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Table of Contents

Pages 1--36 from 12921-9/98

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1999 Aetna U. S. Healthcare TM
A Health Maintenance Organization

Enrollment in this Plan is limited; see page 9 for requirements.
Servicing the following states:
Arizona Indiana North Carolina California Kentucky Ohio

Colorado Louisiana Oklahoma Connecticut Maryland Rhode Island
Delaware Massachusetts South Carolina District of Columbia Michigan Tennessee
Florida Nevada Texas Georgia New Hampshire Virginia
Illinois New York Washington

Special Notice: The Plan has eliminated a portion of its service area for 1999. If you are enrolled under code 2U and live in Carroll county Georgia, or enrolled under code 3G and live in the South Carolina
counties of Beaufort, Kershaw, Sumter, or York, or enrolled under code XC and live in the Indiana counties of Boone, Hamilton, Hancock, Hendricks, Johnson, Madison, Marion, Morgan, or Shelby, you
must select another plan or you must travel to the service area to receive full Plan benefits.
The San Antonio, Texas area, formerly a part of the service area under code 5B, has been redesignated as a separate service area under code 8X. Enrollees living in the San Antonio area are requested to reenroll in
code 8X to receive full benefits from providers within this area. The premium for code 8X is less.
The Service area has increased in portions of Michigan, Nevada, Oklahoma, and Washington.
Aetna U. S. Healthcare provides benefits in Pennsylvania and New Jersey. See the Plan's Federal brochure (RI73-052) for a complete description.

Visit the OPM website at http:// www. opm. gov/ insure and this Plan's website at http:// www. aetnaushc. com/ feds

RI 73-778
Authorized for distribution by the:

For changes
in benefitssee page 29.

United States Office of
Personnel Management 1
1 Page 2 3

Aetna U. S. Healthcare Aetna U. S. Healthcare, Inc., 1425 Union Meeting Road, P. O. Box 3013, Blue Bell, PA 19422, has entered into a contract (CS 2836) with
the Office of Personnel Management (OPM) as authorized by the Federal Employees Health Benefits (FEHB) law, to provide a
comprehensive medical plan herein called Aetna U. S. Healthcare or the Plan.

This brochure is the official statement of benefits on which you can rely. A person enrolled in the Plan is entitled to the benefits stated in
this brochure. If enrolled for Self and Family, each eligible family member is also entitled to these benefits.

Premiums are negotiated with each plan annually. Benefit changes are effective January 1, 1999, and are shown on page 29 of this
brochure.

2
Table of Contents
Page
Inspector General Advisory on Fraud.............................................................................................................. 3

General Information .......................................................................................................................................... 3-6
Confidentiality; If you are a new member; If you are hospitalized when you change plans; Your responsibility;
Things to keep in mind; Coverage after enrollment ends (Former spouse coverage; Temporary continuation of
coverage; Conversion to individual coverage; and Certificate of Creditable Coverage)

Facts about this Plan .......................................................................................................................................... 7-16
Information you have a right to know; Who provides care to Plan members? Role of a primary care doctor;
Choosing your doctor; Plan website; Referrals for specialty care; For new members; Hospital care; Out-of-pocket
maximum; Deductible carryover; Submit claims promptly; Experimental/ investigational determinations; Other
considerations; Reciprocity; The Plan's service areas

General Limitations ........................................................................................................................................... 16-17
Important notice; Circumstances beyond Plan control; Arbitration of claims; Other sources of benefits

General Exclusions ............................................................................................................................................. 17
Benefits ................................................................................................................................................................ 18-24
Medical and Surgical Benefits; Hospital/ Extended Care Benefits; Emergency Benefits; Mental Conditions/
Substance Abuse Benefits; Prescription Drug Benefits

Other Benefits ..................................................................................................................................................... 25-26
Dental care; Vision care

Call the provider and ask for an explanation sometimes the problem is a simple error.
If the provider does not resolve the matter, or if you remain concerned, call your plan at 1-800/ 537-9384 and explain the situation.
If the matter is not resolved after speaking to your plan (and you still suspect fraud has been committed), call or write:

THE HEALTH CARE FRAUD HOTLINE
202/ 418-3300

The Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E. Street, N. W., Room 6400
Washington, D. C. 20415

The inappropriate use of membership identification cards, e. g., to obtain services for a person who is not an eligible family member or
after you are no longer enrolled in the Plan, is also subject to review by the Inspector General and may result in an adverse administrative
action by your agency.

General Information

3
Confidentiality
If you are a new member

Medical and other information provided to the Plan, including claim files, is kept confidential and
will be used only: 1) by the Plan and its subcontractors for internal administration of the Plan,
coordination of benefit provisions with other plans, and subrogation of claims; 2) by law
enforcement officials with authority to investigate and prosecute alleged civil or criminal actions; 3)
by OPM to review a disputed claim or perform its contract administration functions; 4) by OPM and
the General Accounting Office when conducting audits as required by the FEHB law; or 5) for bona
fide medical research or education. Medical data that does not identify individual members may be
disclosed as a result of the bona fide medical research or education.

Use this brochure as a guide to coverage and obtaining benefits. There may be a delay before you
receive your identification card and member information from the Plan. Until you receive your ID
card, you may show your copy of the SF 2809 enrollment form or your annuitant confirmation letter
from OPM to a provider or Plan facility as proof of enrollment in this Plan. If you do not receive
your ID card within 60 days after the effective date of your enrollment, you should contact the Plan.

If you made your open season change by using Employee Express and have not received your new
ID card by the effective date of your enrollment, call the Employee Express HELP number to
request a confirmation letter. Use that letter to confirm your new coverage with Plan providers.

If you are a new member of this Plan, benefits and rates begin on the effective date of your
enrollment, as set by your employing office or retirement system. As a member of this Plan, once
your enrollment is effective, you will be covered only for services provided or arranged by a Plan
doctor except in the case of emergency as described on page 21. If you are confined in a hospital on
the effective date, you must notify the Plan so that it may arrange for the transfer of your care to
Plan providers. See "If you are hospitalized" on page 4.

FEHB plans may not refuse to provide benefits for any condition you or a covered family member
may have solely on the basis that it was a condition that existed before you enrolled in a plan under
the FEHB Program. 3
3 Page 4 5
If you change plans or options, benefits under your prior plan or option cease on the effective date of
your enrollment in your new plan or option, unless you or a covered family member are confined in
a hospital or other covered facility or are receiving medical care in an alternative care setting on the
last day of your enrollment under the prior plan or option. In that case, the confined person will
continue to receive benefits under the former plan or option until the earliest of (1) the day the
person is discharged from the hospital or other covered facility (a move to an alternative care setting
does not constitute a discharge under this provision), or (2) the day after the day all inpatient
benefits have been exhausted under the prior plan or option, or (3) the 92nd day after the last day of
coverage under the prior plan or option. However, benefits for other family members under the new
plan will begin on the effective date. If your plan terminates participation in the FEHB Program in
whole or in part, or if the Associate Director for Retirement and Insurance 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.

It is your responsibility to be informed about your health benefits. Your employing office or
retirement system can provide information about: when you may change your enrollment; who
"family members" are; what happens when you transfer, go on leave without pay, enter military
service, or retire; when your enrollment terminates; and the next open season for enrollment. Your
employing office or retirement system will also make available to you an FEHB Guide, brochures
and other materials you need to make an informed decision.

The benefits in this brochure are effective on January 1 for those already enrolled in this Plan; if
you changed plans or plan options, see "If you are a new member" on page 3. In both cases,
however, the Plan's new rates are effective the first day of the enrollee's first full pay period that
begins on or after January 1 (January 1 for all annuitants).

Generally, you must be continuously enrolled in the FEHB Program for the last five years before
you retire to continue your enrollment for you and any eligible family members after you retire.

The FEHB Program provides Self Only coverage for the enrollee alone or Self and Family
coverage for the enrollee, his or her spouse, and unmarried dependent children under age 22.
Under certain circumstances, coverage will also be provided under a family enrollment for a
disabled child 22 years of age or older who is incapable of self-support.

A member with Self Only coverage who is expecting a baby or the addition of a child may
change to a Self and Family enrollment up to 60 days after the birth or addition. The effective
date of the enrollment change is the first day of the pay period in which the child was born or
became an eligible family member. The enrollee is responsible for his or her share of the Self and
Family premium for that time period; both parent and child are covered only for care received
from Plan providers, except for emergency benefits.

You will not be informed by your employing office (or your retirement system) or your Plan
when a family member loses eligibility.

You must direct questions about enrollment and eligibility, including whether a dependent age 22
or older is eligible for coverage, to your employing office or retirement system. The Plan does
not determine eligibility and cannot change an enrollment status without the necessary
information from the employing agency or retirement system.

An employee, annuitant, or family member enrolled in one FEHB plan is not entitled to receive
benefits under any other FEHB plan.

Report additions and deletions, including divorces, of covered family members to the Plan
promptly.

If you are an annuitant or former spouse with FEHB coverage and you are also covered by
Medicare Part B, you may drop your FEHB coverage and enroll in a Medicare prepaid plan when
one is available in your area. If you later change your mind and want to reenroll in FEHB, you
may do so at the next open season, or whenever you involuntarily lose coverage in the Medicare
prepaid plan or move out of the area it serves.

Most Federal annuitants have Medicare Part A. If you do not have Medicare Part A, you may
enroll in a Medicare prepaid plan, but you will probably have to pay for hospital coverage in
addition to the Part B premium. Before you join the plan, ask whether they will provide hospital
benefits and, if so, what you will have to pay.

If you are hospitalized
Your responsibility
Things to keep in mind

General Information continued 4
4 Page 5 6
General Information continued
5
You may also remain enrolled in this Plan when you join a Medicare prepaid plan.
Contact your local Social Security Administration (SSA) office for information on local
Medicare prepaid plans (also known as Coordinated Care Plans or Medicare HMOs) or request it
from SSA at 1-800/ 638-6833. Contact your retirement system for information on dropping your
FEHB enrollment and changing to a Medicare prepaid plan. See page 27 for information on the
Medicare prepaid plan offered by this Plan.

Federal annuitants are not required to enroll in Medicare Part B (or Part A) in order to be covered
under the FEHB Program nor are their FEHB benefits reduced if they do not have Medicare Part B
(or Part A).

When an employee's enrollment terminates because of separation from Federal service or when a
family member is no longer eligible for coverage under an employee or annuitant enrollment, and
the person is not otherwise eligible for FEHB coverage, he or she generally will be eligible for a free
31-day extension of coverage. The employee or family member also may be eligible for one of the
following:

When a Federal employee or annuitant divorces, the former spouse may be eligible to elect coverage
under the spouse equity law. If you are recently divorced or anticipate divorcing, contact the
employee's employing office (personnel office) or retiree's retirement system to get more facts
about electing coverage.

If you are an employee whose enrollment is terminated because you separate from service, you may
be eligible to temporarily continue your health benefits coverage under the FEHB Program in any
plan for which you are eligible. Ask your employing office for RI 79-27, which describes TCC, and
for RI 70-5, the FEHB Guide for individuals eligible for TCC. Unless you are separated for gross
misconduct, TCC is available to you if you are not otherwise eligible for continued coverage under
the Program. For example, you are eligible for TCC when you retire if you are unable to meet the
five-year enrollment requirement for continuation of enrollment after retirement.

Your TCC begins after the initial free 31-day extension of coverage ends and continues for up to 18
months after your separation from service (that is, if you use TCC until it expires 18 months
following separation, you will only pay for 17 months of coverage). Generally, you must pay the
total premium (both the Government and employee shares) plus a 2 percent administrative charge. If
you use your TCC until it expires, you are entitled to another free 31-day extension of coverage
when you may convert to nongroup coverage. If you cancel your TCC or stop paying premiums, the
free 31-day extension of coverage and conversion option are not available.

Children or former spouses who lose eligibility for coverage because they no longer qualify as
family members (and who are not eligible for benefits under the FEHB Program as employees or
under the spouse equity law) also may qualify for TCC. They also must pay the total premium plus
the 2 percent administrative charge. TCC for former family members continues for up to 36 months
after the qualifying event occurs, for example, the child reaches age 22 or the date of the divorce.
This includes the free 31-day extension of coverage. When their TCC ends (except by cancellation
or nonpayment of premium), they are entitled to another free 31-day extension of coverage when
they may convert to nongroup coverage.

NOTE: If there is a delay in processing the TCC enrollment, the effective date of the enrollment is
still the 32nd day after regular coverage ends. The TCC enrollee is responsible for premium
payments retroactive to the effective date and coverage may not exceed the 18 or 36 month period
noted above.

Separating employees Within 61 days after an employee's enrollment terminates because of separation from service, his or her employing office will notify the employee of the opportunity to
elect TCC. The employee has 60 days after separation (or after receiving the notice from the
employing office, if later) to elect TCC.

Children You must notify your employing office or retirement system when a child becomes eligible for TCC within 60 days after the qualifying event occurs, for example, the child reaches age

22 or marries.

Coverage after enrollment ends
Former spouse coverage
Temporary continuation
of coverage (TCC)

Notification and election
requirements 5
5 Page 6 7
Conversion to individual
coverage

Certificate of Creditable
Coverage

Former spouses You or your former spouse must notify the employing office or retirement system of the former spouse's eligibility for TCC within 60 days after the termination of the
marriage. A former spouse may also qualify for TCC if, during the 36-month period of TCC
eligibility, he or she loses spouse equity eligibility because of remarriage before age 55 or loss of the
qualifying court order. This applies even if he or she did not elect TCC while waiting for spouse
equity coverage to begin. The former spouse must contact the employing office within 60 days of losing
spouse equity eligibility to apply for the remaining months of TCC to which he or she is entitled.

The employing office or retirement system has 14 days after receiving notice from you or the former
spouse to notify the child or the former spouse of his or her rights under TCC. If a child wants TCC,
he or she must elect it within 60 days after the date of the qualifying event (or after receiving the
notice, if later). If a former spouse wants TCC, he or she must elect it within 60 days after any of the
following events: the date of the qualifying event or the date he or she receives the notice, whichever
is later; or the date he or she loses coverage under the spouse equity law because of remarriage
before age 55 or loss of the qualifying court order.

Important: The employing office or retirement system must be notified of a child's or former
spouse's eligibility for TCC within the 60-day time limit. If the employing office or retirement
system is not notified, the opportunity to elect TCC ends 60 days after the qualifying event in the
case of a child and 60 days after the change in status in the case of a former spouse.

When none of the above choices are available or chosen when coverage as an employee or
family member ends, or when TCC coverage ends (except by cancellation or nonpayment of
premium), you may be eligible to convert to an individual, nongroup contract. You will not be
required to provide evidence of good health and the plan is not permitted to impose a waiting period
or limit coverage for preexisting conditions. If you wish to convert to an individual contract, you must
apply in writing to the carrier of the plan in which you are enrolled within 31 days after receiving
notice of the conversion right from your employing agency. A family member must apply to convert
within the 31-day free extension of coverage that follows the event that terminates coverage, e. g.,
divorce or reaching age 22. Benefits and rates under the individual contract may differ from those
under the FEHB Program.

Under Federal law, if you lose coverage under the FEHB Program, you should automatically receive
a Certificate of Group Health Plan Coverage from the last FEHB Plan to cover you. This certificate,
along with any certificates you receive from other FEHB plans you may have been enrolled in, may
reduce or eliminate the length of time a preexisting condition clause can be applied to you by a new
non-FEHB insurer. If you do not receive a certificate automatically, you must be given one on
request.

General Information continued 6
6 Page 7 8
Facts about this Plan
7
This Plan is a comprehensive medical plan, sometimes called a health maintenance organization (HMO). When you enroll in an HMO,
you are joining an organized system of health care that arranges in advance with specific doctors, hospitals and other providers to give
care to members and pays them directly for their services. Benefits are available only from Plan providers except during a medical
emergency. Members are required to select a personal doctor from among participating Plan primary care doctors. Services of a specialty
care doctor can only be received by referral from the selected primary care doctor. There are no claim forms when Plan doctors are used.

Your decision to join an HMO should be based on your preference for the plan's benefits and delivery system, not because a particular
provider is in the plan's network. You cannot change plans because a provider leaves the HMO.

Because the Plan provides or arranges your care and pays the cost, it seeks efficient and effective delivery of health services. By
controlling unnecessary or inappropriate care, it can afford to offer a comprehensive range of benefits. In addition to providing
comprehensive health services and benefits for accidents, illness and injury, the Plan emphasizes preventive benefits such as office visits,
physicals, immunizations and well-baby care. You are encouraged to get medical attention at the first sign of illness.

All carriers in the FEHB Program must provide certain information to you. If you did not receive
information about this Plan, you can obtain it by calling the Carrier at 1-800-537-9384 or you may
write the Carrier at 1425 Union Meeting Road, P. O. Box 3013, Blue Bell, PA 19422. You may also
contact the Carrier by fax at 1-215-775-5870 or at its website at http:// www. aetnaushc. com/ feds.

Information that must be made available to you includes:
Disenrollment rates for 1997.
Compliance with State and Federal licensing or certification requirements and the dates met. If
noncompliant, the reason for noncompliance.

Accreditations by recognized accrediting agencies and the dates received.
Carrier's type of corporate form and years in existence.
Whether the carrier meets State, Federal and accreditation requirements for fiscal solvency,
confidentiality and transfer of medical records.

This Plan is an individual-practice prepayment Plan. Plan participating providers are neither agents
nor employees of the Plan. They are independent doctors who practice in their own offices. Covered
benefits are available only from those doctors and from participating hospitals and participating
pharmacies. The Plan arranges with doctors and hospitals to provide medical care for both the
prevention of disease and the treatment of serious illness.

You must select a primary care doctor for each covered family member. Your primary care doctor
must be a family or general practitioner, pediatrician or medical internist. You must contact your
primary care doctor for a referral before seeing any other doctor or obtaining specialty services. A
wide variety of Board eligible and Board certified specialists are participating Plan doctors. Your
Plan primary care doctor or the specialist to whom you were referred admits you to his/ her hospital
for elective procedures.

The first and most important decision each member must make is the selection of a primary care
doctor. The decision is important since it is through this doctor that all other health services,
particularly those of specialists, are obtained. It is the responsibility of your primary care doctor to
obtain any necessary authorizations from the Plan before referring you to a specialist or making
arrangements for hospitalization. Services of other providers are covered only when you have been
referred by your primary care doctor, with the following exception: open access to Plan participating
gynecologists is available for the diagnosis and treatment of gynecological problems and one routine
gynecological exam and Pap smear each calendar year.

You must select a primary care doctor from the provider directory that corresponds to the enrollment
code you selected.

The Plan's provider directory lists participating primary care doctors (general or family
practitioners, pediatricians, and internists), with their locations and phone numbers, and notes
whether or not the doctor is accepting new patients. Directories are updated on a regular basis and
are available at the time of enrollment or upon request by calling or writing the Member Relations
Department, Aetna U. S. Healthcare, 1425 Union Meeting Road, P. O. Box 3013, Blue Bell, PA
19422 Telephone: 1-800/ 537-9384; you can also find out if your doctor participates with this
Plan by calling this number. If you are interested in receiving care from a specific provider who is

Information you have a right to know
Who provides care to Plan members?
Role of a primary care doctor
Choosing your doctor 7
7 Page 8 9
Plan Website
Referrals for specialty care

For new members
Hospital care
Out-of-pocket maximum

listed in the directory, call the provider to verify that he or she still participates with the Plan and is
accepting new patients. Important note: When you enroll in this Plan, services (except for
emergency benefits) are provided through the Plan's delivery system; the continued availability
and/ or participation of any one doctor, hospital, or other provider cannot be guaranteed.

If you enroll, you will be asked to complete a primary care doctor selection form and send it directly
to the Plan, indicating the name of the primary care doctor( s) you selected for you and each member
of your family. Members may change their doctor selection by notifying the Plan 30 days in
advance.

If you are receiving services from a doctor who leaves the Plan, the Plan will provide payment for
covered services until the Plan can make reasonable and medically appropriate provisions for the
assumption of such services by a participating doctor.

For the most current list of Plan participating providers, please refer to our Internet Website at
www. aetnaushc. com/ feds. After logging onto our website, click on DocFind. This easy-to-use
electronic directory gives you up-to-date provider information. Based on your criteria, a list of
providers should appear when available. Clicking directly on the address of the provider gives you
detailed information about that provider. DocFind is available 24 hours a day, 7 days a week.

Except in a medical emergency, or for direct access benefits, or when a primary care doctor has
designated another doctor to see patients when he or she is unavailable, you must contact your
primary care doctor for a referral before seeing any other doctor or obtaining special services.
Referral to a participating specialist is given at the primary care doctor's discretion; if specialists or
consultants are required beyond those participating in the Plan, the primary care doctor will make
arrangements for appropriate referrals.

When you receive a referral from your primary care doctor, you must return to the primary care
doctor after the consultation. All follow-up care must be provided or authorized by the primary care
doctor. On referrals, the primary care doctor will give specific instructions to the consultant as to
what services are authorized. If additional services or visits are suggested by the consultant, you
must first check with your primary care doctor and obtain another referral. Otherwise you will be
responsible for the costs that you incur for services received.

If you have a chronic, complex, or serious medical condition that causes you to see a Plan specialist
frequently, your primary care doctor will develop a treatment plan with you and your health plan
that allows an adequate number of direct access visits with that specialist. The treatment plan will
permit you to visit your specialist without the need to obtain further referrals.

If you are already under the care of a specialist who is a Plan participant, you must still obtain a
referral from a Plan primary care doctor for the care to be covered by the Plan. If the doctor who
originally referred you prior to joining this Plan is now your primary care doctor, you should call to
explain that you now belong to this Plan and ask that a "referral form" be sent to the specialist for
your next appointment.

If you are selecting a new primary care doctor, you must schedule an appointment so the primary
care doctor can decide whether to treat the condition directly or refer you back to the specialist.

If you require hospitalization, your primary care doctor or authorized specialist will make the
necessary arrangements and continue to supervise your care.

Copayments are required for a few benefits. However, copayments will not be required for the
remainder of the calendar year after your out-of-pocket expenses for services provided or arranged
by the Plan reach 100% of annual premium per Self Only enrollment or 100% of annual premium
per Self and Family enrollment including your premium and the Government's share. This
copayment maximum does not include costs of prescription drugs.

You should maintain accurate records of the copayments made, as it is your responsibility to
determine when the copayment maximum is reached. You are assured a predictable maximum in
out-of-pocket costs for covered health and medical needs. Copayments are due when service is
rendered, except for emergency care.

Facts about this Plan continued

8 8
8 Page 9 10
Facts about this Plan continued
9
If you changed to this Plan during open season from a plan with a deductible and the effective date
of the change was after January 1, any expenses that would have applied to that plan's deductible
will be covered by your old plan if they are for care you got in January before the effective date of
your coverage in this Plan. If you have already met the deductible in full, your old plan will
reimburse these covered expenses. If you have not met it in full, your old plan will first apply your
covered expenses to satisfy the rest of the deductible and then reimburse you for any additional
covered expenses. The old plan will pay these covered expenses according to this year's benefits;
benefit changes are effective January 1.

When you are required to submit a claim to this Plan for covered expenses, submit your claim
promptly. The Plan will not pay benefits for claims submitted later than December 31 of the
calendar year following the year in which the expense was incurred, unless timely filing was
prevented by administrative operations of Government or legal incapacitation, provided the claim
was submitted as soon as reasonably possible.

The Plan's medical policy review group uses the Hays Medical Technology Assessment Service,
HCFA's policy manual, FDA decisions, etc., to determine which medical procedures are
experimental and/ or investigational.

Plan providers will follow generally accepted medical practice in prescribing any course of
treatment. Before you enroll in this Plan, you should determine whether you will be able to accept
treatment or procedures that may be recommended by Plan providers.

When you are beyond a 50-mile radius from home and desire nonemergency or nonurgent care, you
can visit a participating primary care doctor in another state or location throughout the Plan's
national HMO network. Please call 1-800-537-9384 for provider information. You will be able to
choose from 3 primary care doctors in that area and will receive authorization for one visit which
includes any tests or X rays required in connection with that visit. Any subsequent visits must be
coordinated through your own primary care doctor. You pay a $5 copay per visit. This benefit is
good for up to 30 days away from home.

The service area for this Plan, where Plan providers and facilities are located, is described below.
Plan providers and facilities in your Service area must be used. You must live or work in one of the
service areas to enroll in this Plan. Benefits for care outside a service area are limited to emergency
services, as described on page 21 and under the reciprocity benefit.

If you or a covered family member move outside the service area, you may enroll in another
approved plan. It is not necessary to wait until you move or for the open season to make such a
change; contact your employing office or retirement system for information if you are anticipating
a move.

The service areas for this Plan include the following areas:
Serving: Phoenix and Tuscon areas
Enrollment Code:
WQ1 Self Only WQ2 Self and Family

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

Deductible carryover
Submit claims promptly
Experimental/ investigational
determinations
Other considerations

Reciprocity

The Plan's service areas

Arizona 9
9 Page 10 11
California
Connecticut
Colorado

Delaware
10

Serving: Northern California area
Enrollment Code:
BU1 Self Only BU2 Self and Family

Alameda, Contra Costa, Fresno, Madera, Marin, Napa, Sacramento, San Francisco, San Mateo,
Santa Clara, Santa Cruz, Solano, Sonoma, Stanislaus and Yolo counties and portions of El Dorado,
Kings, Merced, Placer, San Joaquin, and Tulare counties defined by listed towns:

El Dorado: Auburn, Cameron Park, El Dorado Hills, Folsom, Garden Valley, Lake Trails, Latrobe,
Lotus, Pilot Hill, Rescue, Shingle Springs

Kings: Armona, Avenal, Corcoran, Hanford, Kettleman City, Lemoore, Lemoore Naval Air Station,
Stratford

Merced: Atwater, Ballico, Cressey, Delhi, Dixon, El Nido, Gustine, Hilmar, Le Grand, Liberty
Farms, Livingston, Los Banos, Merced, Newman, Santa Nella, Santa Rita, Snelling, Stevinson,
Winton

Placer: Applegate, Auburn, Baker Ranch, Boman, Cape Horn, Christian Valley, Clipper Gap,
Colfax, Dutch Flat, Eden Valley, Forest Hill, Heather Glenn, Iowa Hill, Lake of the Pines, Lincoln,
Loomis, Meadow Vista, Michigan Bluff, Newcastle, Ophir, Penryn, Rocklin, Roseville, Shady Glen,
Stanford Ranch, Sunset Whitney Ranch, Todd Valley, Weimar, Yankee Jims

San Joaquin: Farmington, Holt, Lathrop, Linden, Menteca, Ripon, Stockton, Tracy, Vernalis
Tulare: Alpaugh, Badger, California Hot Springs, Camp Nelson, Corcoran, Cutler, Delano, Dinuba,
Ducor, Exeter, Farmersville, Goshen, Independence, Ivanhoe, Lemon Cove, Lindsay, Miramonte,
Orosi, Porterville, Posey, Richgrove, Springville, Strathmore, Sultana, Terra Bella, Three Rivers,
Tipton, Traver, Tulare, Visalia, Waukema, Woodlake, Yettem

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

Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura
counties

Serving: All of Connecticut
Enrollment Code:
H11 Self Only H12 Self and Family

The State of Connecticut

Serving: The Front Range
Enrollment Code:
6F1 Self Only 6F2 Self and Family

Adams, Arapahoe, Boulder, Denver, Douglas, El Paso, Elbert, Fremont, Jefferson, Larimer, Pueblo,
and Teller counties

Serving: All of Delaware
Enrollment Code:
NK1 Self Only NK2 Self and Family

The State of Delaware

Facts about this Plan continued
3/ 96
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FEHB Guide for more information on NCQA.

11/ 96
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10 Page 11 12
District of Columbia
Florida

Georgia

Illinois
Indiana

Kentucky
11

Serving: All of Washington, DC
Enrollment Code:
V81 Self Only V82 Self and Family

All of Washington, DC

Serving: Central and South Florida areas
Enrollment Code:
8A1 Self Only 8A2 Self and Family

Baker, Brevard, Broward, Clay, Dade, Duval, Flagler, Hillsborough, Lake, Lee, Manatee, Marion,
Nassau, Orange, Osceola, Pasco, Pinellas, Polk, Sarasota, Seminole, St. Johns, and Volusia counties

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

Baldwin, Barrow, Bartow, Bibb, Burke, Butts, Cherokee, Clarke, Clayton, Cobb, Columbia,
Coweta, Dawson, Dekalb, Douglas, Fayette, Forsyth, Fulton, Glascock, Gwinnett, Hall, Haralson,
Heard, Henry, Houston, Jackson, Jones, Lamar, Lincoln, Madison, McDuffie, Newton, Oconee,
Oglethorpe, Paulding, Peach, Pickens, Pike, Pulaski, Richmond, Rockdale, Spalding, Taliaferro,
Twiggs, Walton, Warren and Washington counties

Serving: The Chicago area
Enrollment Code:
XC1 Self Only XC2 Self and Family

Cook, DuPage, Kane, Lake, McHenry, and Will counties

Serving: Lake and Porter Counties
Enrollment Code:
XC1 Self Only XC2 Self and Family

Lake and Porter counties

Serving: Southern Indiana
Enrollment Code:
RD1 Self Only RD2 Self and Family

Clark, Floyd, Harrison, Scott, and Washington counties

Serving: Lexington and Louisville areas
Enrollment Code:
RD1 Self Only RD2 Self and Family

Anderson, Boone, Bullitt, Campbell, Clark, Fayette, Grant, Hardin, Harrison, Henry, Jefferson,
Jessamine, Kenton, Larue, Madison, Meade, Nelson, Oldham, Scott, Shelby, Spencer, Trimble, and
Woodford counties

Facts about this Plan continued
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FEHB Guide for more information on NCQA.

5/ 95
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FEHB Guide for more information on NCQA.

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FEHB Guide for more information on NCQA. 11
11 Page 12 13
Louisiana
Maryland
Massachusetts

Serving: The New Orleans area
Enrollment Code:
NG1 Self Only NG2 Self and Family

The parishes of Jefferson, Lafourche, Orleans, St. Bernard, St. Charles, St. John the Baptist, St.
Tammany and portions of Assumption, Plaquemines, St. James, Terrebone and Washington as
defined by the following towns:

Assumption: Belle Rose, Labadieville, Napoleonville, and Pierre Part
Plaquemines: Belle Chasse, Boothville, Braithwaite, Buras, Carlisle, Davant, Empire, Pilottown,
Pointe A La Hache, Port Sulphur, and Venice

St. James: Convent, Gramercy, Hester, Lutcher, Paulina, St. James, Uncle Sam, and Vacherie
Terrebonne: Bourg, Donner, Dulac, Gibson, Houma, Montegut, Schriever, and Theriot
Washington: Angie, Bogalusa, and Franklinton

Serving: The Baton Rouge and Lafayette areas
Enrollment Code:
TK1 Self Only TK2 Self and Family

Baton Rouge area: The parishes of Ascension, East Baton Rouge, East Feliciana, Iberville,
Livingston, Pointe Coupee, St. Helena, Tangipahoa, West Baton Rouge and West Feliciana

Lafayette area: The parishes of Evangeline, Iberia, Lafayette, St. Landry, St. Mary, St. Martin, and
portions of Acadia and Vermilion as defined by the following towns:

Acadia: Branch, Church Point, Crowley, Egan, Estherwood, Evangeline, Iota, Mermentau, Midland,
Morse, and Rayne

Vermilion: Abbeville, Delcambe, Erath, Kaplan, Gueydan, Maurice, and Perry

Serving: North and Central Maryland and the Washington, DC area
Enrollment Code:
V81 Self Only V82 Self and Family

Anne Arundel, Baltimore, Baltimore City, Calvert, Carroll, Cecil, Charles, Frederick, Harford,
Howard, Kent, Montgomery, Prince George's, Queen Anne's, St. Mary's, Talbot, Washington,
Wicomico and Worcester counties

Serving: Eastern/ Central Massachusetts and Hampden County
Enrollment Code:
NE1 Self Only NE2 Self and Family

The Boston area, including the counties of Barnstable, Bristol, Essex, Hampden, Middlesex,
Norfolk, Plymouth, Suffolk, and Worcester counties and zip codes 01082, 01364

Facts about this Plan continued
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12 Page 13 14
Michigan
Nevada
New Hampshire

New York

North Carolina

Serving: The Greater Detroit Metropolitan area
Enrollment Code:
8Z1 Self Only 8Z2 Self and Family

The Detroit area, including Wayne county and portions of Oakland county including Avon
Township, Berkeley (City), Birmingham (City), Bloomfield Hills (City), Bloomfield Township,
Clawson (City), Commerce Township, Farmington Hills (City), Farmington Township, Ferndale
(City), Hazel Park (City), Highland Township, Huntington Woods (City), Independence Township,
Keego Harbor (City), Lake Orion Village, Lathrup Village (City), Madison Heights (City), Novi
(City), Oak Park (City), Orchard Lake Village, Orion Township, Oxford (City), Pontiac (City),
Pontiac Township, Rochester (City), Royal Oak (City), Southfield (City), Southfield Township,
Troy (City), West Bloomfield Township, Walled Lake (City), Waterford Township, Whitelake
Township, Wixom (City), Wolverine Lake (City)

Serving: Southern Nevada and Las Vegas area
Enrollment Code:
8L1 Self Only 8L2 Self and Family

Clark county

Serving: Portions of New Hampshire
Enrollment Code:
UJ1 Self Only UJ2 Self and Family

Cheshire, Hillsborough, Rockingham, and Strafford counties

Serving: New York City area
Enrollment Code:
JC1 Self Only JC2 Self and Family

Bronx, Dutchess, Kings (Brooklyn), Nassau, New York (Manhattan), Orange, Putnam, Queens,
Richmond (Staten Island), Rockland, Suffolk, Sullivan, Ulster, and Westchester counties

Serving: The Charlotte/ Metrolina area
Enrollment Code:
3G1 Self Only 3G2 Self and Family

Cabarrus, Gaston, Iredell, Lincoln, Mecklenberg, Rowan, Stanly, and Union counties

Facts about this Plan continued
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13 Page 14 15
Facts about this Plan continued
14
Serving: Most of Ohio
Enrollment Code:
RD1 Self Only RD2 Self and Family

Adams, Allen, Ashland, Ashtabula, Brown, Butler, Carroll, Champaign, Clark, Clermont, Clinton,
Coshocton, Crawford, Cuyahoga, Delaware, Erie, Fairfeld, Fayette, Franklin, Geauga, Greene,
Guernsey, Hamilton, Highland, Hocking, Holmes, Knox, Lake, Licking, Logan, Lorain, Lucas,
Madison, Mahoning, Marion, Medina, Miami, Montgomery, Morgan, Morrow, Muskingum, Nobel,
Ottawa, Perry, Pickaway, Pike, Portage, Preble, Putnam, Richland, Ross, Scioto, Shelby, Stark,
Summit, Trumbull, Tuscarawas, Union, Warren, and Wayne counties and portions of the following
counties defined by listed towns:

Auglaize: Minster, New Bremen, New Hampshire, New Knoxville, Saint John's, Saint Mary's,
Uniopolis, Wapakoneta, and Waynesfield

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

Fulton: Metamora and Swanton
Huron: Collins, Greenwich, Huron, New London, and Wakeman
Wood: Grand Rapids, Haskins, Millbury, Northwood, Perrysburg, Rossford, Stony Ridge, and
Walbridge

Serving: Northeast Oklahoma
Enrollment Code:
8V1 Self Only 8V2 Self and Family

Tulsa and Rogers counties and portions of the following counties defined by listed towns:
Creek: Kellyville, Kiefer, Mounds, Sapulpa
Osage: Skiatook, Osage, Prue
Wagoner: Choska, Coweta, Fair Oaks, New Tulsa, Oneta

Serving: All of Rhode Island
Enrollment Code:
5U1 Self Only 5U2 Self and Family

The State of Rhode Island

Serving: Portions of South Carolina
Enrollment Code:
3G1 Self Only 3G2 Self and Family

Berkeley, Charleston, Colleton, Dorchester, Lexington, and Richland counties

Serving: Nashville and Middle Tennessee
Enrollment Code:
6J1 Self Only 6J2 Self and Family

Bedford, Cannon, Cheatham, Coffee, Davidson, Dekalb, Dickson, Franklin, Giles, Hickman,
Humphreys, Lawrence, Lewis, Lincoln, Macon, Marshall, Maury, Montgomery, Moore, Perry,
Robertson, Rutherford, Smith, Sumner, Trousdale, Wayne, Williamson, and Wilson counties

Ohio
Oklahoma
Rhode Island
South Carolina

Tennessee

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14 Page 15 16
Serving: Dallas/ Forth Worth area
Enrollment Code:
TS1 Self Only TS2 Self and Family

Collin, Dallas, Denton, Ellis, Erath, Hood, Hunt, Kaufman, Palo Pinto, Rockwall, Somervell, and
Tarrant counties and portions of the following counties defined by listed towns:

Cooke: Gainesville
Delta: Pecan Gap
Fannin: Pecan Gap/ Commerce area
Henderson: Seven Points
Hill: Itasca
Johnson: Burleson, Mansfield, Alvardo
Navarro: Corsicana, Kerens, Barry, Blooming Grove
Parker: Azle, Weatherford
Wise: Northwest Fort Worth area

Serving: Houston area
Enrollment Code:
5B1 Self Only 5B2 Self and Family

The Houston counties of Brazoria, Chambers, Ft. Bend, Galveston, Grimes, Harris, Jefferson,
Liberty, Matagorda, Montgomery, San Jacinto, Walker, Waller, and Wharton

Serving: San Antonio area
Enrollment Code:
8X1 Self Only 8X2 Self and Family

The San Antonio counties of Bexar, Comal, Guadelupe, and Kendall

Serving: Northern Virginia
Enrollment Code:
V81 Self Only V82 Self and Family

The Virginia cities of Alexandria, Arlington, Fairfax, Falls Church, Fredericksburg, Manassas,
Manassas Park; and Caroline, Fairfax, Fauquier, King George, Loudon, Prince William,
Spotsylvania, Stafford, and Westmoreland counties

Serving: The Richmond, Central, and Tri-City area
Enrollment Code:
Z11 Self Only Z12 Self and Family

The Virginia cities of Charles, Colonial Heights, Hopewell, Petersburg, Richmond; and Chesterfield,
Dinwiddie, Goochland, Hanover, Henrico, King William, New Kent, Nottaway, and Powhattan counties

Texas
Virginia

Facts about this Plan continued

15
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FEHB Guide for more information on NCQA.

10/ 97
This service area has full accreditation from the NCQA. See the

FEHB Guide for more information on NCQA.

4/ 97
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FEHB Guide for more information on NCQA. 15
15 Page 16 17
Facts about this Plan continued
16
Serving: Western and Southeast Washington
Enrollment Code:
8J1 Self Only 8J2 Self and Family

Columbia, King, Kitsap, Pierce, Snohomish, Thurston, and Walla Walla counties and portions of the
following counties defined by listed towns:

Clallam: Port Angeles, Sequim
Skagit: Anacortes

Although a specific service may be listed as a benefit, it will be covered for you only if, in the
judgment of your Plan doctor, it is medically necessary for the prevention, diagnosis, or treatment of
your illness or condition. No oral statement of any person shall modify or otherwise affect the
benefits, limitations and exclusions of this brochure, convey or void any coverage, increase or reduce any benefits under this Plan or be used in the prosecution or defense of a claim under

this Plan. This brochure is the official statement of benefits on which you can rely.

In the event of major disaster, epidemic, war, riot, civil insurrection, disability of a significant
number of Plan providers, complete or partial destruction of facilities, or other circumstances
beyond the Plan's control, the Plan will make a good faith effort to provide or arrange for covered
services. However, the Plan will not be responsible for any delay or failure in providing service due
to lack of available facilities or personnel.

Any claim for damages for personal injury, mental disturbance or wrongful death arising out of the
rendition of or failure to render services under this contract must be submitted to binding arbitration.

This section applies when you or your family members are entitled to benefits from a source other
than this Plan. You must disclose information about other sources of benefits to the Plan and
complete all necessary documents and authorizations requested by the Plan.

If you or a covered family member is enrolled in this Plan and Medicare Part A and/ or Part B, the
Plan will coordinate benefits according to Medicare's determination of which coverage is primary.
However, this Plan will not cover services, except those for emergencies, unless you use Plan
providers. You must tell your Plan that you or your family member is eligible for Medicare.
Generally, that is all you will need to do, unless your Plan tells you that you need to file a Medicare claim.

This coordination of benefits (double coverage) provision applies when a person covered by this
Plan also has, or is entitled to benefits from, any other group health coverage, or is entitled to the
payment of medical and hospital costs under no-fault or other automobile insurance that pays
benefits without regard to fault. Information about the other coverage must be disclosed to this Plan.

When there is double coverage for covered benefits, other than emergency services from non-Plan
providers, this Plan will continue to provide its benefits in full, but is entitled to receive payment for
the services and supplies provided, to the extent that they are covered by the other coverage, no-fault
or other automobile insurance or any other primary plan.

One plan normally pays its benefits in full as the primary payer, and the other plan pays a reduced
benefit as the secondary payer. When this Plan is the secondary payer, it will pay the lesser of (1) its
benefits in full or (2) a reduced amount which, when added to the benefits payable by the other
coverage, will not exceed reasonable charges. The determination of which health coverage is
primary (pays its benefits first) is made according to guidelines provided by the National
Association of Insurance Commissioners. When benefits are payable under automobile insurance,
including no-fault, the automobile insurer is primary (pays its benefits first) if it is legally obligated
to provide benefits for health care expenses without regard to other health benefits coverage the
enrollee may have. This provision applies whether or not a claim is filed under the other coverage.
When applicable, authorization must be given this Plan to obtain information about benefits or
services available from the other coverage, or to recover overpayments from other coverages.

Washington
Important notice
Circumstances beyond Plan control
Arbitration of claims
Other sources of benefits

Medicare

Group health insurance and
automobile insurance

General Limitations 16
16 Page 17 18
General Limitations continued
17
If you are covered by both this Plan and the Civilian Health and Medical Program of the Uniformed
Services (CHAMPUS), this Plan will pay benefits first. As a member of a prepaid plan, special
limitations on your CHAMPUS coverage apply; your primary provider must authorize all care. See
your CHAMPUS Health Benefits Advisor if you have questions about CHAMPUS coverage.

If you are covered by both this Plan and Medicaid, this Plan will pay benefits first.
The Plan will not pay for services required as the result of occupational disease or injury for which
any medical benefits are determined by the Office of Workers Compensation Program (OWCP) to
be payable under workers' compensation (under section 8103 of title 5, U. S. C.) or by a similar
agency under another Federal or State law. This provision also applies when a third party injury
settlement or other similar proceeding provides medical benefits in regard to a claim under workers'
compensation or similar laws. If medical benefits provided under such laws are exhausted, this Plan
will be financially responsible for services or supplies that are otherwise covered by this Plan. The
Plan is entitled to be reimbursed by OWCP (or the similar agency) for services it provided that were
later found to be payable by OWCP (or the agency).

Facilities of the Department of Veterans Affairs, the Department of Defense, and the Indian Health
Service are entitled to seek reimbursement from the Plan for certain services and supplies provided
to you or a family member to the extent that reimbursement is required under the Federal statutes
governing such facilities.

The Plan will not provide benefits for services and supplies paid for directly or indirectly by any
other local, State, or Federal Government agency.

If a covered person is sick or injured as a result of the act or omission of another person or party, the
Plan requires that it be reimbursed for the benefits provided in an amount not to exceed the amount
of the recovery, or that it be subrogated to the person's rights to the extent of the benefits received
under this Plan, including the right to bring suit in the person's name. If you need more information
about subrogation, the Plan will provide you with its subrogation procedures.

Care by non-Plan doctors or hospitals except for authorized referrals or emergencies (see
Emergency Benefits);

Expenses incurred while not covered by this Plan;
Services furnished or billed by a provider or facility barred from the FEHB Program;
Services not required according to accepted standards of medical, dental, or psychiatric practice;
Procedures, treatments, drugs, or devices that are experimental or investigational;
Procedures, services, drugs, and supplies related to sex transformations; and
Procedures, services, drugs, and supplies related to abortions except when the life of the mother
would be endangered if the fetus were carried to term or when the pregnancy is the result of an
act of rape or incest.

CHAMPUS
Medicaid
Workers' compensation

DVA facilities, DoD facilities,
and Indian Health Service

Other Government agencies

Liability insurance and third party
actions

General Exclusions
All benefits are subject to the limitations and exclusions in this brochure. Although a specific service may be listed as a benefit, it will
not be covered for you unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness or condition. The following are excluded: 17
17 Page 18 19
What is covered
18

A comprehensive range of preventive, diagnostic and treatment services is provided by Plan doctors
and other Plan providers. This includes all necessary office visits; you pay a $5 copay per visit.
Within the service area, house calls will be provided if in the judgment of the Plan doctor, such care
is necessary and appropriate; you pay a $10 copay for a doctor's house call, nothing for home visits
by nurses and health aides.

The following services are included and are subject to the office visit copay:
Preventive care, including well-baby care and periodic checkups.
Mammograms are covered as follows: for women age 35 through 39, one mammogram during
these five years; for women age 40 through 49, one mammogram every one or two years; for
women age 50 through 64, one mammogram every year; and for women age 65 and above, one
mammogram every two years. In addition to routine screening, mammograms are covered when
prescribed by the doctor as medically necessary to diagnose or treat your illness.

Routine immunizations and boosters.
Consultations by specialists.
Diagnostic procedures, including laboratory tests and Xrays.
Complete obstetrical (maternity) care for all covered females, including prenatal, delivery and
postnatal care by a Plan doctor (after the first visit, office visit copays are waived for obstetrical
care). The mother, at her option, may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a cesarean delivery. Inpatient stays will be extended if medically
necessary. If enrollment in the Plan is terminated during pregnancy, benefits will not be provided
after coverage under the Plan has ended. Ordinary nursery care of the newborn child during the
covered portion of the mother's hospital confinement for maternity will be covered under either a
Self Only or Self and Family enrollment; other care of an infant who requires definitive treatment
will be covered only if the infant is covered under a Self and Family enrollment.

Voluntary sterilization and family planning services, including Norplant implantations and IUD
insertions.

Diagnosis and treatment of diseases of the eye.
Allergy testing and treatment, including testing and treatment materials (such as allergy serum).
The insertion of internal prosthetic devices, such as pacemakers and artificial joints.
Cornea, heart, heart-lung, lung (single and double), skin, tissue, kidney, liver and pancreas
transplants; allogeneic (donor) bone marrow transplants; autologous bone marrow transplants
(autologous stem cell and peripheral stem cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's lymphoma; advanced non-Hodgkin's
lymphoma; advanced neuroblastoma; breast cancer; multiple myeloma; epithelial
ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors. Related
medical and hospital expenses of the donor are covered when the recipient is covered by the Plan.

Women who undergo mastectomies may, at their option, have this procedure performed on an
inpatient basis and remain in the hospital up to 48 hours after the procedure.

Dialysis.
Chemotherapy, radiation therapy, and inhalation therapy.
Surgical treatment of morbid obesity.
Durable medical equipment, such as wheelchairs and hospital beds, orthopedic devices, such as
braces, and prosthetic devices, such as artificial limbs, and lenses following cataract removal are
covered. Prosthetic devices which are worn externally and replace all or part of an internal body
organ or an external body part are covered. Coverage includes repair and replacement when due
to growth or normal wear and tear. Replacement, repairs and maintenance not provided for under
a manufacturer's warranty or purchase agreement will be covered.

Home health services of nurses and health aides, including intravenous fluids and medications,
when prescribed by your Plan doctor who will periodically review the program for continuing
appropriateness and need.

All necessary medical or surgical care in a hospital or extended care facility from Plan doctors
and other Plan providers, at no additional cost to you.

Medical and Surgical Benefits

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS. 18
18 Page 19 20
Limited benefits
What is not covered
19

Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects, such as cleft lip and cleft palate, and for medical or surgical procedures
occurring within or adjacent to the oral cavity or sinuses including, but not limited to, treatment of
fractures and excision of tumors and cysts and removal of bony-impacted wisdom teeth. All other
procedures involving the teeth or intra-oral areas surrounding the teeth are not covered, including
any dental care involved in treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an injury or surgery that has produced a major effect on the member's appearance and if the

condition can reasonably be expected to be corrected by such surgery.
Short-term rehabilitative therapy (physical, speech, occupational, and pulmonary) is provided on an outpatient basis for up to two consecutive months per condition if beginning with the first day of

treatment, significant improvement can be expected; you pay a $5 copay per visit. Speech therapy is
limited to treatment of certain speech impairments of organic origin. 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.

Diagnosis and treatment of infertility including artificial insemination are covered; you pay a $5 copay per visit. The following types of artificial insemination are covered: intravaginal insemination

(IVI), intracervical insemination (ICI), and intrauterine insemination (IUI). The cost of donor sperm
is not covered. Clomiphene Citrate is covered under the Prescription Drug Benefit. Injectable
fertility drugs are not covered. Artificial insemination or surgery for infertility must be
preauthorized. Member must contact the Infertility Program Case Manager at 1-800/ 575-5999
before these treatments are rendered. Infertility care is not covered when the female's follicle-stimulating
hormone (FHS) level is above 19 mIU/ ml.

Cardiac rehabilitation on an outpatient basis following angioplasty, cardiovascular surgery, congestive heart failure, or a myocardial infarction, is covered for up to three visits a week for a total

of 18 visits; you pay a $5 copay per visit.
Chiropractic services are provided for up to 20 visits per calendar year; you pay a $5 copay per visit.

Physical examinations that are not necessary for medical reasons, such as those required for
obtaining or continuing employment or insurance, attending school or camp, or travel.

Immunizations and boosters for travel or work-related exposure.
Reversal of voluntary, surgically-induced sterility.
Treatment for infertility when the cause of the infertility was a previous sterilization.
Surgery primarily for cosmetic purposes.
Homemaker services.
Hearing aids.
Transplants not listed as covered.
Long-term rehabilitative therapy.
Foot orthotics.
Dental implants.
Refractive eye surgery, such as radial keratotomy.
Blood and blood derivatives, except blood derived clotting factors, and the storage of the
patient's own blood for later administration.

Medical and Surgical Benefits continued

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS. 19
19 Page 20 21
What is covered Hospital care
Extended care
Hospice care
Ambulance service
Limited benefits Inpatient dental
procedures

Acute inpatient detoxification

What is not covered

The Plan provides a comprehensive range of benefits with no dollar or day limit when you are
hospitalized under the care of a Plan doctor. You pay nothing. All necessary services are covered,
including:

Semiprivate room accommodations; when a Plan doctor determines it is medically necessary, the
doctor may prescribe private accommodations or private duty nursing care.

Specialized care units, such as intensive care or cardiac care units.

The Plan provides a comprehensive range of benefits with no dollar or day limit when full-time
skilled nursing care is necessary and confinement in a skilled nursing facility is medically
appropriate as determined by a Plan doctor and approved by the Plan. You pay nothing. All
necessary services are covered, including:

Bed, board and general nursing care.
Drugs, biologicals, supplies, and equipment ordinarily provided or arranged by the skilled
nursing facility when prescribed by a Plan doctor.

Supportive and palliative care for a terminally ill member is covered in the home or hospice facility.
Services include inpatient and outpatient care, and family counseling; these services are provided
under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness,
with a life expectancy of approximately six months or less.

Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor.

Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a
need for hospitalization for reasons totally unrelated to the dental procedure; the Plan will cover the
hospitalization, but not the cost of the professional dental services. Conditions for which
hospitalization would be covered include hemophilia and heart disease; the need for anesthesia, by
itself, is not such a condition.

Hospitalization for medical treatment of substance abuse is limited to emergency care, diagnosis,
treatment of medical conditions, and medical management of withdrawal symptoms (acute
detoxification) if the Plan doctor determines that outpatient management is not medically
appropriate. See page 22 for nonmedical substance abuse benefits.

Personal comfort items, such as telephone and television.
Blood and blood derivatives, except blood derived clotting factors, and the storage of the
patient's own blood for later administration.

Custodial care, rest cures, domiciliary or convalescent care.

Hospital/ Extended Care Benefits

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS. 20
20 Page 21 22
What is a medical emergency?
Emergencies within the Service Area

Plan pays . . .
You pay . . .

Emergencies outside the Service Area

Plan pays . . .
You pay . . .

What is covered

What is not covered

Filing claims for non-Plan providers

A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate
medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies
because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that the Plan may
determine are medical emergencies what they all have in common is the need for quick action.
If you are in an emergency situation, please call your primary care doctor. In extreme emergencies or if you are unable to contact your doctor, contact the local emergency system (e. g., the 911

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

If you need to be hospitalized, the Plan must be notified as soon as possible. If you are hospitalized in non-Plan facilities and a Plan doctor believes care can be better provided in a Plan hospital, you
will be transferred when medically feasible with any ambulance charges covered in full.
Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition.

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

Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers.
$10 per after hours doctor's office visit; $35 per hospital emergency room or outpatient department visit, or per urgent care center visit for emergency services that are covered benefits of this plan. If
the emergency results in admission to a hospital, the copay is waived.
Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.

If you need to be hospitalized, the Plan must be notified as soon as possible. If a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically feasible with
any ambulance charges covered in full.
To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or provided by Plan providers.

Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers.
$10 per doctor's office visit; $35 per hospital emergency room or outpatient department visit, or per urgent care center visit for emergency services that are covered benefits of this plan. If the
emergency results in admission to a hospital, the copay is waived.
Emergency care at a doctor's office or an urgent care center.
Emergency care as an outpatient or inpatient at a hospital, including doctors' services.
Ambulance service approved by the Plan.

Elective care or nonemergency care.
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area.

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

With your authorization, the Plan will pay emergency benefits directly to the providers of your emergency care upon receipt of their claims. Physician claims should be submitted on the HCFA
1500 claim form. If you are required to pay for the services, submit itemized bills and your receipts to the Plan along with an explanation of the services and the identification information from your ID
card. Payment will be sent to you (or the provider if you did not pay the bill), unless the claim is denied. If it is denied, you will receive notice of the decision, including the reasons for the denial
and the provisions of the contract on which denial was based. If you disagree with the Plan's decision, you may request reconsideration in accordance with the disputed claims procedure
described on page 28.

Emergency Benefits 21
21 Page 22 23
Mental conditions What is covered
Outpatient care
Inpatient care
What is not covered

Substance Abuse What is covered

What is not covered

To the extent shown below, this Plan provides the following services necessary to the diagnosis and
treatment of acute psychiatric conditions, including the treatment of mental illness or disorders:

Diagnostic evaluation.
Psychological testing.
Psychiatric treatment (including individual and group therapy).
Hospitalization (including inpatient professional services).

Up to 40 outpatient visits to Plan doctors, consultants or other psychiatric personnel per calendar
year, you pay the following for up to 40 visits all charges thereafter:

Visits 1 and 2 nothing
Visits 3 10 a $10 copay per visit
Visits 11 40 a $25 copay per visit

Up to 35 days of hospitalization per calendar year; you pay nothing for the first 35 days all
charges thereafter. Inpatient days may be exchanged for outpatient treatment at a rate of four
outpatient visits or two partial treatment days for each inpatient day when approved by the Plan.

Care for psychiatric conditions which in the professional judgment of Plan doctors are not subject
to significant improvement through relatively short-term treatment.

Psychiatric evaluation or therapy on court order or as a condition of parole or probation, unless
determined by a Plan doctor to be necessary and appropriate.

Psychological testing when not medically necessary to determine the appropriate treatment of a
short-term psychiatric condition.

This Plan provides medical and hospital services such as acute detoxification services for the
medical, non-psychiatric aspects of substance abuse, including alcoholism and drug addiction, the
same as for any other illness or condition. Services for the psychiatric aspects are provided in
conjunction with the mental conditions benefit shown above. Outpatient visits to Plan mental health
providers for follow-up care and counseling are covered, as well as inpatient services necessary for
diagnosis and treatment. The mental conditions visit/ day limitations and copays apply.

Treatment that is not authorized by a Plan doctor.

Mental Conditions/ Substance Abuse Benefits

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS. 22
22 Page 23 24
What is covered
Limited benefits
Additional benefits

Prescription drugs prescribed by a Plan or referral doctor and obtained at a Participating Plan
Pharmacy will be dispensed for up to a 34-day supply. You pay a $5 copay for generic drugs or for
brand name drugs listed on the Plan's formulary and a $10 copay for nonformulary brand name
drugs per prescription unit or refill.

Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary.
The Plan's formulary does not exclude medications from coverage, but requires a higher copayment
for nonformulary drugs. Nonformulary drugs will be covered when prescribed by a Plan doctor.

Members may obtain up to a 90-day supply of certain maintenance type prescription medication
through a participating pharmacy or by mail order. You pay a $10 copay for generic or for brand
name maintenance drugs listed in the Plan's formulary and a $20 copay for nonformulary brand
name maintenance drugs. Nonformulary drugs will be covered when prescribed by a Plan doctor and
authorized by the Plan. Maintenance drugs are medications that are taken by the general population
for extended periods of time such as high blood pressure medications, and do not vary frequently in
terms of dosage. Specific maintenance type drugs that are available under this benefit are listed in
the Plan's formulary.

To obtain up to a 90-day supply under this benefit, you must first receive a 34-day supply of the
maintenance medication and have it filled at a participating pharmacy. Then, up to a 90-day supply
may be obtained as follows.

From a Participating Pharmacy:
Present a doctor authorized prescription for up to a 90-day supply to the pharmacist for filling.
Subsequent refills for up to a 90-day supply will be filled provided the strength and dosage
remain the same.

By mail order:
Call 1-800/ 537-9384 to obtain the necessary forms.
Mail the prescription for up to a 90-day supply, along with the appropriate copay, to the Mail
Order Pharmacy. Subsequent refills for up to a 90-day supply may be obtained the same way
provided the strength and dosage remain the same.

You have up to 45 days after finishing your previous supply (according to your doctor's prescribed
directions) to request a maintenance drug refill. Otherwise, the next refill will be considered an
initial prescription and covered up to a maximum 34-day supply.

Covered medications and accessories of the pharmacy benefit include:
Drugs for which a prescription is required by law.
Oral contraceptive drugs (you may be able to receive up to a 90-day supply through the
maintenance drug program).

Insulin.
Disposable needles and syringes needed to inject covered prescribed medication, including insulin.
Diabetic supplies limited to lancets, alcohol swabs, urine test strips/ tablets, and blood glucose test strips.
Clomiphene Citrate.
Intravenous fluids and medications for home use, implantable drugs, such as Norplant, IUDs and
some injectable drugs are covered under Medical and Surgical Benefits.

Drugs to treat sexual dysfunction are limited. Contact the Plan for dose limits. You pay a $15
copay up to the dosage limits and all charges above that.

Depo Provera, limited to five vials per calendar year. You pay a $10 copay per vial.

One diaphragm per calendar year. You pay a $5 copay.
Drugs obtained at a nonparticipating pharmacy for an out-of-area emergency (must be beyond a
50-mile radius of a participating pharmacy) are reimbursed at 100% of the cost of the
prescription, less the applicable copay. Reimbursements are subject to professional review.

Prescription Drug Benefits

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS. 23
23 Page 24 25
What is not covered
24

Drugs available without a prescription or for which there is a nonprescription equivalent
available.

Drugs obtained at a non-Plan pharmacy.
Vitamins and nutritional substances that can be purchased without a prescription.
Medical supplies such as dressings and antiseptics.
Drugs for cosmetic purposes.
Drugs to enhance athletic performance.
Smoking-cessation drugs and medication, including, but not limited to, nicotine patches and sprays.
Fertility drugs except Clomiphene Citrate.
Drugs used for the purpose of weight reduction (i. e. appetite suppressants).

Prescription Drug Benefits continued

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS. 24
24 Page 25 26
Dental care What is covered
What is not covered
25

The following dental services are covered when provided by your Plan primary care dentist. If you
should require additional dental services, your primary care dentist will provide these services at
reduced fees. A partial list appears below. Please consult your participating dentist for a complete
schedule of current reduced member fees. All member fees must be paid directly to the participating
dentist. You pay a $5 copay per visit for the following procedures:

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

Services not received from a participating dental provider.

Other Benefits
DIAGNOSTIC
Oral evaluations
All X rays
Diagnostic models

PREVENTIVE
Prophylaxis (cleaning of teeth)
every 6 months
Topical fluoride every 6 months
(child under age 18)
Oral hygiene instruction

RESTORATIVE (Fillings)
Amalgam (primary) 1 surface
Amalgam (primary) 2 surfaces
Amalgam (primary) 3 surfaces

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

PROSTHODONTICS REMOVABLE
Denture adjustments
(complete or partial/ upper or lower)

ENDODONTICS (Root Canal)
Pulp cap direct
Pulp cap indirect

You pay up to a
maximum
DIAGNOSTIC
Sealant per permanent tooth $32
Space maintainer $418

RESTORATIVE (Fillings)
Resin (anterior) 1 surface $79
Resin (anterior) 2 surfaces $105
Resin (anterior) 3 surfaces $131
Resin (anterior) 4 or more surfaces or
incisal angle $139
Metallic inlay $545

PROSTHODONTICS REMOVABLE
Complete denture (upper or lower) $770
Immediate denture (upper or lower) $834
Partial denture resin base (upper or lower) $593
Partial denture cast metal framework with
resin base (upper or lower) $901
Denture repairs $113
Add tooth to existing partial $100
Add clasp to existing partial $113
Denture rebase $285
Denture relines $245
Interim denture (complete or partial/
upper or lower) $349
Tissue conditioning $81

PROSTHODONTICS FIXED
Bridge pontic $645
Metallic inlay/ onlay $612

You pay up to a
maximum
PROSTHODONTICS FIXED (continued)
Cast metal retainer for resin bonded prosthesis $237
Crown porcelain $645
Crown cast $652
Recement bridge $62
Post and core $235

ORAL SURGERY
Extractions (nonsurgical and tissue impacted) $357
Anesthesia (general in office, first
half-hour session) $202

PERIODONTICS (Gum Treatment)
Gingivectomy per quadrant $236
Gingival curettage per quadrant $114
Periodontal surgery $570
Provisional splinting $118
Scaling and root planing per quadrant $114
Periodontal maintenance procedure $80

ENDODONTICS (Root Canal)
Therapeutic pulpotomy $93
Root canals (anterior, bicuspid, molar)
excluding final restoration $573
Apicoectomy anterior $382

ORTHODONTICS (Braces)
Pre-orthodontic treatment visit $263
Fully banded case (adult age 19 and over) $4,395
Fully banded case (child age 18 and under) $4,395

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS. 25
25 Page 26 27
Vision Care What is covered
What is not covered

In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of
the eye, the Plan provides the following vision care benefits when received from Plan providers.

Routine eye refraction based on the schedule below, including a written lens prescription. You
pay a $5 copay.

If member wears eyeglasses or contact lenses, an eye refraction may be obtained as follows:
Member age 1 through 18 once every 12-month period.
Member age 19 and over once every 24-month period.

If member does not wear eyeglasses or contact lenses, an eye refraction may be obtained as
follows:

Member to age 45 once every 36-month period.
Member age 45 and over once every 24-month period.

Up to $70 reimbursement per 24-month period for corrective eyeglasses and frames or contact
lenses (hard or soft lenses).

Eye exercises.
Fitting of contact lenses.

Other Benefits continued

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS. 26
26 Page 27 28
27
Non-FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program, but are made
available to all enrollees and family members of this Plan. The cost of the benefits described on this page is not included in the
FEHB premium and any charges for these services do not count toward any FEHB deductibles, or out-of-pocket maximums. These
benefits are not subject to the FEHB disputed claims procedure.

Member Health Management

Women's Health for Life Programs
Vision Care
National Medical Excellence Program

Medicare Prepaid Plan Enrollment

Our wellness and preventive programs provide you with access to materials and services to promote, in conjunction with advice from your physician, a healthy lifestyle and good health.
The new Healthy Eating TM Program is an easy-to-follow approach to better health through good nutrition. It's designed to provide members and their families with information to develop
a long-term healthful eating plan that is also realistic. Members will also understand how to lower the amount of fat in their diets and become more physically active.

Our Healthy Breathing Smoking-Cessation Program will help you safely quit smoking with educational materials, phone support and discounts on over-the-counter smoking-cessation
products. The member may also enroll in an eight-to twelve-week smoking-cessation program.

Our proactive programs encourage women to receive yearly primary and preventive gynecologic care with emphasis on cervical and breast cancer screening.
The L'il Appleseed Program provides risk screening and assistance for all pregnant members. We also offer special benefits such as educational literature about pregnancy and childbirth, $40
reimbursement for attending prenatal classes, nurse visits, and discounts on baby care products.
Our Infertility Program provides extensive help and services to enhance the chances of pregnancy for couples having difficulty conceiving.

You are eligible to receive substantial discounts on eyeglasses, contact lenses and nonprescription items such as sunglasses and contact lens solutions through the Vision One
Program (1-800-793-8616) at more than 6,000 locations across the country.
This discount enriches our routine vision care coverage, which includes an eye exam from a participating provider. Additionally, it may include coverage for a portion of the cost of

prescription eyeglasses or contact lenses.

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

Usually, the recommended treatment can be found in your area. But if your needs extend beyond your region, the National Medical Excellence Program may be available to send you to
out-of-area experts.
The first priority is to determine an appropriate treatment program. If your treatment program cannot be provided in the local area, Aetna U. S. Healthcare will arrange and pay for your care

as well as related travel expenses to wherever the necessary care is available.

This Plan offers Medicare recipients (except for those enrolled in codes 3G, 6F, 6J, 8L, 8V, 8Z, NK, V8, Z1, NE, UJ, and 5U) the opportunity to enroll in the Plan through Medicare. As
indicated on page 4, annuitants and former spouses with FEHB coverage and Medicare Part B may elect to drop their FEHB coverage and enroll in a Medicare prepaid plan when one is
available in their area. They may then later reenroll in the FEHB Program. Most Federal annuitants have Medicare Part A. Those without Medicare Part A may join this Medicare
prepaid plan but will probably have to pay for hospital coverage in addition to the Part B premium. Before you join the plan, ask whether the plan covers hospital benefits and, if so,
what you will have to pay. Contact your retirement system for information on dropping your FEHB enrollment and changing to a Medicare prepaid plan. Contact us at 1-800/ 832-2640 for
information on the Medicare prepaid plan and the cost of that enrollment.
If you are Medicare eligible and are interested in enrolling in a Medicare HMO sponsored by this Plan without dropping your enrollment in this Plan's FEHB plan, call 1-800/ 832-2640 for

information on the benefits available under the Medicare HMO.

Benefits on this page are not part of the FEHB contract. 27
27 Page 28 29
Questions
Disputed claims review Plan
reconsideration

OPM review

If you have a question concerning Plan benefits or how to arrange for care, contact the Plan's
Membership Services Office at 1-800/ 537-9384 or 1-800/ 628-3323 (Hearing Impaired-TDD), or you
may write to the Plan at 1425 Union Meeting Road, P. O. Box 3013, Blue Bell, PA 19422. You may
also contact the Plan by fax at 1-215/ 775-5870 or at its website at http:// www. aetnaushc. com/ feds.

If a claim for payment or services is denied by the Plan, you must ask the Plan, in writing and within
six months of the date of the denial, to reconsider its denial before you request a review by OPM.
(This time limit may be extended if you show you were prevented by circumstances beyond your
control from making your request within the time limit.) OPM will not review your request unless
you demonstrate that you gave the Plan an opportunity to reconsider your claim. Your written
request to the Plan must state why, based on specific benefit provisions in this brochure, you believe
the denied claim for payment or service should have been paid or provided.

Within 30 days after receipt of your request for reconsideration, the Plan must affirm the denial in
writing to you, pay the claim, provide the service, or request additional information reasonably
necessary to make a determination. If the Plan asks a provider for information it will send you a
copy of this request at the same time. The Plan has 30 days after receiving the information to give its
decision. If this information is not supplied within 60 days, the Plan will base its decision on the
information it has on hand.

If the Plan affirms its denial, you have the right to request a review by OPM to determine whether
the Plan's actions are in accordance with the terms of its contract. You must request the review
within 90 days after the date of the Plan's letter affirming its initial denial.

You may also ask OPM for a review if the Plan fails to respond within 30 days of your written
request for reconsideration or 30 days after you have supplied additional information to the Plan. In
this case, OPM must receive a request for review within 120 days of your request to the Plan for
reconsideration or of the date you were notified that the Plan needed additional information, either
from you or from your doctor or hospital.

This right is available only to you or the executor of a deceased claimant's estate. Providers, legal
counsel, and other interested parties may act as your representative only with your specific written
consent to pursue payment of the disputed claim. OPM must receive a copy of your written consent
with their request for review.

Your written request for an OPM review must state why, based on specific benefit provisions in this
brochure, you believe the denied claim for payment or service should have been paid or provided. If
the Plan has reconsidered and denied more than one unrelated claim, clearly identify the documents
for each claim.

Your request must include the following information or it will be returned by OPM:
A copy of your letter to the Plan requesting reconsideration;
A copy of the Plan's reconsideration decision (if the Plan failed to respond, provide instead (a)
the date of your request to the Plan, or (b) the dates the Plan requested and you provided
additional information to the Plan);

Copies of documents that support your claim (such as doctors' letters, operative reports, bills,
medical records, and explanation of benefit (EOB) forms); and

Your daytime phone number.
Medical documentation received from you or the Plan during the review process becomes a
permanent part of the disputed claim file, subject to the provisions of the Freedom of Information
Act and the Privacy Act.

Send your request for review to:
Office of Personnel Management
Office of Insurance Programs
Contracts Division IV
P. O. Box 436
Washington, D. C. 20044

You (or a person acting on your behalf) may not bring a lawsuit to recover benefits on a claim for
treatment, services, supplies or drugs covered by this Plan until you have exhausted the OPM review
procedure, established at section 890.105, title 5, Code of Federal Regulations (CFR). If OPM upholds

How to Obtain Benefits 28
28 Page 29 30
Program-wide changes
Changes to this Plan

the Plan's decision on your claim, and you decide to bring a lawsuit based on the denial, the lawsuit
must be brought no later than December 31 of the third year after the year in which the services or
supplies upon which the claim is predicated were provided. Pursuant to section 890.107, title 5,
CFR, such a lawsuit must be brought against the Office of Personnel Management in Federal court.

Federal law exclusively governs all claims for relief in a lawsuit that relates to this Plan's benefits or
coverage or payments with respect to those benefits. Judicial action on such claims is limited to the
record that was before OPM when it rendered its decision affirming the Plan's denial of the benefit.
The recovery in such a suit is limited to the amount of benefits in dispute.

Privacy Act statement If you ask OPM to review a denial of a claim for payment or service, OPM is authorized by chapter 89 of title 5, U. S. C., to use the information collected from you and the

Plan to determine if the Plan has acted properly in denying you the payment or service, and the
information so collected may be disclosed to you and/ or the Plan in support of OPM's decision on
the disputed claim.

Several changes have been made to comply with the President's mandate to implement the
recommendations of the Patient Bill of Rights.

If you have a chronic, complex, or serious medical condition that causes you to frequently see a
Plan specialist, your primary care doctor will develop a treatment plan with you and your health
Plan that allows an adequate number of direct access visits with that specialist, without the need
to obtain further referrals (see page 8 for details).

A medical emergency is defined as the sudden and unexpected onset of a condition or an injury
that you believe endangers your life or could result in serious injury or disability, and requires
immediate medical or surgical care (see page 21).

The medical management of mental conditions will be covered under this Plan's Medical and
Surgical Benefits provisions. Related drug costs will be covered under this Plan's Prescription
Drug Benefits, and any costs for psychological testing or psychotherapy will be covered under
this Plan's Mental Conditions Benefits. Office visits for the medical aspects of treatment do not
count toward the 40 outpatient Mental Conditions visit limit.

Infertility benefits have decreased. In Vitro Fertilization (IVF), Zygote Intra-Fallopian Transfer
(ZIFT) and Gamete Intra-Fallopian Transfer (GIFT) procedures are excluded.

There is a $10 copay applied to each vial of Depo Provera.
The office visit copay for dental care is $5.
The copays for various dental procedures have changed. See page 25.

How to Obtain Benefits continued
How Aetna U. S. Healthcare Changes January 1999 Do not rely on this page; it is not an official statement of benefits. 29
29 Page 30 31
Notes 30
30 Page 31 32
Notes 31
31 Page 32 33
32
Summary of Benefits for Aetna U. S. Healthcare 1999
Do not rely on this chart alone. All benefits are provided in full unless otherwise indicated, subject to the limitations and exclusions set
forth in the brochure. This chart merely summarizes certain important expenses covered by the Plan. If you wish to enroll or change your
enrollment in this Plan, be sure to indicate the correct enrollment code on your enrollment form (codes appear on pages 9 16 of this
brochure). ALL SERVICES COVERED UNDER THIS PLAN, WITH THE EXCEPTION OF EMERGENCY CARE, ARE
COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS.

Benefits Plan pays/ provides Page
Inpatient Hospital care

Extended care
Mental conditions

Substance abuse

Outpatient care

Home health care
Mental conditions

Substance abuse
Emergency care

Prescription drugs

Dental care
Vision care
Out-of-pocket maximum

Comprehensive range of medical and surgical services without dollar or day limit. Includes
in-hospital doctor care, room and board, general nursing care, private room and private
nursing care if medically necessary, diagnostic tests, drugs and medical supplies, use of
operating room, intensive care and complete maternity care. You pay nothing .....................

All necessary services, no dollar or day limit. You pay nothing.............................................
Diagnosis and treatment of acute psychiatric conditions for up to 35 days of inpatient care
per calendar year. You pay nothing.........................................................................................

Covered under mental conditions benefit ................................................................................

Comprehensive range of services such as diagnosis and treatment of illness or injury,
including specialist care; preventive care, including well-baby care, periodic check-ups
and routine immunizations; laboratory tests and X rays; complete maternity care. You pay
a $5 copay per visit (after the first visit, office visit copays are waived for the maternity
care); $10 copay per house call by a doctor.............................................................................

All medically necessary visits by nurses and health aides. You pay nothing .........................

Up to 40 outpatient visits per calendar year. You pay the following......................................
Visits 1 and 2 covered in full
Visits 3 10 a $10 copay per visit
Visits 11 40 a $25 copay per visit

Covered under mental conditions benefit ................................................................................

Reasonable charges for services required because of a medical emergency. You pay a
$10 copay after hours at a primary doctor's office; a $35 copay to the hospital for each
emergency room visit and any charges for services that are not covered by this Plan..............

Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy. You pay a $5 copay
for generic drugs or formulary brand name drugs and a $10 copay for nonformulary brand
name drugs per prescription unit or refill. Maintenance type drugs are available for up to a
90-day supply; you pay a $10 copay for generic drugs or formulary brand name drugs and
a $20 copay for nonformulary drugs........................................................................................

Preventive dental care, comprehensive range of restorative, orthodontic and other services.
You pay variable copays..........................................................................................................

Routine refraction and up to $70 for eyeglasses or contact lenses per 24-month period; you
pay a $5 copay per visit ...........................................................................................................

Copayments are required for a few benefits; however, after your out-of-pocket expenses
reach a maximum of 100% of annual premium per Self Only enrollment or 100% of annual
premium per Self and Family enrollment per calendar year, covered benefits will be
provided at 100%. This copay maximum does not include prescription drugs .......................

20
20

22
22

18
18

22
21

23
25
26

8 32
32 Page 33 34
33
1999 Rate Information for Aetna U. S. Healthcare
Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category, refer to the FEHBGuide for that category or contact the agency that maintains your health benefits enrollment.
Postal ratesapply to most career U. S. Postal Service employees, but do not apply to noncareer Postal employees, Postal retirees, certain special Postal employment categories or associate members of any Postal employee organization. If you are in a special
Postal employment category, refer to the FEHBGuide for that category.

Postal Premium
Biweekly
Non-Postal Premium
Biweekly Monthly

Gov't Your Gov't Your USPS Your
Type of Enrollment Code Share Share Share Share Share Share

Self Only WQ1 $57.29 $19.10 $124.13 $41.38 $67.80 $8.59
Self and Family WQ2 $160.39 $54.23 $347.51 $117.50 $183.29 $31.33

Arizona: Phoenix and Tuscon Areas

Self Only BU1 $72.06 $28.32 $156.13 $61.36 $84.98 $15.40
Self and Family BU2 $160.39 $64.85 $347.51 $140.51 $183.29 $41.95

California: Northern California and Central Valley

Self Only 2X1 $62.93 $20.98 $136.36 $45.45 $74.47 $9.44
Self and Family 2X2 $147.27 $49.09 $319.09 $106.36 $174.27 $22.09

California: Southern California

Self Only 6F1 $55.34 $18.45 $119.91 $39.97 $65.49 $8.30
Self and Family 6F2 $147.35 $49.12 $319.27 $106.42 $174.37 $22.10

Colorado: The Front Range

Self Only H11 $72.06 $37.38 $156.13 $80.99 $84.98 $24.46
Self and Family H12 $160.39 $133.89 $347.51 $290.10 $183.29 $110.99

Connecticut: All of Connecticut

Self Only NK1 $72.06 $47.62 $156.13 $103.18 $84.98 $34.70
Self and Family NK2 $160.39 $171.74 $347.51 $372.11 $183.29 $148.84

Delaware: All of Delaware

12921-9/ 98 33
33 Page 34 35
34
Self Only 8A1 $72.06 $26.69 $156.13 $57.83 $84.98 $13.77
Self and Family 8A2 $160.39 $113.51 $347.51 $245.94 $183.29 $90.61

Florida: Central and South Florida

Self Only 2U1 $62.66 $20.88 $135.75 $45.25 $74.14 $9.40
Self and Family 2U2 $160.39 $54.98 $347.51 $119.13 $183.29 $32.08

Georgia: Atlanta/ Augusta/ Athens/ Macon Areas

Self Only XC1 $53.63 $17.88 $116.21 $38.73 $63.47 $8.04
Self and Family XC2 $160.39 $65.32 $347.51 $141.53 $183.29 $42.42

Illinois/ Indiana: Chicago Area/ Lake and Porter counties

Self Only RD1 $72.01 $24.00 $156.02 $52.00 $84.98 $11.03
Self and Family RD2 $160.39 $74.60 $347.51 $161.64 $183.29 $51.70

Kentucky/ Indiana/ Ohio: Lexington and Louisville/ Southern Indiana/ Most of Ohio

Self Only TK1 $50.07 $16.69 $108.49 $36.16 $59.25 $7.51
Self and Family TK2 $160.39 $56.54 $347.51 $122.51 $183.29 $33.64

Louisiana: Baton Rouge and Lafayette Areas

Self Only NG1 $60.60 $20.20 $131.30 $43.77 $71.71 $9.09
Self and Family NG2 $157.55 $52.52 $341.36 $113.79 $183.29 $26.78

Louisiana: New Orleans Area

Self Only V81 $72.06 $34.25 $156.13 $74.21 $84.98 $21.33
Self and Family V82 $160.39 $99.46 $347.51 $215.50 $183.29 $76.56

Maryland/ Washington, D. C./ Virginia: Northern and Central Maryland/ Washington, D. C./
Northern Virginia

Self Only NE1 $72.06 $33.99 $156.13 $73.65 $84.98 $21.07
Self and Family NE2 $160.39 $126.08 $347.51 $273.18 $183.29 $103.18

Massachusetts: Eastern/ Central Massachusetts and Hampden County

Postal Premium
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Gov't Your Gov't Your USPS Your
Type of Enrollment Code Share Share Share Share Share Share 34
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Gov't Your Gov't Your USPS Your
Type of Enrollment Code Share Share Share Share Share Share

Self Only 8Z1 $62.03 $20.67 $134.39 $44.79 $73.40 $9.30
Self and Family 8Z2 $160.39 $55.36 $347.51 $119.95 $183.29 $32.46

Michigan: Greater Detroit Metropolitan Area

Self Only 8L1 $56.60 $18.86 $122.63 $40.87 $66.97 $8.49
Self and Family 8L2 $148.21 $49.40 $321.12 $107.04 $175.38 $22.23

Nevada: Southern Nevada and Las Vegas Area

Self Only UJ1 $70.42 $23.47 $152.57 $50.86 $83.33 $10.56
Self and Family UJ2 $160.39 $90.45 $347.51 $195.98 $183.29 $67.55

New Hampshire: Portions of New Hampshire

Self Only JC1 $69.26 $23.08 $150.05 $50.02 $81.95 $10.39
Self and Family JC2 $160.39 $73.44 $347.51 $159.12 $183.29 $50.54

New York: New York City Area

Self Only 3G1 $64.32 $21.44 $139.36 $46.45 $76.11 $9.65
Self and Family 3G2 $160.39 $63.73 $347.51 $138.08 $183.29 $40.83

North and South Carolina: The Charlotte/ MetrolinaArea/ Portions of South Carolina

Self Only 8V1 $57.09 $19.03 $123.70 $41.23 $67.56 $8.56
Self and Family 8V2 $149.06 $49.68 $322.95 $107.65 $176.38 $22.36

Oklahoma: Northeast Oklahoma

Self Only 5U1 $56.17 $18.72 $121.70 $40.56 $66.46 $8.43
Self and Family 5U2 $152.25 $50.75 $329.87 $109.96 $180.16 $22.84

Rhode Island: All of Rhode Island

Self Only 6J1 $48.58 $16.19 $105.26 $35.08 $57.48 $7.29
Self and Family 6J2 $135.17 $45.05 $292.86 $97.62 $159.95 $20.27

Tennessee: Nashville and Middle Tennessee 35
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Gov't Your Gov't Your USPS Your
Type of Enrollment Code Share Share Share Share Share Share

Self Only TS1 $56.76 $18.92 $122.98 $40.99 $67.17 $8.51
Self and Family TS2 $160.39 $108.22 $347.51 $234.48 $183.29 $85.32

Texas: Dallas/ Ft. Worth Area

Self Only 5B1 $72.06 $24.65 $156.13 $53.41 $84.98 $11.73
Self and Family 5B2 $160.39 $110.00 $347.51 $238.34 $183.29 $87.10

Texas: Houston Area

Self Only 8X1 $69.90 $23.30 $151.45 $50.48 $82.72 $10.48
Self and Family 8X2 $160.39 $100.30 $347.51 $217.32 $183.29 $77.40

Texas: San Antonio Area

Self Only Z11 $70.58 $23.53 $152.93 $50.98 $83.52 $10.59
Self and Family Z12 $160.39 $75.93 $347.51 $164.52 $183.29 $53.03

Virginia: Richmond/ Central/ Tri-City Areas

Self Only 8J1 $57.97 $19.32 $125.60 $41.86 $68.59 $8.70
Self and Family 8J2 $151.79 $50.59 $328.87 $109.62 $179.61 $22.77

Washington: Western and Southeast Washington 36

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