Pages 1--45 from

Aetna U S Healthcare 2000 A Health Maintenance Organization
Enrollment in this Plan is limited see page 7 for requirements
Servicing the following states
Arizona Kentucky North Carolina California Louisiana Ohio

Colorado Maine Oklahoma Connecticut Massachusetts Rhode Island
Delaware Michigan Tennessee Georgia Missouri Texas
Illinois Nevada Virginia Indiana New York Washington
Kansas

Special Notice The Plan has eliminated a portion of its service area for 2000 If you are enrolled under
code 8A in Florida or code UJ in New Hampshire or 3G and live in South Carolina or 6J and live in the Tennessee county of Montgomery you must select a new plan If you do not select a new plan your benefits

will be limited to emergency care
New service areas have been added in portions of Illinois Kansas Missouri and all of Maine The service area has increased in portions of Arizona Massachusetts Oklahoma and Washington

Aetna U S Healthcare provides benefits in Pennsylvania New Jersey Maryland Washington DC and Northern Virginia If you are enrolled in code V8 your enrollment will be transferred to the Plan's
enrollment code JN High Option See the Plan's Federal brochure RI73 052 for a complete description

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

Authorized for distribution by the
United States Office of
Personnel Management
RI 73 778 1
1 Page 2 3

Table of Contents
Page

Introduction 3
Plain language 3
How to use this brochure 3
Section 1 Health Maintenance Organizations 4
Section 2 How we change for 2000 4 6
Section 3 How to get benefits 7 16
Section 4 What to do if we deny your claim or request for service 17 19
Section 5 Benefits 20 31
Section 6 General exclusions Things we don't cover 32
Section 7 Limitations Rules that affect your benefits 32 33
Section 8 FEHB FACTS 34 37
Department of Defense FEHB Demonstration Project 38 39
Inspector General Advisory Stop Health Care Fraud 39
Summary of benefits 40
Premiums 41 45 2
2 Page 3 4
Introduction
Aetna U S Healthcare Inc
1425 Union Meeting Road
P O Box 3013
Blue Bell PA 19422

This brochure describes the benefits you can receive from Aetna U S Healthcare under its contract CS2836 with the Office of
Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law This brochure is the official
statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you
are enrolled for Self and Family coverage each eligible family member is also entitled to these benefits

OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on page
4 Premiums are listed at the end of this brochure

Plain language
The President and Vice President are making the Government's communication more responsive accessible and understandable to
the public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have
worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary
technical terms you and other personal pronouns active voice and short sentences

We refer to Aetna U S Healthcare as this Plan throughout this brochure even though in other legal documents you will see a plan
referred to as a carrier

These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year

How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits
with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier

1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how
they work

2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not to
pay for your claim or to deny your request for a service

5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find information
about non FEHB benefits

6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB FACTS Read this for information about the Federal Employees Health Benefits FEHB Program

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Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and
other providers that contract with us These providers coordinate your health care services The care you receive includes preventative
care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury

When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay
copayments and coinsurance listed in this brochure When you receive emergency services you may have to submit claim forms

You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change
plans because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will be available
and or remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of
treatment

Section 2 How we change for 2000
Program wide changes To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care office visits

This year you have a right to more information about this Plan care management our networks
facilities and providers

If you have a chronic or disabling condition and your provider leaves the Plan at our request you
may continue to see your specialist for up to 90 days If your provider leaves the Plan and you are
in the second or third trimester of pregnancy you may be able to continue seeing your OB GYN
until the end of your postpartum care You have similar rights if this Plan leaves the FEHB
program See Section 3 How to get benefits for more information

You may review and obtain copies of your medical records on request If you want copies of your
medical records ask your health care provider for them You may ask that a physician amend a
record that is not accurate not relevant or incomplete If the physician does not amend your
record you may add a brief statement to it If they do not provide you your records call us and we
will assist you

If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years
This screening is for colorectal cancer

Changes to this Plan If you are enrolled in Code V8 your enrollment will be transferred to the Plan enrollment code JN High Option See the Plan's Federal Brochure RI 173 052 for a complete description
The following areas have been eliminated from the Plan's service area Code 8A in Florida
Code UJ in New Hampshire Code 3G South Carolina only and Montgomery County in Code
6J Tennessee

All oral fertility drugs are now covered under the Prescription Drug Benefit
You now pay 5 for generic formulary 10 for brand name formulary and 25 for nonformulary
drugs per prescription up to a 30 day supply

You now pay a 50 copay for drugs used to treat sexual dysfunction

Diaphragms now require a 10 copay
All prescriptions over 30 days must now be filled through the mail order program A 31 to
90 day supply is available You pay a copay of two times the amount for a 30 day supply

You now receive up to a 100 reimbursement per 24 month period for corrective eyeglasses and
frames or contact lenses

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Section 2 How we change for 2000 continued
The maximum fees you pay for various dental procedures has changed See page 29
Arizona Code WQ Your share of the non postal premium will decrease by 0.5 for Self Only
or decrease by 1.4 for Self and Family

California Code BU Your share of the non postal premium will increase by 19.8 for Self
Only or increase by 18.0 for Self and Family

California Code 2X Your share of the non postal premium will decrease by 3.8 for Self Only
or decrease by 4.0 for Self and Family

Colorado Code 6F Your share of the non postal premium will increase by 6.6 for Self Only
or increase by 5.8 for Self and Family

Connecticut Code H1 Your share of the non postal premium will decrease by 9.6 for Self
Only or decrease by 5.0 for Self and Family

Delaware Code NK Your share of the non postal premium will increase by 45.5 for Self
Only or increase by 32.5 for Self and Family

Georgia Code 2U Your share of the non postal premium will increase by 13.1 for Self Only
or increase by 22.7 for Self and Family

Illinois Code XC Your share of the non postal premium will decrease by 2.0 for Self Only or
decrease by 15.0 for Self and Family

Indiana Code XC Your share of the non postal premium will decrease by 2.0 for Self Only
or decrease by 15.0 for Self and Family

Indiana Code RD Your share of the non postal premium will increase by 8.6 for Self Only or
increase by 10.1 for Self and Family

Kentucky Code RD Your share of the non postal premium will increase by 8.6 for Self Only
or increase by 10.1 for Self and Family

Louisiana Code TK Your share of the non postal premium will increase by 6.2 for Self Only
or increase by 2.3 for Self and Family

Louisiana Code NG Your share of the non postal premium will increase by 12.5 for Self
Only or increase by 15.0 for Self and Family

Maine Code 9M Your share of the non postal premium will increase by 59.3 for Self Only or
increase by 57.4 for Self and Family

Massachusetts Code NE Your share of the non postal premium will increase by 10.5 for Self
Only or increase by 5.6 for Self and Family

Michigan Code 8Z Your share of the non postal premium will increase by 3.3 for Self Only
or increase by 0.6 for Self and Family

Nevada Code 8L Your share of the non postal premium will decrease by 2.7 for Self Only or
decrease by 2.7 for Self and Family

New York Code JC Your share of the non postal premium will increase by 6.4 for Self Only
or decrease by 3.4 for Self and Family

North Carolina Code 3G Your share of the non postal premium will increase by 1.8 for Self
Only or decrease by 11.1 for Self and Family

Ohio Code RD Your share of the non postal premium will increase by 8.6 for Self Only or
increase by 10.1 for Self and Family

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Section 2 How we change for 2000 continued
Oklahoma Code 8V Your share of the non postal premium will decrease by 6.6 for Self Only
or decrease by 7.4 for Self and Family

Rhode Island Code 5U Your share of the non postal premium will decrease by 0.5 for Self
Only or decrease by 2.9 for Self and Family

Tennessee Code 6J Your share of the non postal premium will increase by 15.8 for Self Only
or increase by 15.9 for Self and Family

Texas Code TS Your share of the non postal premium will increase by 29.8 for Self Only or
decrease by 8.1 for Self and Family

Texas Code 5B Your share of the non postal premium will decrease by 11.3 for Self Only or
decrease by 37.2 for Self and Family

Texas Code 8X Your share of the non postal premium will decrease by 19.2 for Self Only or
decrease by 47.4 for Self and Family

Virginia Code Z1 Your share of the non postal premium will increase by 8.2 for Self Only or
increase by 5.1 for Self and Family

Washington Code 8J Your share of the non postal premium will decrease by 5.3 for Self
Only or decrease by 5.3 for Self and Family

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Section 3 How to get benefits
What is this Plan's service To enroll with us you must live or work in our service area This is where our providers practice
area Our service area is

Arizona Serving Phoenix and Tucson areas
Enrollment Code
WQ1 Self Only

12 98 WQ2 Self and Family
This service has full Cochise Graham Maricopa Pima Santa Cruz Yavapai and Yuma counties and portions of Pinal
accreditation from the NCQA as defined by the towns of Apache Junction and Casa Grande
See the FEHB Guide for more
information on NCQA

California Serving Northern California area
Enrollment Code
BU1 Self Only

6 99 BU2 Self and Family
This service has full Alameda Contra Costa Fresno Madera Marin Napa Sacramento San Francisco San Mateo
accreditation from the NCQA Santa Clara Santa Cruz Solano Sonoma Stanislaus and Yolo counties and portions of El
See the FEHB Guide for more Dorado Kings Merced Placer San Joaquin and Tulare counties defined by listed towns
information on NCQA

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
Enrollment Code

11 96 2X1 Self Only
This service has full 2X2 Self and Family
accreditation from the NCQA Kern Los Angeles Orange Riverside San Bernardino San Diego Santa Barbara and Ventura
See the FEHB Guide for more counties
information on NCQA

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Section 3 How to get benefits continued
Colorado 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

Connecticut Serving All of Connecticut
Enrollment Code
H11 Self Only

11 98 H12 Self and Family
This service has full The State of Connecticut
accreditation from the NCQA
See the FEHB Guide for more
information on NCQA

Delaware Serving All of Delaware
Enrollment Code
NK1 Self Only

11 97 NK2 Self and Family
This service has full The State of Delaware
accreditation from the NCQA
See the FEHB Guide for more
information on NCQA

Georgia 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

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Section 3 How to get benefits continued
Illinois Serving The Chicago area
Enrollment Code
XC1 Self Only

11 96 XC2 Self and Family
This service has full Cook DuPage Kane Lake McHenry and Will counties
accreditation from the NCQA
See the FEHB Guide for more
information on NCQA Serving The Metropolitan St Louis area

Enrollment Code
6T1 Self Only
6T2 Self and Family

Madison and St Clair counties

Indiana 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

Kansas Serving Kansas City Metropolitan area
Enrollment Code
7K1 Self Only
7K2 Self and Family

Douglas Franklin Johnson Leavenworth Miami and Wyandotte counties

Kentucky Serving Lexington and Louisville
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

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Section 3 How to get benefits continued
Louisiana 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

Maine Serving All of Maine
Enrollment Code
9M1 Self Only
9M2 Self and Family

The State of Maine

Massachusetts 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 Franklin Hampden
Hampshire Middlesex Norfolk Plymouth Suffolk and Worcester counties

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Section 3 How to get benefits continued
Michigan 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

Missouri Serving Metropolitan Kansas City and Metropolitan St Louis area
Enrollment Code
6T1 Self Only
6T2 Self and Family

Buchanan Cass Clay Jackson Jefferson Lafayette Platte Ray St Charles St Louis City and
St Louis counties

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

Clark county

New York Serving New York City area
Enrollment Code
JC1 Self Only

1 98 JC2 Self and Family
This service has full Bronx Dutchess Kings Brooklyn Nassau New York Manhattan Orange Putnam Queens
accreditation from the NCQA Richmond Staten Island Rockland Suffolk Sullivan Ulster and Westchester counties
See the FEHB Guide for more
information on NCQA

North Carolina Serving The Charlotte Metrolina area
Enrollment Code
3G1 Self Only
3G2 Self and Family

Cabarrus Gaston Iredell Lincoln Mecklenberg Rowan Stanly and Union counties

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Section 3 How to get benefits continued
Ohio Serving Most of Ohio
Enrollment Code
RD1 Self Only

4 99 RD2 Self and Family
This service has full Adams Allen Ashland Ashtabula Brown Butler Carroll Champaign Clark Clermont Clinton
accreditation from the NCQA Coshocton Crawford Cuyahoga Delaware Erie Fairfeld Fayette Franklin Geauga Greene
See the FEHB Guide for more Guernsey Hamilton Highland Hocking Holmes Knox Lake Licking Logan Lorain Lucas
information on NCQA 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

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

Cleveland Oklahoma Pottawatomie Rogers and Tulsa counties and portions of the following
counties defined by listed towns

Canadian Concho El Reno Mustang Piedmont Union City and Yukon
Creek Kellyville Kiefer Mounds Sapulpa
Grady Amber Minco and Tuttle
Lincoln Fallis Jacktown Meeker Midway Payson Sparks and Wellston
Logan Cedar Valley Coyle Guthrie Meridian Mulhall Navina and Seward
McClain Blanchard Byars Cole Criner Dibble Goldsby Newcastle Purcell Rosedale and
Washington

Osage Skiatook Osage Prue
Wagoner Choska Coweta Fair Oaks New Tulsa Oneta

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Section 3 How to get benefits continued
Rhode Island Serving All of Rhode Island
Enrollment Code
5U1 Self Only
5U2 Self and Family

The State of Rhode Island

Tennessee 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 Moore Perry Robertson
Rutherford Smith Sumner Trousdale Wayne Williamson and Wilson counties

Texas Serving Dallas Fort Worth area
Enrollment Code
TS1 Self Only

9 97 TS2 Self and Family
This service has full Collin Dallas Denton Ellis Erath Hood Hunt Kaufman Palo Pinto Rockwall Somervell and
accreditation from the NCQA Tarrant counties and portions of the following counties defined by listed towns
See the FEHB Guide for more
information on NCQA 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

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Section 3 How to get benefits continued
Texas continued Serving Houston area
Enrollment Code
5B1 Self Only

10 97 5B2 Self and Family
This service has full Brazoria Chambers Ft Bend Galveston Grimes Harris Jefferson Liberty Matagorda
accreditation from the NCQA Montgomery San Jacinto Walker Waller and Wharton counties
See the FEHB Guide for more
information on NCQA

Serving San Antonio area

Enrollment Code
8X1 Self Only
8X2 Self and Family

Bexar Comal Guadelupe and Kendall counties

Virginia Serving The Richmond Central and Tri City area
Enrollment Code
Z11 Self Only
Z12 Self and Family

Charles Chesterfield Colonial Heights Dinwiddie Goochland Hanover Henrico Hopewell
King William New Kent Nottaway Petersburg Powhattan and Richmond counties

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

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

Clallam Port Angeles Sequim
Skagit Anacortes

Ordinarily you must get your care from providers who contract with us If you receive care
outside our service area we will pay for emergency care

If you need to visit a participating primary care physician for a covered service and you are 50
miles or more away from home you may visit a primary care physician from our Plan's approved
HMO network

Call 1 800 537 9384 for provider information and location
Select a doctor from three primary care doctors in that area
The Plan will authorize you for one visit and any tests or X rays ordered by that primary care
physician

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

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Section 3 How to get benefits continued
You must pay a 10 copay for each visit
You can use this benefit for the first 30 days you are away from home
If you or a covered family member move outside of our service area you can enroll in another
plan If you or a family member move you do not have to wait until Open Season to change plans
Contact your employing or retirement office

How much do I pay for You must share the cost of some services This is called either a copayment a set dollar amount
services or coinsurance a set percentage of charges Please remember you must pay this amount when you receive services

Do I have to submit You normally won't have to submit claims to us unless you receive emergency services from a
claims provider who doesn't contract with us If you file a claim please send us all of the documents for your claim as soon as possible You must submit claims by December 31 of the year after the year

you received the service Either OPM or we can extend this deadline if you show that
circumstances beyond your control prevented you from filing on time

Who provides my health This is a direct contract prepayment Plan which means that participating providers are neither
care agents nor employees of the Plan Rather they are independent doctors and providers who practice in their own offices or facilities The Plan arranges with licensed providers and hospitals

to provide medical services for both the prevention of disease and the treatment of illness and
injury for benefits covered under the Plan

When you first join the Plan you must choose a primary care doctor for you and each covered
member of your family You may select your primary care physician from a list of family or
general practitioners pediatricians or medical internists For women 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

What do I do if my Call us We will help you select a new one
primary care physician
leaves the Plan

What do I do if I need to Talk to your Plan physician If you need to be hospitalized your primary care physician or
go into the hospital specialist will make the necessary hospital arrangements and supervise your care

What do I do if I'm in First call our customer service department at 1 800 537 9384 If you are new to the FEHB
the hospital when I join Program we will arrange for you to receive care If you are currently in the FEHB Program and
this Plan are switching to us your former plan will pay for the hospital stay until

You are discharged not merely moved to an alternative care center or

The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized

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Section 3 How to get benefits continued
How do I get specialty Your primary care physician will arrange your referral to a specialist
care If you need to see a specialist frequently because of a chronic complex or serious medical

condition your primary care physician will develop a treatment plan that allows you to see your
specialist for a certain number of visits without additional referrals Your primary care physician
will use our criteria when creating your treatment plan

What do I do if I am Your primary care physician will decide what treatment you need If they decide to refer you to a
seeing a specialist when I specialist ask if you can see your current specialist If your current specialist does not participate
enroll with us you must receive treatment from a specialist who does Generally we will not pay for you to see a specialist who does not participate with our Plan

What do I do if Call your primary care physician who will arrange for you to see another specialist You may
my specialist leaves the receive services from your current specialist until we can make arrangements for you to see
Plan someone else

But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to
serious illness and my continue seeing your provider for up to 90 days after we notify you that we are terminating our
provider leaves the Plan contract with the provider unless the termination is for cause If you are in the second or third
or this Plan leaves the trimester of pregnancy you may continue to see your OB GYN until the end of your postpartum
Program care

You may also be able to continue seeing your provider if your plan drops out of the FEHB
Program and you enroll in a new FEHB plan Contact the new plan and explain that you have a
serious or chronic condition or are in your second or third trimester Your new plan will pay for
or provide your care for up to 90 days after you receive notice that your prior plan is leaving the
FEHB Program If you are in your second or third trimester your new plan will pay for the
OB GYN care you receive from your current provider until the end of your postpartum care

How do you authorize Your physician must get our approval before sending you to a hospital referring you to a
medical services specialist or recommending follow up care Before giving approval we consider if the service is medically necessary and if it follows generally accepted medical practice

How do you decide The Plan's medical policy review group uses the Hays Medical Technology Assessment Service
if a service is experimental HCFA's policy manual FDA decisions etc to determine which medical procedures are
or investigational experimental and or investigational

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Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were
unable to make a timely request due to reasons beyond your control

We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30
days after we receive the additional information If we do not receive the requested information within 60 days we will make our
decision based on the information we already have

When may I ask OPM to You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal
review a denial OPM will determine if we correctly applied the terms of our contract when we denied your claim or request for service

What if I have a serious Call us at 1 800 537 9384 and we will expedite our review
or life threatening
condition and you haven't
responded to my request
for service

What if you have denied If we expedite your review due to a serious medical condition and deny your claim we will inform
my request for care and OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's
my condition is serious or health benefits Contract Division IV at 202 606 0737 between 8 a m and 5 p m Serious or life
life threatening threatening conditions are ones that may cause permanent loss of bodily functions or death if they are not treated as soon as possible

Are there other time You must write to OPM and ask them to review our decision within 90 days after we uphold our
limits initial denial or refusal of service You may also ask OPM to review your claim if

1 We do not answer your request within 30 days In this case OPM must receive your request
within 120 days of the date you asked us to reconsider your claim

2 You provided us with additional information we asked for and we did not answer within 30
days In this case OPM must receive your request within 120 days of the date we asked you for
additional information

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Section 4 What to do if we deny your claim or request for service continued
What do I send to OPM Your request must be complete or OPM will return it to you You must send the following information

1 A statement about why you believe our decision is wrong based on specific benefit provisions in
this brochure

2 Copies of documents that support your claim such as physicians letters operative reports
bills medical records and explanation of benefits EOB forms

3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to
which claim

Who can make the Those who have a legal right to file a disputed claim with OPM are
request 1 Anyone enrolled in the Plan

2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled
person's representative They must send a copy of the person's specific written consent with the
review request

Where should I mail my Send your request for review to Office of Personnel Management Office of Insurance Programs
disputed claim to OPM Contract Division IV P O Box 436 Washington DC 20044

What if OPM upholds the OPM's decision is final There are no other administrative appeals If OPM agrees with our
Plan's denial decision your only recourse is to sue

If you decide to sue you must file the suit against OPM in Federal court by December 31 of the
third year after the year in which you received the disputed services or supplies

What laws apply if I file a Federal law governs your lawsuit benefits and payment of benefits The Federal court will base
lawsuit its review on the record that was before OPM when OPM made its decision on your claim You may recover only the amount of benefits in dispute

You or a person acting on your behalf may not sue to recover benefits on a claim for treatment
services supplies or drugs covered by us until you have completed the OPM review procedure
described above

Your records and the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you
Privacy Act and us to determine if our denial of your claim is correct The information OPM collects during the review process becomes a permanent part of your disputed claims file and is subject to the

provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this
information to support the disputed claim decision If you file a lawsuit this information will
become part of the court record

18 18
18 Page 19 20
Section 4 What to do if we deny your claim or request for service continued
Third Party Review If this Plan denied your claim for payment or services you can ask us to reconsider your claim If we still deny your claim you can seek an independent external review before asking OPM to

review it if
1 The amount of your claim or service is more than 500 and
2 The Plan denied your claim because it did not consider the treatment medically necessary or
considered it experimental or investigational

The independent external review will use a neutral independent physician with related expertise
to conduct the review The Plan will cover the professional fee for the review and you will pay the
cost to compile and send your submission to the Plan

To request an External Review Form call 1 800 537 9384 within 60 days after receiving the
Plan's written notification that it will uphold its original decision to deny your claim

The external reviewer will make a decision within 30 days after you send us all the necessary
information with the External Review Request Form Your primary care doctor can request an
expedited review in cases of clinical urgency where your health would be seriously jeopardized
if you waited the full 30 days In this case the external review organization or physician will make
a decision within 72 hours

To request a detailed description of the external review requirements call the Plan's Member
Relations Office at 1 800 537 9384 Once you have completed the external review process you
can use OPM's review process as detailed in this section

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19 Page 20 21
Section 5 Benefits
Medical and Surgical Benefits
What is covered 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 10 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 15 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 X rays
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 nonHodgkin'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

20 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 20
20 Page 21 22
Section 5 Benefits continued
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 external breast prosthesis and surgical
bra following a mastectomy 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

Limited benefits 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 A patient and her
attending physician may decide whether to have breast reconstruction surgery following a
mastectomy and whether surgery on the other breast is needed to produce a symmetrical
appearance

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 10 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
10 copay per visit The following types of artificial insemination are covered intravaginal
insemination IVI intracervical insemination ICI and intrauterine insemination IUI Coverage
is for 6 cycles Oral fertility drugs are covered under the Prescription Drug Benefit Injectable
fertility medications are not covered Artificial insemination must be preauthorized Member must
contact the Infertility Case Manager at 1 800 575 5999 for approval Services not listed are not
covered

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 10 copay per visit

Chiropractic services are provided for up to 20 visits per calendar year you pay a 10 copay per
visit

21 21
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Section 5 Benefits continued
What is not covered 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
Infertility treatment when the FSH level is greater than 19 mIU ml
The purchase freezing and storage of donor sperm and donor embryos
Assisted reproductive technology ART procedures not shown such as in vitro fertilization and
embryo transfer including but not limited to GIFT and ZIFT

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

22 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 22
22 Page 23 24
Section 5 Benefits continued
Hospital Extended Care Benefits
What is covered

Hospital care 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

Extended care 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

Hospice care 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

Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a
procedures 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

Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis
detoxification 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 26 for nonmedical substance abuse benefits

What is not covered 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

CARE CARE MUST MUST BE BE RECEIVED RECEIVED FROM FROM OR OR ARRANGED ARRANGED BY BY PLAN PLAN DOCTORS DOCTORS 23 23
23 Page 24 25
Section 5 Benefits continued
Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you
emergency 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

Emergencies within the If you are in an emergency situation please call your primary care doctor In extreme emergencies
Service Area 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

Plan pays Reasonable charges for emergency services to the extent the services would have been covered if
received from Plan providers

You pay 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

Emergencies outside the Benefits are available for any medically necessary health service that is immediately required
Service Area 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

Plan pays Reasonable charges for emergency services to the extent the services would have been covered if
received from Plan providers

24 24
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Section 5 Benefits continued
You pay 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

What is covered 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

What is not covered 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

Filing claims for non Plan With your authorization the Plan will pay emergency benefits directly to the providers of your
providers 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 17

25 25
25 Page 26 27
Section 5 Benefits continued
Mental Conditions
Substance Abuse Benefits

Mental conditions
What is 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

Outpatient care 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

Inpatient care 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

What is not covered 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

Substance abuse
What is covered 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

What is not covered Treatment that is not authorized by a Plan doctor

26 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 26
26 Page 27 28
Section 5 Benefits continued
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Participating Plan Pharmacy will be dispensed for up to a 30 day supply You pay a 5 copay for generic formulary

drugs a 10 copay for brand name formulary drugs and a 25 copay for nonformulary 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 Certain drugs require your doctor to get precertification from the Plan before they can
be prescribed under the Plan

Members must obtain a 31 to 90 day supply of prescription medication through mail order You
pay two times the amount of your 30 day supply copay

To obtain a 31 to 90 day supply by mail order
Call 1 800 537 9384 to obtain the necessary forms
Mail the prescription for a 31 to 90 day supply along with the appropriate copay to the Mail
Order Pharmacy

Covered medications and accessories of the pharmacy benefit include
Drugs for which a prescription is required by Federal law
Oral contraceptive drugs
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

Oral fertility drugs

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

Limited benefits Drugs to treat sexual dysfunction are limited Contact the Plan for dose limits You pay a 50 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

Additional benefits One diaphragm per calendar year You pay a 10 copay
Drugs obtained at a nonparticipating pharmacy for an out of area emergency are reimbursed at
100 of the cost of the prescription less the applicable copay Reimbursements are subject to
professional review

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 27 27
27 Page 28 29
Section 5 Benefits continued
What is not covered 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

Injectable fertility drugs
Drugs used for the purpose of weight reduction i e appetite suppressants

28 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 28
28 Page 29 30
Section 5 Benefits continued
Other Benefits
Dental care
What is covered 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 Note Each employee and dependent must select a primary care dentist from
the directory and include the name on the enrollment or provider selection form Benefits are only
payable if performed by your primary care dentist you have selected or a participating specialist
You pay a 5 copay per visit for the following procedures

DIAGNOSTIC RESTORATIVE Fillings continued
Oral evaluations Amalgam primary 4 surfaces
All X rays Amalgam permanent 1 surface
Diagnostic models Amalgam permanent 2 surfaces

PREVENTIVE Amalgam permanent 3 surfaces
Prophylaxis cleaning of teeth every 6 months Amalgam permanent 4 surfaces
Topical fluoride every 6 months child under age 18 PROSTHODONTICS REMOVABLE
Oral hygiene instruction Denture adjustments complete or partial

RESTORATIVE Fillings upper or lower
Amalgam primary 1 surface ENDODONTICS Root Canal
Amalgam primary 2 surfaces Pulp cap direct
Amalgam primary 3 surfaces Pulp cap indirect

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

You pay You pay up to a up to a
maximum maximum
DIAGNOSTIC PROSTHODONTICS FIXED continued
Sealant per permanent tooth 35 Cast metal retainer for resin bonded prosthesis 250
Space maintainer 445 Crown porcelain 685

RESTORATIVE Fillings Crown cast 690
Resin anterior 1 surface 85 Recement bridge 65
Resin anterior 2 surfaces 115 Post and core 250
Resin anterior 3 surfaces 140 ORAL SURGERY
Resin anterior 4 or more surfaces or Extractions nonsurgical and tissue impacted 380
incisal angle 150 Anesthesia general in office first
Metallic inlay 580 half hour session 215

PROSTHODONTICS REMOVABLE PERIODONTICS Gum Treatment
Complete denture upper or lower 820 Gingivectomy per quadrant 250
Immediate denture upper or lower 885 Gingival curettage per quadrant 120
Partial denture resin base upper or lower 630 Periodontal surgery 605
Partial denture cast metal framework with Provisional splinting 125
resin base upper or lower 955 Scaling and root planing per quadrant 120
Denture repairs 120 Periodontal maintenance procedure 85
Add tooth to existing partial 105 ENDODONTICS Root Canal
Add clasp to existing partial 120 Therapeutic pulpotomy 100
Denture rebase 300 Root canals anterior bicuspid molar
Denture relines 260 excluding final restoration 605
Interim denture complete or partial Apicoectomy anterior 405
upper or lower 370
Tissue conditioning 85 ORTHODONTICS Braces Pre orthodontic treatment visit 280

PROSTHODONTICS FIXED Fully banded case adult age 19 and over 4,400
Bridge pontic 685 Fully banded case child age 18 and under 4,400
Metallic inlay onlay 650

What is not covered Services not received from a participating dental provider

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 29 29
29 Page 30 31
Section 5 Benefits continued
Vision care
What is 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 10 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 100 reimbursement per 24 month period for corrective eyeglasses and frames or contact
lenses hard or soft lenses

What is not covered Eye exercises
Fitting of contact lenses

30 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 30
30 Page 31 32
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 Our wellness and preventive programs provide you with access to materials and services to
Management promote in conjunction with advice from your physician a healthy lifestyle and good health

The 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 smokingcessation
products The member may also enroll in an eight to twelve week smokingcessation
program

Vision Care 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

National Medical Our National Medical Excellence Program coordinates services for complicated or rare
Excellence Program 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

Medicare Prepaid Plan This Plan offers Medicare recipients except for those enrolled in codes TS 5B 8X 3G 6F
Enrollment 6J 8L 8V 8Z NK NE and 5U the opportunity to enroll in the Plan through Medicare As indicated on page 32 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

31 31
31 Page 32 33
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless
your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition

We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits
Experimental or investigational procedures treatments drugs or devices
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

Procedures services drugs and supplies related to sex transformations

Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan

Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On

occasion you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain
enrolled with us

If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
Medicare Choice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a Medicare Choice plan contact your retirement office If you
later want to re enroll in the FEHB Program generally you may do so only at the next Open
Season

If you involuntarily lose coverage or move out of the Medicare Choice service area you may reenroll
in the FEHB Program at any time

If you do not have Medicare Part A or B you can still be covered under the FEHB Program and
your benefits will not be reduced We cannot require you to enroll in Medicare

For information on Medicare Choice plans contact your local Social Security Administration
SSA office or request it from SSA at 1 800 638 6833 For information on the Medicare Choice
plan offered by this Plan see page 31

Other group insurance When anyone has coverage with us and with another group health plan it is called double
coverage coverage You must tell us if you or a family member has double coverage You must also send us documents about other insurance if we ask for them

When you have double coverage one plan is the primary payer it pays benefits first The other
plan is secondary it pays benefits next We decide which insurance is primary according to the
National Association of Insurance Commissioners Guidelines

32 32
32 Page 33 34
Section 7 Limitations Rules that affect your benefits continued
If we pay second we will determine what the reasonable charge for the benefit should be After
the first plan pays we will pay either what is left of the reasonable charge or our regular benefit
whichever is less We will not pay more than the reasonable charge If we are the secondary payer
we may be entitled to receive payment from your primary plan

We will always provide you with the benefits described in this brochure Remember even if you
do not file a claim with your other plan you must still tell us that you have double coverage

Circumstances beyond Under certain extraordinary circumstances we may have to delay your services or be unable to
our control provide them In that case we will make all reasonable efforts to provide you with necessary care

When others are When you receive money to compensate you for medical or hospital care for injuries or illness
responsible for injuries that another person caused you must reimburse us for whatever services we paid for We will cover the cost of treatment that exceeds the amount you received in the settlement If you do not

seek damages you must agree to let us try This is called subrogation If you need more
information contact us for our subrogation procedures

TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you
we are the primary payer See your TRICARE Health Benefits Advisor if you have questions
about TRICARE coverage

Workers compensation We do not cover services that
You need because of a workplace related disease or injury that the Office of Workers
Compensation Programs OWCP or a similar Federal or State agency determine they must
provide

OWCP or a similar agency pays for through a third party injury settlement or other similar
proceeding that is based on a claim you filed under OWCP or similar laws

Once the OWCP or similar agency has paid its maximum benefits for your treatment we will
provide your benefits

Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government agency directly or
Agencies indirectly pays for

33 33
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Section 8 FEHB FACTS
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the
information about your right to information about your health plan its networks providers and facilities You can also
HMO find out about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website

www opm gov lists the specific types of information that we must make available to you
If you want specific information about us call 1 800 537 9384 or write to 1425 Union Meeting
Road P O Box 3013 Blue Bell PA 19422 You may also contact us by fax at 215 775 5870 or
visit our website at www aetnaushc com feds

Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal
information about Employees Health Benefits Plans brochures for other plans and other materials you need to make
enrolling in the FEHB an informed decision about
Program When you may change your enrollment

How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter
military service or retire

When your enrollment ends and
The next Open Season for enrollment
We don't determine who is eligible for coverage and in most cases cannot change your
enrollment status without information from your employing or retirement office

When are my benefits and The benefits in this brochure are effective on January 1 If you are new to this plan your coverage
premiums effective and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants premiums begin January 1

What happens when I When you retire you can usually stay in the FEHB Program Generally you must have been
retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet this requirement you may be eligible for other forms of coverage such as Temporary

Continuation of Coverage which is described later in this section

What types of coverage Self Only coverage is for you alone Self and Family coverage is for you your spouse and your
are available for my unmarried dependent children under age 22 including any foster or step children your employing
family and me or retirement office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who is incapable of self support

If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry
give birth or add a child to your family You may change your enrollment 31 days before to 60
days after you give birth or add the child to your family The benefits and premiums for your Self
and Family enrollment begin on the first day of the pay period in which the child is born or
becomes an eligible family member

Your employing or retirement office will not notify you when a family member is no longer
eligible to receive health benefits nor will we Please tell us immediately when you add or remove
family members from your coverage for any reason including divorce

If you or one of your family members is enrolled in one FEHB plan that person may not be
enrolled in another FEHB plan

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Section 8 FEHB FACTS continued
Are my medical and We will keep your medical and claims information confidential Only the following will have
claims records access to it
confidential OPM this Plan and subcontractors when they administer this contract

This Plan and appropriate third parties such as other insurance plans and the Office of
Workers Compensation Programs OWCP when coordinating benefit payments and
subrogating claims

Law enforcement officials when investigating and or prosecuting alleged civil or criminal
actions

OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your
identity or

OPM when reviewing a disputed claim or defending litigation about a claim

Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You can also

use an Employee Express confirmation letter

What if I paid a Your old plan's deductible continues until our coverage begins
deductible under my old
plan

Pre existing conditions We will not refuse to cover the treatment of a condition that you or a family member had before you enrolled in this Plan solely because you had the condition before you enrolled

When you lose benefits
What happens if my You will receive an additional 31 days of coverage for no additional premium when
enrollment in this Plan Your enrollment ends unless you cancel your enrollment or
ends
You are a family member no longer eligible for coverage

You may be eligible for former spouse coverage or Temporary Continuation of Coverage

What is former spouse If you are divorced from a Federal employee or annuitant you may not continue to get benefits
coverage under your former spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse equity law If you are recently divorced or are anticipating a divorce contact

your ex spouse's employing or retirement office to get more information about your coverage
choices

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Section 8 FEHB FACTS continued
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For

example you can receive TCC if you are not able to continue your FEHB enrollment after you
retire You may not elect TCC if you are fired from your Federal job due to gross misconduct Get
the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health
Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office

Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums
from the 32 nd day after your regular coverage ends even if several months have passed

You pay the total premium and generally a 2 percent administrative charge The government
does not share your costs

You receive another 31 day extension of coverage when your TCC enrollment ends unless you
cancel your TCC or stop paying the premium

You are not eligible for TCC if you can receive regular FEHB Program benefits

How do I enroll in If you leave Federal service your employing office will notify you of your right to enroll under
TCC TCC You must enroll within 60 days of leaving or receiving this notice whichever is later

Children You must notify your employing or retirement office within 60 days after your child is
no longer an eligible family member That office will send you information about enrolling in
TCC You must enroll your child within 60 days after they become eligible for TCC or receive
this notice whichever is later

Former spouses You or your former spouse must notify your employing or retirement office
within 60 days of one of these qualifying events

Divorce

Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about
enrolling in TCC Your former spouse must enroll within 60 days after the event which qualifies
them for coverage or receiving the information whichever is later

Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify
your employing or retirement office within the 60 day deadline

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Section 8 FEHB FACTS continued
How can I convert to You may convert to an individual policy if
individual coverage Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did

not pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is
available You must apply in writing to us within 31 days after you receive this notice However
if you are a family member who is losing coverage the employing or retirement office will not
notify you You must apply in writing to us within 31 days after you are no longer eligible for
coverage

Your benefits and rates will differ from those under the FEHB Program however you will not
have to answer questions about your health and we will not impose a waiting period or limit your
coverage due to pre existing conditions

How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage
Certificate of Group that indicates how long you have been enrolled with us You can use this certificate when getting
Health Plan Coverage health insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or

exclusions for health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other
FEHB plans you may request a certificate from them as well

37 37
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Department of Defense FEHB Demonstration Project
What is the Department The National Defense Authorization Act for 1999 Public Law 105 261 established the
of Defense DoD and DoD FEHBP Demonstration Project It allows some active and retired uniformed service members
FEHB Program and their dependents to enroll in the FEHB Program The demonstration will last for three years
Demonstration Project beginning with the 1999 Open Season for the year 2000 Open Season enrollments will be effective January 1 2000 DoD and OPM have set up some special procedures to successfully implement the

Demonstration Project noted below Otherwise the provisions described in this brochure apply

Who is eligible DoD determines who is eligible to enroll in FEHB Generally you may enroll if
You are an active or retired uniformed service member and are eligible for Medicare

You are a dependent of an active or retired uniformed service member and are eligible for
Medicare

You are a qualified former spouse of an active or retired uniformed service member and you
have not remarried or

You are a survivor dependent of a deceased active or retired uniformed service member and
You live in one of the eight geographic demonstration areas
If you are eligible to enroll in a plan under the regular Federal Employees Health Benefits
Program you are not eligible to enroll under the DoD FEHBP Demonstration Project

Where are the Dover AFB DE
demonstration areas Commonwealth of Puerto Rico

Fort Knox KY
Greensboro Winston Salem High Point NC
Dallas TX
Humboldt County CA area
Naval Hospital Camp Pendleton CA
New Orleans LA

When can I join Your first opportunity to enroll will be during the 1999 Open Season November 8 1999 through December 13 1999 Your coverage will begin January 1 2000 DoD has set up an Information
Processing Center IPC in Iowa to provide you with information about how to enroll IPC staff
will verify your eligibility and provide you with FEHB Program information plan brochures
enrollment instructions and forms The toll free phone number for the IPC is 1 877 DOD FEHB
1 877 363 3342

You may select coverage for yourself self only or for you and your family self and family
during the 1999 2000 and 2001 Open Seasons Your coverage will begin January 1 of the year
following the Open Season that you enrolled

If you become eligible for the DoD FEHBP Demonstration Project outside of Open Season contact
the IPC to find out how to enroll and when your coverage will begin

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Department of Defense FEHB Demonstration Project continued
DoD has a website devoted to the Demonstration Project You can view information such as their
Marketing Beneficiary Education Plan Frequently Asked Questions demonstration area locations
and zip code lists at www tricare osd mil fehbp You can also view information about the
demonstration project including The 2000 Guide to Federal Employees Health Benefits Plans
Participating in the DoD FEHBP Demonstration Project on the OPM website at www opm gov

Am I eligible for See Section 10 FEHB Facts for information about TCC Under this Demonstration Project the
Temporary Continuation only individual eligible for TCC is one who ceases to be eligible as a member of family under
of Coverage TCC your self and family enrollment This occurs when a child turns 22 for example or if you divorce and your spouse does not qualify to enroll as an unremarried former spouse under title 10 United

States Code For these individuals TCC begins the day after their enrollment in the DoD FEHBP
Demonstration Project ends TCC enrollment terminates after 36 months or the end of the
Demonstration Project whichever occurs first You your child or another person must notify the
IPC when a family member loses eligibility for coverage under the DoD FEHBP Demonstration
Project

TCC is not available if you move out of a DoD FEHBP Demonstration Project area you cancel
your coverage or your coverage is terminated for any reason TCC is not available when the
demonstration project ends

Do I have the 31 day These provisions do not apply to the DoD FEHBP Demonstration Project
extension and right to
convert

Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for services
you did not receive billed you twice for the same service or misrepresented any information do the following

Call the provider and ask for an explanation There may be an error

If the provider does not resolve the matter call us at 1 800 537 9384 and explain the situation
If we do not resolve the issue call or write

THE HEALTH CARE FRAUD HOTLINE
202 418 3300

U S Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington DC 20415

Penalties for Fraud
Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud Also the Inspector General may
investigate anyone who uses an ID card if they

Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits
Your agency may also take administrative action against you

39 39
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Summary of Benefits for Aetna U S Healthcare 2000
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 7 14 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 Comprehensive range of medical and surgical services without dollar or day limit
care 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 23

Extended care All necessary services no dollar or day limit You pay nothing 23
Mental Diagnosis and treatment of acute psychiatric conditions for up to 35 days of inpatient care
conditions per calendar year You pay nothing 26

Substance Covered under Mental Conditions benefit 26
abuse

Outpatient Comprehensive range of services such as diagnosis and treatment of illness or injury
care 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 10 copay per visit after the first visit office visit copays are waived for the maternity
care 15 copay per house call by a doctor 20

Home health All medically necessary visits by nurses and health aides You pay nothing 21
care

Mental Up to 40 outpatient visits per calendar year You pay the following 26
conditions Visits 1 and 2 covered in full

Visits 3 10 a 10 copay per visit
Visits 11 40 a 25 copay per visit

Substance abuse Covered under Mental Conditions benefit 26
Emergency care 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 24

Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 copay
for generic formulary drugs a 10 copay for brand name formulary drugs and a 25
copay for nonformulary drugs per prescription unit or refill You pay two times the
amount of your 30 day supply 27

Dental care Preventive dental care comprehensive range of restorative orthodontic and other services
You pay variable copays 29

Vision care Routine refraction and up to 100 for eyeglasses or contact lenses per 24 month period
you pay a 10 copay per visit 30

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2000 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 FEHB Guide for that
category or contact the agency that maintains your health benefits enrollment

Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates referred to as
Category A rates and Category B rates will apply for certain career employees If you are a career postal employee but not a
member of a special postal employment class refer to the category definitions in The Guide to Federal Employees Health Benefits
Plans for United States Postal Service Employees RI 70 2 to determine which rate applies to you

Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or associate
members of any postal employee organization Such persons not subject to postal rates must refer to the applicable Guide to Federal
Employees Health Benefits Plans

Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly

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

Arizona Phoenix and Tucson Areas
Self Only WQ1 57.00 19.00 123.50 41.17 67.45 8.55 67.45 8.55

Self and Family WQ2 160.40 53.46 347.52 115.84 189.80 24.06 189.80 24.06

California Northern California and Central Valley
Self Only BU1 78.83 33.92 170.80 73.49 93.06 19.69 93.26 19.49

Self and Family BU2 175.97 76.51 381.27 165.77 207.74 44.74 201.02 51.46

California Southern California
Self Only 2X1 60.58 20.19 131.25 43.75 71.68 9.09 71.68 9.09

Self and Family 2X2 141.46 47.15 306.50 102.16 167.39 21.22 167.39 21.22

Colorado The Front Range
Self Only 6F1 59.01 19.67 127.85 42.62 69.83 8.85 69.83 8.85

Self and Family 6F2 155.84 51.95 337.66 112.55 184.41 23.38 184.41 23.38

Connecticut All of Connecticut
Self Only H11 78.83 33.80 170.80 73.23 93.06 19.57 93.26 19.37

Self and Family H12 175.97 127.24 381.27 275.69 207.74 95.47 201.02 102.19

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2000 Rate Information for Aetna U S Healthcare continued
Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly

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

Delaware All of Delaware
Self Only NK1 78.83 69.30 170.80 150.15 93.06 55.07 93.26 54.87

Self and Family NK2 175.97 227.64 381.27 493.22 207.74 195.87 201.02 202.59

Georgia Atlanta Augusta Athens Macon Areas
Self Only 2U1 70.85 23.61 153.50 51.16 83.83 10.63 83.83 10.63

Self and Family 2U2 175.97 67.46 381.27 146.16 207.74 35.69 201.02 42.41

Illinois Metropolitan St Louis Area
Self Only 6T1 59.14 19.71 128.13 42.71 69.98 8.87 69.98 8.87

Self and Family 6T2 157.18 52.39 340.55 113.52 185.99 23.58 185.99 23.58

Illinois Indiana Chicago Area Lake and Porter counties
Self Only XC1 52.56 17.52 113.88 37.96 62.20 7.88 62.20 7.88

Self and Family XC2 166.49 55.49 360.72 120.24 197.01 24.97 197.01 24.97

Kansas Kansas City Metropolitan Area
Self Only 7K1 63.35 21.11 137.25 45.75 74.96 9.50 74.96 9.50

Self and Family 7K2 167.81 55.93 363.58 121.19 198.57 25.17 198.57 25.17

Kentucky Indiana Ohio Lexington and Louisville Southern Indiana Most of Ohio
Self Only RD1 78.22 26.07 169.47 56.49 92.56 11.73 92.56 11.73

Self and Family RD2 175.97 82.17 381.27 178.03 207.74 50.40 201.02 57.12

Louisiana Baton Rouge and Lafayette Areas
Self Only TK1 53.20 17.73 115.26 38.42 62.95 7.98 62.95 7.98

Self and Family TK2 173.57 57.85 376.06 125.35 205.39 26.03 201.02 30.40

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2000 Rate Information for Aetna U S Healthcare continued
Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly

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

Louisiana New Orleans Area
Self Only NG1 68.20 22.73 147.77 49.25 80.70 10.23 80.70 10.23

Self and Family NG2 175.97 60.40 381.27 130.87 207.74 28.63 201.02 35.35

Maine All of Maine
Self Only 9M1 78.83 45.60 170.80 98.80 93.06 31.37 93.26 31.17

Self and Family 9M2 175.97 100.97 381.27 218.77 207.74 69.20 201.02 75.92

Massachusetts Eastern Central Massachusetts and Hampden County
Self Only NE1 78.83 37.57 170.80 81.40 93.06 23.34 93.26 23.14

Self and Family NE2 175.97 133.11 381.27 288.40 207.74 101.34 201.02 108.06

Michigan Greater Detroit Metropolitan Area
Self Only 8Z1 64.05 21.35 138.77 46.26 75.79 9.61 75.79 9.61

Self and Family 8Z2 167.10 55.70 362.05 120.68 197.74 25.06 197.74 25.06

Missouri Metropolitan Kansas City and Metropolitan St Louis Areas
Self Only 6T1 59.14 19.71 128.13 42.71 69.98 8.87 69.98 8.87

Self and Family 6T2 157.18 52.39 340.55 113.52 185.99 23.58 185.99 23.58

Nevada Southern Nevada and Las Vegas Area
Self Only 8L1 55.07 18.35 119.31 39.77 65.16 8.26 65.16 8.26

Self and Family 8L2 144.24 48.08 312.52 104.17 170.68 21.64 170.68 21.64

New York New York City Area
Self Only JC1 73.68 24.56 159.64 53.21 87.19 11.05 87.19 11.05

Self and Family JC2 175.97 70.95 381.27 153.72 207.74 39.18 201.02 45.90

43 43
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2000 Rate Information for Aetna U S Healthcare continued
Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly

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

North Carolina The Charlotte Metrolina Area
Self Only 3G1 65.51 21.83 141.93 47.31 77.51 9.83 77.51 9.83

Self and Family 3G2 170.02 56.67 368.37 122.79 201.19 25.50 201.02 25.67

Oklahoma Northeast Oklahoma
Self Only 8V1 53.32 17.77 115.52 38.51 63.09 8.00 63.09 8.00

Self and Family 8V2 137.99 45.99 298.97 99.65 163.28 20.70 163.28 20.70

Rhode Island All of Rhode Island
Self Only 5U1 55.89 18.63 121.10 40.36 66.14 8.38 66.14 8.38

Self and Family 5U2 147.86 49.29 320.37 106.79 174.97 22.18 174.97 22.18

Tennessee Nashville and Middle Tennessee
Self Only 6J1 56.24 18.75 121.86 40.62 66.55 8.44 66.55 8.44

Self and Family 6J2 156.70 52.23 339.51 113.17 185.43 23.50 185.43 23.50

Texas Dallas Ft Worth Area
Self Only TS1 73.70 24.56 159.68 53.22 87.21 11.05 87.21 11.05

Self and Family TS2 175.97 99.43 381.27 215.43 207.74 67.66 201.02 74.38

Texas Houston Area
Self Only 5B1 65.57 21.86 142.07 47.36 77.59 9.84 77.59 9.84

Self and Family 5B2 175.97 69.11 381.27 149.74 207.74 37.34 201.02 44.06

Texas San Antonio Area
Self Only 8X1 56.50 18.83 122.42 40.80 66.86 8.47 66.86 8.47

Self and Family 8X2 158.41 52.80 343.22 114.40 187.45 23.76 187.45 23.76

44 44
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2000 Rate Information for Aetna U S Healthcare continued
Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly

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

Virginia Richmond Central Tri City Areas
Self Only Z11 76.42 25.47 165.57 55.19 90.43 11.46 90.43 11.46

Self and Family Z12 175.97 79.77 381.27 172.83 207.74 48.00 201.02 54.72

Washington Western and Southeast Washington
Self Only 8J1 54.88 18.29 118.91 39.63 64.94 8.23 64.94 8.23

Self and Family 8J2 143.72 47.90 311.89 103.79 170.06 21.56 170.06 21.56

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