Hardin, Harris, Jasper, Jefferson, Liberty, Matagorda, Montgomery, Newton, Orange, San Jacinto, Tyler, Walker, Waller and Wharton counties.

Texas, San Antonio – Atascosa, Bandera, Bexar, Comal, De Witt, Guadalupe, Kendall, Lavaca, Medina and Wilson counties.

Virginia, Central/Richmond, VA – Albemarle, Amelia, Buckingham, Caroline, Charles City, Charlotte, Charlottesville City, Chesterfield, Colonial Heights City, Culpeper, Cumberland, Dinwiddie, Fluvanna, Goochland, Hanover, Henrico, Hopewell City, King George, King William, Lunenburg, Nelson, New Kent, Nottoway, Petersburg City, Powhatan, Prince Edward, Prince George, Richmond City, and Westmoreland counties.

Virginia, Northern VA area (part of District of Columbia network) – Arlington, Clarke, Fairfax, Fauquier, Loudon, Prince William, Spotsylvania, and Stafford counties; plus the cities of Alexandria, Fairfax, Falls Church, Fredericksburg, Manassas, Manassas Park, and Winchester.

Washington, Seattle/Puget Sound – Clallam, Cowlitz, Grays Harbor, Island, Jefferson, King, Kitsap, Lewis, Mason, Pacific, Pierce, San Juan, Skagit, Snohomish, Thurston, and Whatcom counties.

If you or a covered family member move or live outside of our service areas, you can continue to access out-of-network care or you can enroll in another plan. 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 3. How you get care

Identification cards	We will send you an identification (ID) card when you enroll. If you enroll as Self and Family, you will receive two Family ID cards. You should carry your ID card with you at all times. You must show it whenever you receive services from a Network provider or fill a prescription at a Network 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 request them through our Web site at www.aetna.com/fed.
Where you get covered care	You can get care from any licensed provider or licensed facility. How much we pay – and you pay – depends on whether you use a network or non-network provider or facility. If you use a non-network provider, you will pay more.
Ø Network providers	Network 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 Network providers according to national standards. We list Network providers in the provider directory, which we update periodically. The most current information on our Network providers is also on our Web site at www.aetna.com/fed under DocFind.
Ø Network facilities	Network facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these facilities in the provider directory, which we update periodically. The most current information on our Network facilities is also on our Web site at www.aetna.com/fed under DocFind.
Ø Non-network providers and facilities	You can access care from any licensed provider or facility. Providers and facilities not in Aetna’s networks are considered non-network providers and facilities.
What you must do to get covered care	It depends on the kind of care you want to receive. You can go to any provider you want, but we must approve some care in advance.
Ø Traditional care	Specialty care: If you have a chronic or disabling condition and 5) Lose access to your network specialist because we terminate our contract with your specialist for other than cause; or 6) Lose access to your specialist because we drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or 7) Reduce our service area and you enroll in another FEBH plan, you may be able to continue seeing your specialist and receive any in-network benefits 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 and any in-network benefits continue until the end of your postpartum care, even if it is beyond the 90 days.
Ø Hospital care	Your Network 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. Note: Non-network physicians will generally also make these arrangements, but you are responsible for any precertification requirements. If you are in the hospital when your enrollment in our Plan begins, call Member Services 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: 8) You are discharged, not merely moved to an alternative care center; or 9) The day your benefits from your former plan run out; or 10) 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.
How to Get Approval for…
Ø Your hospital stay	In most cases, your Network physician or hospital will take care of precertification. Because you are still responsible for ensuring that we are asked to precertify your care, you should always ask your physician or hospital whether they have contacted us. Note: If you go to a Non-network hospital, you are responsible for precertifying your care.
Warning	If you are using a non-network physician or hospital, we will reduce our benefits for the inpatient hospital stay by $500 if no one contacts us for precertification. If the stay is not medically necessary, we will not pay any benefits.
Ø How to precertify an admission	Certification of days of confinement can be obtained as follows: If the admission is a non-urgent admission or if you are being admitted to a Non-network hospital, you must get the days certified by calling the number shown on your ID card. This must be done at least 14 days before the date the person is scheduled to be confined as a full-time inpatient. If the admission is an emergency or an urgent admission, you, the person’s physician, or the hospital must get the days certified by calling the number shown on your ID card. This must be done: 11) Before the start of a confinement as a full-time inpatient which requires an urgent admission; or 12) Not later than 48 hours following the start of a confinement as a full-time inpatient which requires an emergency admission; unless it is not possible for the physician to request certification within that time. In that case, it must be done as soon as reasonably possible. In the event the confinement starts on a Friday or Saturday, the 48 hour requirement will be extended to 72 hours. If, in the opinion of the person’s physician, it is necessary for the person to be confined for a longer time than already certified, you, the physician, or the hospital may request that more days be certified by calling the number shown on your ID card. This must be done no later than on the last day that has already been certified. Written notice of the number of days certified will be sent promptly to the hospital. A copy will be sent to you and to the physician.

Ø Maternity care	You do not need to precertify a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional days. Further, if your baby stays after you are discharged, then your physician or the hospital must contact us for precertification of additional days for your baby.
Ø What happens when you do not follow the precertification rules when using Non-network Facilities	13) If no one contacts us, we will decide whether the hospital stay was medically necessary. · If we determine that the stay was medically necessary, we will pay the inpatient charges, less the $500 penalty. · If we determine that it was not medically necessary for you to be an inpatient, we will not pay inpatient hospital benefits. We will only pay for any covered medical supplies and services that are otherwise payable on an outpatient basis. 14) If we denied the precertification request, we will not pay inpatient hospital benefits. We will only pay for any covered medical supplies and services that are otherwise payable on an outpatient basis. 15) When we precertified the admission but you remained in the hospital beyond the number of days we approved and did not get the additional days precertified, then: · for the part of the admission that was medically necessary, we will pay inpatient benefits, but · for the part of the admission that was not medically necessary, we will pay only medical services and supplies otherwise payable on an outpatient basis and will not pay inpatient benefits.
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	Some services require prior 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: 16) For inpatient mental health and substance abuse care. You must contact Member Services at 1-800/537-9384 or call the behavioral health contractor for information on precertification; 17) For surgical treatment of morbid obesity; 18) For orthognathic surgery and TMJ surgery, and surgery to correct congenital defects; 19) For select outpatient surgery; 20) For inpatient confinements, skilled nursing facilities, rehabilitation facilities, and inpatient hospice; 21) For covered transplant surgery; 22) When full-time skilled nursing care is necessary in an extended care facility; 23) For non-emergent ambulance and air ambulance transportation services; 24) For growth hormone therapy treatment; 25) For intravenous immunoglobulin (IVIG) therapy treatment; 26) For penile implants; 27) For certain durable medical equipment; 28) For all home health care services; and 29) For home intravenous (IV) and antibiotic therapy. Members must call Member Services at 1-800/537-9384 for authorization.

Section 4. Your costs for covered services

This is what you will pay out-of-pocket for your covered care:

Copayments	A copay is the fixed amount of money you pay to the pharmacy when you receive services.
Deductible	A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for them. Consumer Driven Health Plan (CDHP) After you have exhausted your Medical Fund, you must satisfy your deductible before your Traditional Medical Coverage begins. For the CDHP, your deductible is $1,000 for a Self Only enrollment and $2,000 for a Self and Family enrollment. The Self and Family deductible can be satisfied by one or more members. The full Family deductible must be met for the plan of benefits to apply. There is no individual limit within the Family 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. And, if you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your new option. High Deductible Health Plan (HDHP) You must satisfy your deductible before your Traditional Medical Coverage begins. For the HDHP, your deductible is $2,500 for a Self Only enrollment and $5,000 for a Self and Family enrollment. The Self and Family deductible can be satisfied by one or more members. The full Family deductible must be met for the plan of benefits to apply. There is no individual limit within the Family 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. And, if you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your new option.
Coinsurance	Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance doesn’t begin until you meet your deductible. Example: You pay 15% of our Plan allowance for in-network durable medical equipment under CDHP, and 10% under HDHP.
Differences between our Plan allowance and the bill	30) Network Providers agree to accept our Plan allowance so if you use a network provider, you never have to worry about paying the difference between our Plan allowance and the billed amount for covered services. 31) Non-Network Providers: If you use a non-network provider, you will have to pay the difference between our Plan allowance and the billed amount.

Your catastrophic protection out-of-pocket maximum

CDHP

If you have exceeded your Medical Fund and met your deductible the following would apply:

Self Only: Your annual out-of-pocket maximum is $3,000.

Self and Family: Your annual out-of-pocket maximum is $6,000.

The following cannot be included in the accumulation of out-of-pocket expenses:

32) Any expenses paid by the Plan under your Medical Fund.

33) Any expenses paid by the Plan under your In-network Preventive Care benefit

34) Expenses in excess of our Plan allowance or maximum benefit limitations or expenses not covered under the Traditional Medical Coverage

35) Copay expenses for prescription drugs

36) Any coinsurance expenses you have paid for infertility services

37) Dental care expenses above the maximum limitations provided under your Dental Fund

38) The $500 penalty for failure to obtain precertification when using a Non-network facility and any other amounts you pay because benefits have been reduced for non-compliance with this Plan’s cost containment requirements

39) Expenses in excess of hospice care maximums

HDHP

Self Only: Your annual out-of-pocket maximum is $4,000.

Self and Family: Your annual out-of-pocket maximum is $8,000.

The following cannot be included in the accumulation of out-of-pocket expenses:

40) Any expenses paid by the Plan under your In-network Preventive Care benefit

41) Expenses in excess of our allowance or maximum benefit limitations or expenses not covered under the Traditional Medical Coverage

42) Any coinsurance expenses you have paid for infertility services

43) The $500 penalty for failure to obtain precertification when using a Non-network facility and any other amounts you pay because benefits have been reduced for non-compliance with this Plan’s cost containment requirements

44) Expenses in excess of hospice care maximums

Out-of-Pocket Maximums

Out-of-pocket maximums are the amount of out-of-pocket expenses that a Self Only or a Self and Family will have to pay in a plan year. Out-of-pocket maximums apply on a calendar year basis only.

Expenses applicable to out-of-pocket maximums– Only the deductible and those out-of-pocket expenses resulting from the application of coinsurance percentage (except any penalty amounts) may be used to satisfy the out-of-pocket maximums.

Note: For the CDHP, once you have exhausted your Medical Fund, paid your deductible, and satisfied your out-of-pocket maximums, eligible medical expenses will be covered at 100%. For the HDHP, once you have paid your deductible and satisfied your out-of-pocket maximums, eligible medical expenses will be covered at 100%.

Section 5.1 In-Network Medical and Dental Preventive Care

	I M P O R T A N T	Here are some important things you should keep in mind about these in-network medical and dental preventive care benefits: - The Plan pays 100% for the medical and dental preventive care services listed in this Section as long as you use a network provider. - If you choose to access preventive care with an out-of-network provider, you will not qualify for 100% preventive care coverage. Please see Section 5.2 – Medical and Dental Fund, Section 5.3 – Traditional Medical Coverage (Subject to the Deductible). - For preventive care not listed in this Section or preventive care from a non-network provider, please see Section 5.2 – Medical and Dental Funds. - For all other covered expenses, please see section 5.2 – Medical and Dental Funds and Section 5.3 – Traditional Medical Coverage (Subject to the Deductible). - Note that the in-network medical and dental preventive care paid under this Section does NOT count against or use up your Medical or Dental Fund. - 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.		I M P O R T A N T
Benefit Description			You pay
In-Network Medical Preventive Care, adult
Routine screenings, such as: 45) Blood test 46) Urinalysis 47) Total Blood Cholesterol 48) Routine Prostate Specific Antigen (PSA) test — one annually for men age 50 and older 49) 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 10 years starting at age 50 50) Routine annual digital rectal exam (DRE) for men age 40 and older 51) Routine well-woman exam including Pap test, one visit every 12 months from last date of service 52) 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			In-network: Nothing at a network provider. Out-of-network: Nothing at a non-network provider up to your available Medical Fund balance. Charges above the available Medical Fund balance, according to the Traditional Medical Coverage (Section 5.3), and the deductible.
In-Network Medical Preventive Care, adult (continued)			You pay
53) Routine physicals: · One exam every 24 months up to age 65 · One exam every 12 months age 65 and older 54) Routine immunizations and exams, limited to: · Tetanus-diphtheria (Td) booster — once every 10 years, ages 19 and over (except as provided for under Childhood immunizations) · Influenza vaccine, annually · Pneumococcal vaccine, age 65 and over · 1 routine eye exam every 12 months · 1 routine OB/GYN exam every 12 months including 1 Pap smear and related services · 1 routine hearing exam every 24 months			In-network: Nothing at a network provider. Out-of-network: Nothing at a non-network provider up to your available Medical Fund balance. Charges above the available Medical Fund balance, according to the Traditional Medical Coverage (Section 5.3), and the deductible.
Not covered: - Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams or travel. - Immunizations, boosters, and medications for travel or work-related exposure.			All charges.
In-Network Medical Preventive Care, children
55) Childhood immunizations recommended by the American Academy of Pediatrics 56) Well-child visits for routine examinations, immunizations and care (up to age 22) · 6 exams in the first 12 months of life · 2 exams in the 13-24th months of life · 1 exam every 12 months thereafter up to age 18 · 1 exam every 24 months for children age 18 and older 57) 1 routine eye exam every 12 months 58) 1 routine hearing exam every 24 months			In-network: Nothing at a network provider. Out-of-network: Nothing at a non-network provider up to your available Medical Fund balance. Charges above the available Medical Fund balance, according to the Traditional Medical Coverage (Section 5.3), and the deductible.
Not covered: - Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams or travel. - Immunizations, boosters, and medications for travel or work-related exposure.			All charges.
In-Network Dental Preventive Care			You pay
Preventive care limited to: 59) Prophylaxis (cleaning of teeth) – limited to 2 treatments per calendar year 60) Fluoride applications (limited to 1 treatment per calendar year and for children under age 16) 61) Sealants – (once every 3 years, from the last date of service, on permanent molars for children under age 16) 62) Space maintainer (primary teeth only) 63) Bitewing x-rays (one set per calendar year) 64) Complete series x-rays (one complete series every 3 years) 65) Periapical x-rays 66) Routine oral evaluations (limited to 2 per calendar year)			In-network: Nothing at a network dentist Out-of-network: Nothing at a non-network dentist up to your available Dental Fund balance. However, you are responsible for non-network dentist fees that exceed our Plan allowance. See Section 5.2 Dental Fund.

Section 5.2 Medical and Dental Funds

	I M P O R T A N T	Here are some important things you should keep in mind about your Medical Fund: 67) All eligible medical care expenses up to the Plan allowance in Section 5.3 (except in-network preventive care) are paid first from your Medical Fund. Traditional Medical Coverage will only start once your Medical Fund is exhausted and your deductible is satisfied. 68) Note that in-network preventive care covered under Section 5.1 does NOT count against your Medical Fund. 69) The Medical Fund provides full coverage for eligible expenses from both in-network and non-network providers. However, your Medical Fund will generally go much further when you use network providers because network providers agree to discount their fees. 70) You have flexibility about how to spend your Medical Fund, and the Plan provides you with the resources to manage your Medical Fund. You can track your Medical Fund on Aetna’s Navigator Web site, by telephone at 1-800/537-9384 (toll-free), or, when you incur claims, with monthly statements mailed directly to you at home. 71) If you join this Plan during Open Season, you receive the full Medical Fund ($1,000 per Self Only or $2,000 per Self and Family enrollment.) as of your effective date of coverage. If you join at any other time during the year, your Medical Fund for your first year will be prorated at a rate of $83 per month for Self Only or $167 per month for Self and Family for each full month of coverage remaining in that calendar year. If your enrollment effective date falls between the first and fifteenth day of the month, you will be given credit as of the first of the month. If your enrollment effective date is the sixteenth or later in the month, you will be given credit as of the first of the following month. 72) Medicare premium reimbursement – Medicare participating annuitants may request reimbursement for Medicare premiums paid if Health Fund dollars are available. Please contact us at 1-800/537-9384 for more information. 73) If you terminate your participation in this Plan, any Medical Fund balance you may have will be lost. 74) YOUR NETWORK PHYSICIAN MUST PRECERTIFY HOSPITAL STAYS FOR IN-NETWORK FACILITY CARE; YOU MUST PRECERTIFY HOSPITAL STAYS FOR NON-NETWORK FACILITY CARE; FAILURE TO DO SO WILL RESULT IN A $500 PENALTY FOR NON-NETWORK FACILITY CARE. Please refer to the precertification information shown in Section 3 to confirm which services require precertification. 75) 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.		I M P O R T A N T
Benefit Description			You pay
Medical Fund
A Medical Fund is provided by the Plan for each enrollment. Each year the Plan adds to your account: 76) $1,000 per year for a Self Only enrollment, or; 77) $2,000 per year for a Self and Family enrollment. The Medical Fund covers eligible expenses at 100%. For example, if you are ill and go to a network doctor for a $60 visit, the doctor will submit your claim and the cost of the visit will be deducted automatically from your Medical Fund; you pay nothing. Balance in Medical Fund for Self Only $ 1,000 Less: Cost of visit - 60 Remaining Balance in Medical Fund $ 940			Nothing for eligible expenses until you exhaust your Medical Fund. However, you are responsible for non-network medical fees that exceed our Plan allowance.
Medical Fund expenses are the same medical, surgical, hospital, emergency, mental health and substance abuse, and prescription drug services and supplies covered under the Traditional Medical Coverage (see Section 5.3 for details). To make the most of your Medical Fund, you should: 78) Use the network providers whenever possible; and 79) Use generic prescriptions whenever possible
Medical Fund Rollover Provided you remain enrolled in the CDHP, any unused, remaining balance in your Medical Fund at the end of the calendar year may be rolled over to subsequent years. Note: This rollover feature can increase your Medical Fund in the following year(s) up to a maximum rollover of $4,000 for Self Only or $8,000 for a Self and Family enrollment.
Not covered: - Eyeglasses and contact lenses (see the non-FEHBP page for our Vision One Program) - **Non-network preventive care services not included under Section 5.1 - Services or supplies shown as not covered under Traditional Medical Coverage (see Section 5.3) - Charges of non-network providers that exceed our Plan allowance.**			All charges.
Dental Fund
	I M P O R T A N T	Here are some important things you should keep in mind about your Dental Fund: 80) Note that in-network preventive dental care covered under Section 5.1 does NOT count against your Dental Fund. 81) When you join this Plan, you will have access to the entire Dental Fund ($300 for Self Only or $600 for Self and Family to share between you and your enrolled family members). 82) Participating network PPO dentists offer members services at a negotiated rate – so, you are generally charged less for your dental care when you visit a participating network PPO dentist. Refer to our DocFind® online provider directory at www.aetna.com/fed to find a participating network PPO dentist, or call Member Services at 1-800/537-9384. 83) All eligible dental expenses will be paid from your Dental Fund. You can track your Dental Fund on Aetna’s Navigator Web site or by telephone at 1-800/537-9384. Note: Once your fund is exhausted, you will continue to save on the cost of your dental care with access to the negotiated rates offered by participating network PPO dentists. 84) You can visit any licensed dentist for covered services under the Dental Fund. However, you can make your Dental Fund go further by taking advantage of the negotiated rates offered by a participating network PPO dentist. These negotiated rates are generally less than the dentist’s usual fees. 85) REMEMBER: If you terminate your participation in this Plan, any Dental Fund balance you may have will be lost. 86) Any unused, remaining balance in your Dental Fund at the end of your calendar year will not rollover, regardless of whether you stay in the Plan or not. - 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.		I M P O R T A N T
Benefit Description			You pay
Dental Fund
Dental Fund expenses include dental services up to a maximum of $300 for Self Only or $600 for Self and Family enrollment. The Dental Fund covers eligible expenses at 100%. For example, if you go to a network dentist for a $125 visit, the doctor will submit your claim and the cost of the visit will be deducted automatically from your Dental Fund; you pay nothing. Balance in Dental Fund for Self Only $ 300 Less: Cost of visit - 125 Remaining Balance in Dental Fund $ 175 Note: Any unused remaining balance in your Dental Fund at the end of the calendar year cannot be rolled over to the next year. Eligible dental covered services include: Diagnostic and Preventive Care From Non-Network Dentists: 87) Prophylaxis (cleaning of teeth) – limited to 2 treatments per calendar year 88) Fluoride applications (limited to 1 treatment per calendar year and for children under age 16)			Nothing for eligible expenses until you exhaust your Dental Fund. However, you are responsible for non-network dentist fees that exceed our Plan allowance. Note: Once your Dental Fund is exhausted, you pay the negotiated rates offered by participating network PPO dentists. You are responsible for the full charges for services accessed from a non-network dentist.
Dental Fund (continued)			You pay
89) Sealants – (once every 3 years, from the last date of service, on permanent molars for children under age 16) 90) Space maintainer (primary teeth only) 91) Bitewing x-rays (one set per calendar year) 92) Complete series x-rays (one complete series every 3 years) 93) Periapical x-rays 94) Routine oral evaluations (limited to 2 per calendar year)			Nothing for eligible expenses until you exhaust your Dental Fund. However, you are responsible for non-network dentist fees that exceed our Plan allowance. Note: Once your Dental Fund is exhausted, you pay the negotiated rates offered by participating network PPO dentists. You are responsible for the full charges for services accessed from a non-network dentist.
Restorative Care (Basic and Major): 95) Amalgam and resin-based composite restorations (“fillings”) 96) Inlays and onlays 97) Crowns 98) Fixed partial dentures (“bridgework”) 99) Root canal (“endodontics”) therapy, including necessary x-rays 100) Extractions (oral surgery) such as simple, surgical, soft tissue and bony impacted teeth 101) Osseous surgery (“periodontics”) - one per quadrant every 3 years, from the last date of service 102) General anesthesia and intravenous sedation 103) Repairs to removable partial dentures and complete dentures, within 6 months of installation 104) Occlusal guards (for bruxism only) – limited to one every 3 years, from the last date of service			Nothing for eligible expenses until you exhaust your Dental Fund. However, you are responsible for non-network dentist fees that exceed our Plan allowance. Note: Once your Dental Fund is exhausted, you pay the negotiated rates offered by participating network PPO dentists. You are responsible for the full charges for services accessed from a non-network dentist.
Not covered: - Orthodontia - Dental treatment for cosmetic purposes - Dental care involved with the treatment of temporomandibular joint (TMJ) pain dysfunction syndrome - Dental implants - Replacement of crowns, fixed partial dentures (bridges), removable partial dentures or complete dentures, if the existing crown, fixed partial denture (bridge), removable partial denture or complete denture was originally placed less than 8 years prior to the replacement. - Charges of non-network providers that exceed our Plan allowance			All charges.