CALL - THE HEALTH CARE FRAUD HOTLINE

202-418-3300

OR WRITE TO:

United States Office of Personnel Management

Office of the Inspector General Fraud Hotline

1900 E Street NW Room 6400

Washington, DC20415-1100

Precertification

Precertification is the process of collecting information prior to inpatient admissions and performance of selected ambulatory procedures and services. The process permits advance eligibility verification, determination of coverage, and communication with the physician and/or member. It also allows Aetna to coordinate the patient�s transition from the inpatient setting to the next level of care (discharge planning), or to register patients for specialized programs like disease management, case management, or our prenatal program. In some instances, precertification is used to inform physicians, members and other health care providers about cost-effective programs and alternative therapies and treatments.

Certain health care services, such as hospitalization or outpatient surgery, require precertification with Aetna to ensure coverage for those services. When a member is to obtain services requiring precertification through a participating provider, this provider should precertify those services prior to treatment.

Concurrent Review

The concurrent review process assesses the necessity for continued stay, level of care, and quality of care for members receiving inpatient services. All inpatient services extending beyond the initial certification period will require Concurrent Review.

Discharge Planning

Discharge planning may be initiated at any stage of the patient management process and begins immediately upon identification of post-discharge needs during precertification or concurrent review. The discharge plan may include initiation of a variety of services/benefits to be utilized by the member upon discharge from an inpatient stay.

Retrospective Record Review

The purpose of retrospective record review is to retrospectively analyze potential quality and utilization issues, initiate appropriate follow-up action based on quality or utilization issues, and review all appeals of inpatient concurrent review decisions for coverage and payment of health care services. Our effort to manage the services provided to members includes the retrospective review of claims submitted for payment, and of medical records submitted for potential quality and utilization concerns.

Open Access HMO

This does not apply to members in Enrollment Codes 2X or 8J.

Aetna offers Open Access to our members in those FEHBP service areas identified starting on page 10. You can go directly to any network specialist for covered services without a referral from your primary care physician. Note: This does not apply to mental health services and/or substance abuse services. Referrals must be obtained for those services. Please see the Mental Health/Substance Abuse section on page 42. Whether your covered services are provided by your selected primary care physician (for your PCP copay) or by any other participating provider in the network (for the specialist copay), you will be responsible for payment which may be in the form of a copay (flat dollar amount) or coinsurance (a percentage of covered expenses). You still must select a PCP and notify Member Services of your selection (1-800/537-9384). If you do not select a PCP, the specialist copay will apply. If you go directly to a specialist, you are responsible for verifying that the specialist is participating in our Plan.

Identification cards

We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 1-800/537-9384 or write to us at Aetna, 1425 Union Meeting Road, P.O. Box 1125, Blue Bell, PA 19422. You may also request replacement cards through our Web site at www.aetna.com/fed.

Where you get covered care

You get covered care from "Plan providers" and "Plan facilities." You will only pay copayments or coinsurance, and you will not have to file claims.

Plan providers

Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan providers according to national standards.

We list Plan providers in the provider directory, which we update periodically. The most current information on our Plan providers is also on our Web site at www.aetna.com/fed under DocFind.

To ensure covered services, you must notify Member Services at 1-800/537-9384 of your primary care physician selection.

Plan facilities

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update periodically. The most current information on our Plan facilities is also on our Web site at www.aetna.com/fed.

What you must do to get covered care

It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since your primary care physician provides or arranges for most of your health care. You must select a Plan provider who is located in your service area as defined by your enrollment code.

Primary care

Your primary care physician can be a general practitioner, family practitioner, internist or pediatrician. Your primary care physician will provide or coordinate most of your health care.

If you want to change primary care physicians or if your primary care physician leaves the Plan, call us or visit our Web site. We will help you select a new one.

Specialty care

If you are enrolled in Enrollment Codes 2X or 8J, your primary care physician will refer you to a specialist for needed care. If you need laboratory, radiological and physical therapy services, your primary care physician must refer you to certain plan providers. If you need mental health or substance abuse care, you may call your primary care physician or the behavioral health vendor number on the front of your ID card. Your primary care physician may refer you to any participating specialist for other specialty care. When you receive a referral from your primary care physician, you must return to the primary care physician after the consultation, unless your primary care physician authorized a certain number of visits without additional referrals. The primary care physician must provide or authorize follow-up care. Do not go to the specialist for return visits unless your primary care physician gives you a referral. However, you may see a Plan gynecologist, (within an IPA, you must see an IPA-approved gynecologist), for a routine well-woman exam, including a Pap smear (if appropriate) and an unlimited number of visits for gynecological problems and follow-up care as described in your benefit plan without a referral. You may also see a Plan mental health provider, Plan vision specialist or a Plan dentist without a referral.

Here are some other things you should know about specialty care:

If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary care physician will use our criteria when creating your treatment plan (the physician may have to get an authorization or approval beforehand).

If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. If he or she decides to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.

If you have a chronic and disabling condition and lose access to your specialist because we:

Terminate our contract with your specialist for other than cause; or

Drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program Plan; or

Reduce our service area and you enroll in another FEHB Plan, you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us, or if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

Hospital care

Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.

If you are in the hospital when your enrollment in our Plan begins, call our Member Services department immediately at 1-800/537-9384. If you are new to the FEHB Program, we will arrange for you to receive care.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

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

The day your benefits from your former plan run out; or

The 92^nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such case, the hospitalized family member�s benefits under the new plan begin on the effective date of enrollment.

Circumstances beyond our control

Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to provide you with the necessary care.

Services requiring our prior approval

Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice.

We call this review and approval process precertification.

You must obtain approval for certain services such as:

For artificial insemination you must contact the Infertility Case Manager at
1-800/575-5999;

You must obtain precertification from your primary care doctor and Aetna for covered follow-up care with non-participating providers;

You must contact Member Services at 1-800/537-9384 or call the behavioral health contractor for information on precertification before you have mental health and substance abuse services.

Your Plan physician must obtain approval for certain services such as hospitalization and the following services:

For surgical treatment of morbid obesity;

For select outpatient surgery;

For air ambulance;

For surgical correction of congenital defects, such as cleft lip and cleft palate;

For home IV and antibiotic therapy;

For limb and torso prosthetics;

For orthognathic surgery and TMJ surgery;

For inpatient confinements, skilled nursing facilities, rehabilitation facilities, and inpatient hospice;

For covered transplant surgery;

When full-time skilled nursing care is necessary in an extended care facility;

For non-emergent ambulance transportation service;

For certain drugs before they can be prescribed;

For growth hormone therapy treatment;

For intravenous immunoglobulin (IVIG) therapy treatment;

For penile implants;

For all home health care services; and

For certain outpatient imaging studies such as CT scans, MRIs, and MRAs.

You or your physician must obtain an approval for certain durable medical equipment. Members must call 1-800/537-9384 for authorization.

Copayments

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a copayment of $20 per office visit or $30 when you see a participating specialist.

Deductible

We do not have a deductible.

Note: If you change plans during open season, you do not have to start a new deductible under your old plan between January 1 and the effective date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan.

Coinsurance

Coinsurance is the percentage of our allowance that you must pay for your care

Example: In our Plan, you pay 50% of our allowance for drugs to treat sexual dysfunction.

Your catastrophic protection out-of-pocket maximum

After your copayments and coinsurance total $1,500/Self Only enrollment or $3,000/Self and Family enrollment in any calendar year, you do not have to pay any more for covered services. However, copayments and coinsurance for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments and coinsurance for these services:

Prescription drugs

Dental services

Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us when you reach the maximum.

I

M

P

O

R

T

A

N

T

Here are some important things you should keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

If you live or work in an Open Access HMO service area, you should select a PCP by calling Member Services at 1-800/537-9384. If you do not select a PCP and you self-refer to a participating PCP for care, you will pay a specialist copay.

If you live or work in an Open Access HMO service area, you do not have to obtain a referral from your PCP to see a specialist (does not apply to enrollment codes 2X or 8J).

I

M

P

O

R

T

A

N

T

Professional services of physicians

In physician�s office

Office medical consultations

Second surgical or medical opinion

Initial examination of a newborn child covered under a family enrollment

In an urgent care center for a routine service

During a hospital stay

In a skilled nursing facility

$20 per primary care physician (PCP) visit

$30 per specialist visit

At home

$25 per PCP visit

$30 per specialist visit

At home visits by nurses and health aides

Nothing

Tests, such as:

Blood tests

Urinalysis

Non-routine pap tests

Pathology

X-rays

Non-routine Mammograms

CAT Scans/MRI

Ultrasound

Nothing if you receive these services during your office visit; otherwise, $20 per PCP visit or $30 per specialist visit

Electrocardiogram and EEG

Nothing if you receive these services during your office visit; otherwise, $20 per PCP visit or $30 per specialist visit

Routine screenings, such as:

Blood

Total Blood Cholesterol

Routine Prostate Specific Antigen (PSA) test � one annually for men age 50 and older

Colorectal Cancer Screening, including

Fecal occult blood test yearly starting at age 50;

Sigmoidoscopy, screening � every five years starting at age 50;

Double contrast barium enema � every five years starting at age 50;

Colonoscopy screening � every ten years starting at age 50

Note: You may pay either a specialist copay or an outpatient hospital copay depending on where the procedure is performed.

$20 per PCP visit $30 per specialist visit

Nothing if provided during the office visit

Routine Pap test

Note: No copay for the Pap test if performed on the same day as the office visit.

$20 per PCP visit $30 per specialist visit

Nothing if provided during the office visit

Routine mammogram � covered for women age 35 and older, as follows:

From age 35 through 39, one during this five year period

From age 40 through 64, one every calendar year

At age 65 and older, one every two consecutive calendar years

$20 per PCP visit $30 per specialist visit

Nothing if provided during the office visit

Routine physicals:

One exam every 24 months up to age 65

One exam every 12 months age 65 or older

$20 per PCP visit $30 per specialist visit

Routine immunizations, limited to:

Tetanus-diphtheria (Td) booster � once every 10 years, ages19 and over (except as provided for under Childhood immunizations)

Influenza vaccine, annually

Pneumococcal vaccine, age 65 and older

$20 per PCP visit $30 per specialist visit

Nothing if provided during the office visit

Not covered:

Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.

Immunizations and boosters for travel or work-related exposure.

All charges.

Childhood immunizations recommended by the American Academy of Pediatrics

Nothing

Well-child care charges for routine examinations, immunizations and care (up to age 22)

Examinations, such as:

Eye exams through age 17 to determine the need for vision correction

Ear exams through age 17 to determine the need for hearing correction

Examinations done on the day of immunizations (up to age 22)

$20 per PCP visit

$30 per specialist visit

Not covered:

Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.

Immunizations and boosters for travel or work-related exposure.

All charges.

Complete maternity (obstetrical) care, such as:

Prenatal care

Delivery

Postnatal care

Note: Here are some things to keep in mind:

You do not need to precertify your normal delivery; see below for other circumstances, such as extended stays for you or your baby.

You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary , but you, your representative, your participating doctor, or your hospital must precertify the extended stay.

We cover routine nursery care of the newborn child during the covered portion of the mother�s maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.

We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and Surgery benefits (Section 5b).

$20 for the first PCP visit only or $30 for the first specialist visit only

Note: If your PCP or specialist refers you to another provider or facility for additional services, you pay the applicable copay for the service rendered

Not covered: Routine sonograms to determine fetal age, size or sex.

All charges.

A range of voluntary family planning services, limited to:

Voluntary sterilization (See Surgical procedures Section 5 (b))

Surgically implanted contraceptives

Injectable contraceptive drugs (such as Depo provera)

Intrauterine devices (IUDs)

Diaphragms

Note: We cover oral contraceptives and Depo provera under the prescription drug benefit.

$20 per PCP visit

$30 per specialist visit

Not covered:

1) Reversal of voluntary surgical sterilization

2) Genetic counseling.

All charges.

Infertility is defined as the inability to conceive after 12 months of unprotected intravaginal sexual relations (or 12 cycles of artificial insemination) for women under age 35 and 6 months of unprotected intravaginal sexual relations (or 6 cycles of artificial insemination) for women age 35 and over.

Diagnosis and treatment of infertility such as:

Artificial insemination:

intravaginal insemination (IVI)

intracervical insemination (ICI)

intrauterine insemination (IUI)

Infertility surgery

Note: Coverage is only for 3 cycles (per lifetime). Artificial insemination must be authorized. You must use our select network of Plan infertility providers. You must contact the Infertility Case Manager at 1-800/575-5999.

Fertility drugs except injectables

Note: We cover oral fertility drugs under the prescription drug benefit.

$30 per specialist visit

Not covered:

Reversal of voluntary, surgically-induced sterility.

Treatment for infertility when the cause of the infertility was a previous sterilization.

Injectable fertility drugs

Infertility treatment when the FSH level is 19 mIU/ml or greater on day 3 of menstrual cycle.

The purchase, freezing and storage of donor sperm and donor embryos.

Assisted reproductive technology (ART) procedures, such as:

in vitro fertilization

embryo transfer, including but not limited to gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)

All charges.

Testing and treatment

Allergy injections

Note: You pay the applicable copay for each visit to a doctor�s office including each visit to a nurse for an injection.

$20 per PCP visit

$30 per specialist visit

Allergy serum

Nothing

Not covered: Provocative food testing and sublingual allergy desensitization

All charges.

Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 34.

Respiratory and inhalation therapy

Dialysis � hemodialysis and peritoneal dialysis

Intravenous (IV)/Infusion Therapy � Home IV and antibiotic therapy must be precertified by your Plan physician

Growth hormone therapy (GHT)

Note: Growth hormone therapy is covered under Medical Benefits, office copay applies.

Note: We will only cover GHT when we preauthorize the treatment. Call
1-800/245-1206 for preauthorization. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment; otherwise, we will only cover GHT services from the date you submit the information and it is authorized by Aetna. If you do not ask or if we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3

$30 per specialist visit

Two consecutive months per condition per member per calendar year, beginning with the first day of treatment for the services of each of the following:

qualified physical therapists and

occupational therapists

Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury.

Note: Occupational therapy is limited to services that assist the member to achieve and maintain self-care and improved functioning in other activities of daily living. Inpatient rehabilitation is covered under Hospital/Extended Care Benefits.

Physical therapy to treat temporomandibular joint (TMJ) pain dysfunction syndrome

$30 per visit

Nothing during a covered inpatient admission

Not covered: Long-term rehabilitative therapy

All charges.

Two consecutive months per condition per member per calendar year for pulmonary rehabilitation to treat functional pulmonary disability.

Cardiac rehabilitation following angioplasty, cardiovascular surgery, chronic heart failure or a myocardial infarction is provided for up to 3 visits a week for a total of 18 visits.

$30 per visit

Nothing during a covered inpatient admission

Not covered: Long-term rehabilitative therapy

All charges.

Two consecutive months per condition per member per calendar year, beginning with the first day of treatment

$30 per visit

Nothing during a covered inpatient admission

Hearing services (testing, treatment, and supplies)

Covered for audiological testing and medically necessary treatment for hearing problems

$20 per PCP visit

$30 per specialist visit

Not covered: Hearing aids, testing and examinations for them

All charges.

Treatment of eye diseases and injury

$20 per PCP visit

$30 per specialist visit

Corrective eyeglasses and frames or contact lenses (hard or soft) per 24 month period.

All charges over $100

Routine eye refraction based on the following schedule:

If member wears eyeglasses or contact lenses:

Age 1 through 18 � once every 12-month period

Age 19 and over � once every 24-month period

If member does not wear eyeglasses or contact lenses:

To age 45 � once every 36-month period

Age 45 and over � once every 24-month period

Note: See Preventive Care, Children for eye exams for children

$30 per specialist visit

Not covered:

Optic nerve imaging methods including confocal laser scanning tomography, nerve fiber layer testing or analyses, and stereophotogrammetry

Fitting of contact lenses

Eye exercises

Radial keratotomy and laser eye surgery, including related procedures designed to surgically correct refractive errors

All charges.

Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

Note: See Orthopedic and prosthetic devices for information on podiatric shoe inserts.

$20 per PCP visit

$30 per specialist visit

Not covered:

Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above

Treatment of weak, strained or flat feet; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open manipulation or fixation)

Foot orthotics

Podiatric shoe inserts

All charges.

Orthopedic devices such as braces and prosthetic devices such as artificial limbs and eyes. Limb and torso prosthetics must be preauthorized.

Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, penile implants, defibrillator, surgically implanted breast implant following mastectomy, and lenses following cataract removal. Note: See 5(b) for coverage of the surgery to insert the device

Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

Ostomy supplies specific to ostomy care (quantities and types vary according to the ostomy, location, construction, etc.)

Note: Coverage includes repair and replacement when due to growth or normal wear and tear.

Nothing

Not covered:

Orthopedic and corrective shoes not attached to a covered brace

Arch supports

Foot orthotics

Heel pads and heel cups

Lumbosacral supports

All charges.

Rental or purchase, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as oxygen equipment. Under this benefit, we also cover:

Hospital beds (Clinitron and electric beds must be preauthorized);

Wheelchairs (motorized wheelchairs and scooters must be preauthorized);

Crutches;

Walkers; and

Insulin pumps and related supplies such as needles and catheters.

Note: Some DME may require precertification by you or your physician

Nothing

Not covered:

Elastic stockings and support hose

Bathroom equipment such as bathtub seats, benches, rails and lifts

Home modifications such as stairglides, elevators and wheelchair ramps

Wheelchair lifts and accessories needed to adapt to the outside environment or convenience for work or to perform leisure or recreational activities

All charges.

Home health care ordered by a Plan Physician and provided by nurses and home health aides. Your Plan Physician will periodically review the program for continuing appropriateness and need.

Services include oxygen therapy, intravenous therapy and medications.

Note: Short-term physical therapy or occupational therapy accumulate toward the applicable benefit limit (see physical and occupational therapy benefit in this section).

Note: Home health services must be precertified by your Plan physician.

Nothing

Not covered:

Nursing care requested by, or for the convenience of, the patient or the patient�s family.

Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative.

Services provided by a family member or resident in the member�s home.

Services rendered at any site other than the member�s home.

All charges.

Chiropractic services up to 20 visits per member per calendar year

Manipulation of the spine and extremities

Adjunctive procedures such as ultrasound, electric muscle stimulation, vibratory therapy and cold pack application

$30 per specialist visit

Not covered: Any services not listed above

All charges.

No benefits

All charges.

We offer the following Aetna disease management programs at no cost to you:

Asthma

Diabetes

Chronic heart failure

Low back pain

Coronary artery disease

To request more information on our disease management programs, call
1-800/537-9384. Also see the Non-FEHB page for our InteliHealth and Fitness Program.

Nothing

I

M

P

O

R

T

A

N

T

Here are some important things you should keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5(c) for charges associated with the facility (i.e., hospital, surgical center, etc.).

YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.

I

M

P

O

R

T

A

N

T

A comprehensive range of services, such as:

Operative procedures

Treatment of fractures, including casting

Normal pre- and post-operative care by the surgeon

Correction of amblyopia and strabismus

Endoscopy procedures

Biopsy procedures

Removal of tumors and cysts

Correction of congenital anomalies (see Reconstructive surgery)

Surgical treatment of morbid obesity -- a condition in which an individual weighs 100 pounds or 100% over his or her normal weight according to current underwriting standards; eligible members must be age 18 or over. This procedure must be approved by the HMO.

Insertion of internal prosthetic devices. See 5(a) � Orthopedic and prosthetic devices for device coverage information

Voluntary sterilization (e.g., Tubal ligation, Vasectomy)

Treatment of burns

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pacemaker.

$20 per PCP visit

$30 per specialist visit

Nothing for the surgery

Not covered:

Reversal of voluntary surgically-induced sterilization

Surgery primarily for cosmetic purposes

Radial keratotomy and laser surgery, including related procedures designed to surgically correct refractive errors

Whole blood and concentrated red blood cells not replaced by the member

Routine treatment of conditions of the foot; see Foot care

All charges.

Surgery to correct a functional defect

Surgery to correct a condition caused by injury or illness if:

the condition produced a major effect on the member�s appearance and

the condition can reasonably be expected to be corrected by such surgery

Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital and developmental anomalies are: cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes. All surgical requests must be preauthorized.

All stages of breast reconstruction surgery following a mastectomy, such as:

surgery to produce a symmetrical appearance of breasts;

treatment of any physical complications, such as lymphedemas;

breast prostheses and surgical bras and replacements (see Prosthetic devices)

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

$30 per specialist visit and nothing for the surgery

Not covered:

Cosmetic surgery � any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury

Surgeries related to sex transformation

All charges.

Oral surgical procedures, that are medical in nature, such as:

Treatment of fractures of the jaws or facial bones;

Removal of stones from salivary ducts;

Excision of benign or malignant lesions;

Medically necessary surgical treatment of TMJ, must be preauthorized; and

Excision of tumors and cysts.

Note: When requesting oral and maxillofacial services, please check DocFind or call Member Services at 1-800/537-9384 for a participating oral and maxillofacial surgeon.

$30 per specialist visit and nothing for the surgery.

Not covered:

Dental implants

Dental care (such as restorations) involved with the treatment of temporomandibular joint (TMJ) pain dysfunction syndrome

All charges.

Limited to:

Cornea

Heart

Heart/lung

Kidney

Liver

Lung: Single � Double

Pancreas

Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach, and pancreas

Skin

Tissue

Allogeneic (donor) bone marrow/peripheral stem cell transplants

Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute lymphocytic or non-lymphocytic leukemia; advanced Hodgkin�s lymphoma; advanced non-Hodgkin�s lymphoma; advanced neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors

Autologous tandem transplants for ovarian cancers as well as testicular cancers

$30 per specialist office visit and nothing for the surgery

Organ/tissue transplants � continued on next page

National Transplant Program (NTP) � Transplants which are non-experimental or non-investigational are a covered benefit. Covered transplants must be ordered by your primary care doctor and plan specialist physician and approved by our medical director in advance of the surgery. The transplant must be performed at hospitals (Institutes of Excellence) specifically approved and designated by us to perform these procedures. A transplant is non-experimental and non-investigational when we have determined, in our sole discretion, that the medical community has generally accepted the procedure as appropriate treatment for your specific condition. Coverage for a transplant where you are the recipient includes coverage for the medical and surgical expenses of a live donor, to the extent these services are not covered by another plan or program.

Limited Benefits � Treatment for breast cancer, multiple myeloma and epithelial ovarian cancer may be provided in a National Cancer Institute (NCI)- or National Institutes of Health (NIH)-approved clinical trial at a Plan-designated center of excellence and if approved by the Plan�s medical director in accordance with the Plan�s protocols.

Note: Harvesting of tissue for storage purposes only is not eligible for coverage. If both the donor and the transplant recipient are covered by us, donor expenses are attributed to the transplant recipient�s coverage. Aetna does not extend coverage for donor services when the transplant recipient is not our member.

$30 per specialist office visit and nothing for the surgery

Not covered: Transplants not listed as covered

All charges.

Professional services provided in �

Hospital (inpatient)

Hospital outpatient department

Skilled nursing facility

Ambulatory surgical center

Office

Note: For sedation or anesthesia relating to dental services performed in a dental office, see Section 5(h), Dental benefits.

Note: When the anesthesiologist is the primary giver of services, such as for pain management, the specialist copay applies.

Nothing

I

M

P

O

R

T

A

N

T

Here are some important things you should keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge (i.e., physicians, etc.) are in Sections 5(a) or (b).

YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification.

I

M

P

O

R

T

A

N

T

Room and board, such as

Ward, semiprivate, or intensive care accommodations;

General nursing care; and

Meals and special diets.

Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

$150 per day up to a maximum of $750 per admission

Other hospital services and supplies, such as:

Operating, recovery, maternity, and other treatment rooms

Prescribed drugs and medicines

Diagnostic laboratory tests and X-rays

Administration of blood and blood products

Blood products, derivatives and components, artificial blood products and biological serum. Blood products include any product created from a component of blood such as, but not limited to, plasma, packed red blood cells, platelets, albumin, Factor VIII, Immunoglobulin, and prolastin

Dressings, splints, casts, and sterile tray services

Medical supplies and equipment, including oxygen

Anesthetics, including nurse anesthetist services

Take-home items

Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home.

Nothing

Not covered:

Whole blood and concentrated red blood cells not replaced by the member

Non-covered facilities, such as nursing homes, schools

Custodial care, rest cures, domiciliary or convalescent cares

Personal comfort items, such as telephone and television

Private nursing care

All charges.

Operating, recovery, and other treatment rooms

Prescribed drugs and medicines

Radiologic procedures, diagnostic laboratory tests, and X-rays when associated with a medical procedure being done the same day

Pathology Services

Administration of blood, blood plasma, and other biologicals

Blood products, derivatives and components, artificial blood products and biological serum

Pre-surgical testing

Dressings, casts, and sterile tray services

Medical supplies, including oxygen

Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.

$200 per visit

Services not associated with a medical procedure being done the same day, such as:

Mammogram

Radiologic procedures

Lab tests

$30 per specialist visit

Not covered: Whole blood and concentrated red blood cells not replaced by the member.

All charges.

Extended care benefit: All necessary services during confinement in a skilled nursing facility with a 90-day limit per calendar year when full-time nursing care is necessary and the confinement is medically appropriate as determined by a Plan doctor and approved by the Plan.

Nothing

Not covered: Custodial care

All charges.

Supportive and palliative care for a terminally ill member in the home or hospice facility, including inpatient and outpatient care and family counseling, when provided under the direction of a Plan doctor, who certifies the patient is in the terminal stages of illness, with a life expectancy of approximately 6 months or less.

Nothing

Ambulance service ordered or authorized by a Plan doctor

Nothing

Not covered: Ambulance services for routine transportation to receive outpatient or inpatient services.

All charges.

I

M

P

O

R

T

A

N

T

Here are some important things to keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

I

M

P

O

R

T

A

N

T

What is a medical emergency?

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

What to do in case of emergency:

If you need emergency care, you are covered 24 hours a day, 7 days a week, anywhere in the world. An emergency medical condition is one manifesting itself by acute symptoms of sufficient severity such that a prudent layperson, who possesses average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the person�s health, or with respect to a pregnant woman, the health of the woman and her unborn child.

Whether you are in or out of an Aetna HMO service area, we simply ask that you follow the guidelines below when you believe you need emergency care.

Call the local emergency hotline (e.g., 911) or go to the nearest emergency facility. If a delay would not be detrimental to your health, call your primary care physician. Notify your primary care physician as soon as possible after receiving treatment.

After assessing and stabilizing your condition, the emergency facility should contact your primary care physician so he/she can assist the treating physician by supplying information about your medical history.

If you are admitted to an inpatient facility, you or a family member or friend on your behalf should notify your primary care physician or Aetna as soon as possible.

What to Do Outside Your Aetna HMO Service Area:

Members who are traveling outside their HMO service area or students who are away at school are covered for emergency and urgently needed care. Urgent care may be obtained from a private practice physician, a walk-in clinic, an urgent care center or an emergency facility. Certain conditions, such as severe vomiting, earaches, sore throats or fever, are considered �urgent care� outside your Aetna HMO service area and are covered in any of the above settings.

If, after reviewing information submitted to us by the provider that supplied care, the nature of the urgent or emergency problem does not qualify for coverage, it may be necessary to provide us with additional information. We will send you an Emergency Room Notification Report to complete, or a Member Services representative can take this information by telephone.

Follow-up Care after Emergencies

All follow-up care should be coordinated by your PCP or network specialist. Follow-up care with non-participating providers is only covered with a referral from your primary care physician and pre-approval from Aetna. Whether you were treated inside or outside your Aetna service area, you must obtain a referral before any follow-up care can be covered. Suture removal, cast removal, X-rays and clinic and emergency room revisits are some examples of follow-up care.

What to do in case of emergency:

Emergencies within our service area: If you are in an emergency situation, call you primary care doctor. In extreme emergencies or if you are unable to contact your doctor, contact the local emergency system (e.g., the 911 telephone system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify your primary care doctor. You or a family member must notify your primary care doctor as soon as possible after receiving emergency care. It is your responsibility to ensure that your primary care doctor has been timely notified.

If you need to be hospitalized, the Plan must be notified as soon as possible. If you are hospitalized in non-Plan facilities and a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

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

Emergencies outside our service area: Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.

If you need to be hospitalized, the Plan must be notified as soon as possible. If a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

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

Emergency care at a doctor�s office

$20 per PCP visit

$30 per specialist visit

Emergency care as an outpatient in a hospital or an urgent care center

Note: If the emergency results in admission to a hospital the copay is waived.

$100 per visit

Not covered: Elective care or non-emergency care

All charges.

Emergency outside our service area

Emergency care at a doctor�s office

$30 per specialist visit

Emergency care as an outpatient in a hospital or an urgent care center

Note: If the emergency results in admission to a hospital the copay is waived.

$100 per visit

Not covered:

Elective care or non-emergency 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.

All charges.

Professional ambulance service when medically appropriate. Air ambulance may be covered. Prior approval is required.

Note: See 5(c) for non-emergency service.

Nothing

Not covered: Air ambulance without prior approval.

All charges.

I

M

P

O

R

T

A

N

T

When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance abuse benefits will be no greater than for similar benefits for other illnesses and conditions.

Here are some important things to keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

I

M

P

O

R

T

A

N

T

All diagnostic and treatment services recommended by a Plan provider and contained in a treatment plan that we approve. The treatment plan may include services, drugs, and supplies described elsewhere in this brochure.

Note: Plan benefits are payable only when we determine the care is clinically appropriate to treat your condition and only when you receive the care as part of a treatment plan that we approve.

Your cost sharing responsibilities are no greater than for other illnesses or conditions.

Professional services, including individual or group therapy by providers such as psychiatrists, psychologists, or clinical social workers

Medication management

$30 per visit

Diagnostic tests

$30 per visit

Outpatient Services provided by a hospital or other facility

Services in approved alternative care settings such as partial hospitalization, facility based intensive outpatient treatment

$30 per outpatient visit

Inpatient services:

Approved residential treatment facility

Hospital service

$150 per day up to a maximum of $750 per admission

Not covered:

Services we have not approved.

Out of network mental health and substance abuse services

Note: OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.

All charges.

Mental health and substance abuse benefits - continued on next page.

Preauthorization

Behavioral health care services (e.g., treatment or care for mental disease or illness, alcohol abuse and/or substance abuse) are managed by an independently contracted organization (Behavioral Health Contractor). This organization makes initial coverage determinations and coordinates referrals; any behavioral health care referrals will be made to providers affiliated with the organization, unless your needs for covered services extend beyond the capability of the affiliated providers. Emergency care is covered (See Section 5(d), Emergency services/accidents). You can receive information regarding the appropriate way to access the behavioral health care services that are covered under your specific plan by calling Member Services at 1-800/537-9384 or by calling the Behavioral Health Contractor number on the front of your ID card. A referral from your PCP is not necessary to access the Behavioral Health Contractor but your PCP may assist with your referral to the Behavioral Health Contractor.

Limitation

We may limit your benefits if you do not obtain a treatment plan.

I

M

P

O

R

T

A

N

T

Here are some important things to keep in mind about these benefits:

We cover prescribed drugs and medications, as described in the chart beginning on the next page.

Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

Certain drugs require your doctor to get precertification from the Plan before they can be prescribed under the Plan. Upon approval by the Plan, the prescription is good for the current calendar year or a specified time period, whichever is less.

I

M

P

O

R

T

A

N

T

There are important features you should be aware of. These include:

239) Who can write your prescription. A licensed Plan physician or dentist must write the prescription.

240) Where you can obtain them. You must fill non-emergency prescriptions at a participating Plan retail pharmacy for up to a 30-day supply, or by mail order for a 31-day up to a 90-day supply of medication (if authorized by your physician). Please call Member Services at 1-800/537-9384 for more details on how to use the mail order program. In an emergency or urgent care situation, you may fill your covered prescription at any retail pharmacy. If you obtain your prescription at a participating pharmacy and request direct reimbursement from us, we will review your claim to determine whether the claim is covered under the terms and conditions of your benefit plan. If you obtain your prescription at a pharmacy that does not participate with the plan, you will need to pay the pharmacy the full price of the prescription and submit a claim for reimbursement subject to the terms and conditions of the plan.

241) We use a formulary. 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. Certain drugs require your doctor to get precertification from the Plan before they can be prescribed under the Plan. Visit our Web site at www.aetna.com/fed to review our Formulary Guide or call 1-800/537-9384.

242) Precertification. Your pharmacy benefits plan includes our precertification program. Precertification helps encourage the appropriate and cost-effective use of certain drugs. These drugs must be pre-authorized by our Pharmacy Management Precertification Unit before they will be covered. Only your physician or pharmacist in the case of an antibiotic or analgesic can request prior authorization for a drug. Step-therapy is another type of precertification under which certain medications will be excluded from coverage unless you try one or more �prerequisite� drug(s) first, or unless a medical exception is obtained. The drugs requiring precertification or step-therapy are subject to change. Visit our Web site at www.aetna.com/fed for the most current information regarding the precertification and step-therapy lists.

243) These are the dispensing limitations. Covered prescription drugs prescribed by a licensed physician or dentist and obtained at a participating Plan retail pharmacy may be dispensed for up to a 30-day supply. Members must obtain a 31-day up to a 90-day supply of covered prescription medication through mail order. In no event will the copay exceed the cost of the prescription drug. A generic equivalent will be dispensed if available, unless your physician specifically requires a brand name.

244) In the event that a member is called to active military duty and requires coverage under their prescription plan benefits of an additional filling of their medication(s) prior to departure, their pharmacist will need to contact Aetna. Coverage of additional prescriptions will only be allowed if there are refills remaining on the member�s current prescription or a new prescription has been issued by their physician. The member is responsible for the applicable copayment for the additional prescription.

245) Aetna allows coverage of a medication filling when at least 75% of the previous prescription, according to the physician�s prescribed directions, has been utilized. For a 30-day supply of medication, this provision would allow a new prescription to be covered on the 23rd day, thereby allowing a member to have an additional supply of their medication, in case of emergency.

Why use generic drugs? Generics contain the same active ingredients in the same amounts as their brand name counterparts and have been approved by the FDA. By using generic drugs, when available, most members see cost savings, without jeopardizing clinical outcome or compromising quality.

When you do have to file a claim. Send your itemized bill(s) to: Aetna, Pharmacy Management, Claim Processing,
P.O. Box 398106, Minneapolis, MN 55439-8106.

We cover the following medications and supplies prescribed by a Plan physician or dentist and obtained from a Plan pharmacy or through our mail order program:

Drugs for which a prescription is required by Federal law, except those listed as Not covered.

Oral contraceptive drugs

Insulin

Disposable needles and syringes needed to inject covered prescribed medications

Diabetic supplies limited to lancets, alcohol swabs, urine test strips/tablets, and blood glucose test strips

Contraceptive drugs and devices

Oral fertility drugs

Retail Pharmacy, for up to a 30-day supply per prescription or refill:

$10 per covered generic formulary drug;

$25 per covered brand name formulary drug; and

$40 per covered non-formulary (generic or brand name) drug.

Mail Order Pharmacy, for a 31-day up to a 90-day supply per prescription or refill:

$20 per covered generic formulary drug

$50 per covered brand name formulary drug; and

$80 per covered non-formulary (generic or brand name) drug.

Limited benefits:

Drugs to treat sexual dysfunction are limited. Contact the Plan for dose limits

Depo Provera is limited to 5 vials per calendar year

One diaphragm per calendar year

50%

$25 copay per vial

$25 per diaphragm

Here are some things to keep in mind about our prescription drug program:

A generic equivalent may be dispensed if it is available, and where allowed by law.

To request a copy of the Aetna Medication Formulary Guide, call
1-800/537-9384. The information in the Medication Formulary Guide is subject to change. As brand name drugs lose their patents and new generics become available on the market, the brand name drug may be removed from the formulary. Under your benefit plan, this will result in a savings to you, as you pay a lower prescription copayment for generic formulary drugs. Please visit our Web site at www.aetna.com/fed for current Medication Formulary Guide information.

Not covered:

Drugs available without a prescription or for which there is a nonprescription equivalent available, (i.e., an over-the-counter (OTC) drug)

Drugs obtained at a non-Plan pharmacy except when related to out-of-area emergency care

Vitamins and nutritional substances that can be purchased without 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)

Prophylactic drugs including, but not limited to, anti-malarials for travel

All charges.

Services for the deaf and hearing-impaired

1-800/628-3323

Informed Health^� Line

Provides eligible members with telephone access to registered nurses experienced in providing information on a variety of health topics. Informed Health Line is available 24 hours a day, 7 days a week. You may call Informed Health Line at 1-800/556-1555. Through Informed Health Line, members also have 24-hour access to an audio health library � equipped with information on more than 2,000 health topics, and accessible on demand through any touch tone telephone. Topics are available in both English and Spanish. We provide TDD service for the hearing and speech-impaired. We also offer foreign language translation for non-English speaking members. Informed Health Line nurses cannot diagnose, prescribe medication or give medical advice.

Maternity Management Program

Aetna�s Moms-to-Babies� Maternity Management Program provides services, information and resources to help improve pregnancy outcomes. Features of the program include a pregnancy risk survey, obstetrical nurse care coordination, comprehensive educational information on prenatal care, labor and delivery, newborn and baby care, a smoking-cessation program, and more. To enroll in the program, call toll-free 1-800/CRADLE-1.

National Medical Excellence Program

National Medical Excellence Program helps eligible members access appropriate, covered treatment for solid organ and tissue transplants using our Institutes of Excellence� network. We coordinate specialized treatment needed by members with certain rare or complicated conditions and assist members who are admitted to a hospital for emergency medical care when they are traveling temporarily outside of the United States. Services under this program must be preauthorized.

Reciprocity benefit

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 network.

Call 1-800/537-9384 for provider information and location

Select a doctor from 3 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.

I

M

P

O

R

T

A

N

T

Here are some important things to keep in mind about these benefits:

264) Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

265) Your selected Plan primary care dentist must provide or arrange covered care. Please select a primary care dentist before you need care!

266) We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. See Section 5 (c) for inpatient hospital benefits. We do not cover the dental procedure unless it is described below.

267) Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

I

M

P

O

R

T

A

N

T

Dental benefits

Diagnostic

Office visit for routine oral evaluation � limited to 2 visits per year

Bitewing x-rays � limited to 2 sets of bitewing x-rays per year

Complete x-ray series � limited to 1 complete x-ray series in any 3 year period

Periapical x-rays and other dental x-rays � as necessary

Diagnostic casts

$5

$5

$5

$5

$5

Preventive

Prophylaxis (cleaning of teeth) � limited to 2 treatments per year

Topical application of fluoride � limited to 2 courses of treatment per year and to children under age 18

Oral hygiene instruction

$5

$5

$5

Restorative (Fillings)

Amalgam 1 surface, primary or permanent

Amalgam 2 surfaces, primary or permanent

Amalgam 3 surfaces, primary or permanent

Amalgam 4 or more surfaces, primary or permanent

$5

$5

$5

$5

Prosthodontics Removable

Denture adjustments (complete or partial/upper or lower)

$5

Dental benefits � continued on next page

Dental benefits (continued)

Service

You pay

Endodontics

Pulp cap � direct

Pulp cap � indirect

$5

$5

Note: The above services are only covered when provided by your selected participating primary care dentist in accordance with the terms of your Plan. If rendered by a participating specialist, they are provided at reduced fees. Pediatric dentists are considered specialists. Certain other services will be provided by your selected participating primary care dentist at reduced fees. A partial list appears below. Ask your selected participating primary care dentist for a complete schedule of current reduced member fees. All member fees must be paid directly to the participating dentist.

Each employee and dependent must select a primary care dentist from the directory and include the dentist�s name on the enrollment or provider selection form.

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

Service

You pay up to a maximum fee of

Preventive

Sealant � per permanent tooth

Space maintainer

$35

$560

Restorative (Fillings)

Resin-based composite (anterior) 1 surface

Resin-based composite (anterior) 2 surfaces

Resin-based composite (anterior) 3 surfaces

Resin-based composite (anterior) 4 or more surfaces or incisal angle

Metallic inlay

$110

$145

$175

$190

$725

Prosthodontics, removable

Complete denture, (upper or lower)

Immediate denture (upper or lower)

Partial denture resin base (upper or lower)

Partial denture cast metal framework with resin base (upper or lower)

Denture repairs

Add tooth to existing partial

Add clasp to existing partial

Denture rebase

Denture relines

Interim denture (complete or partial/upper or lower)

Tissue conditioning

$1,025

$1,110

$790

$1,200

$150

$135

$150

$375

$325

$465

$110

Dental benefits � continued on next page

Dental benefits (continued)

Service

You pay up to a maximum fee of

Prosthodontics, fixed

Bridge pontic

Metallic inlay/onlay

Cast metal retainer for resin bonded prosthesis

Crown porcelain/ceramic

Crown cast metal

Recement bridge

Post and core

$875

$815

$315

$860

$865

$85

$315

Oral surgery

Extractions (surgical, soft tissue, and bony impacted teeth)

Deep sedation/general anesthesia (in office)

$482

$267

Periodontics (Gum treatment)

Gingivectomy or gingivoplasty, per quadrant

Osseous surgery, per quadrant

Provisional splinting

Periodontal Scaling and root planing per quadrant

Periodontal maintenance procedure

$315

$760

$160

$150

$110

Endodontics (Root canal)

Therapeutic pulpotomy

Root canals therapy (anterior, bicuspid, molar) excluding final restoration

Apicoectomy/periradicular surgery � anterior, bicuspid, or molar

$125

$760

$510

Orthodontics

Pre-orthodontic treatment visit

Comprehensive orthodontic treatment fully banded case (adult age 19 and over)

Comprehensive orthodontic treatment fully banded case (child age 18 and under)

$350

$5,625

$5,625

Specific fees vary by area of the country up to the stated maximum. Please note that this is a partial list of services provided by your selected participating primary care dentist at reduced fees. Ask your primary care dentist for a complete schedule of reduced fees.

Note: If requesting oral and maxiollofacial services such as TMJ surgery, please refer to Section 5(b), Oral and Maxillofacial surgery.

Not covered: Services not received from a participating dental provider. We offer no other dental benefits than those shown above.

All charges.

Medical, hospital and drug benefits

In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form. Your facility will file on the UB-92 form. For claims questions and assistance, call us at 1-800/537-9384.

When you must file a claim � such as for services you receive outside the Plan�s service area � submit it on the HCFA-1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show:

Covered member�s name and ID number;

Name and address of the physician or facility that provided the service or supply;

Dates you received the services or supplies;

Diagnosis;

Type of each service or supply;

The charge for each service or supply;

A copy of the explanation of benefits, payments, or denial from any primary payer � such as the Medicare Summary Notice (MSN); and

Receipts, if you paid for your services.

Submit your medical, hospital and dental claims to: Aetna, 1425 Union Meeting Road, P.O. Box 1125, Blue Bell, PA 19422.

Submit your drug claims to: Aetna, Pharmacy Management, Claim Processing, P.O. Box 398106, Minneapolis, MN 55439-8106.

Deadline for filing your claim

Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.

When we need more information

Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond.

1

Ask us in writing to reconsider our initial decision. You must:

a) Write to us within 6 months from the date of our decision; and

b) Send your request to us at: Aetna, Attention: National Accounts, P.O. Box 14463, Lexington, KY 40512;and

c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

2

We have 30 days from the date we receive your request to:

a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or

b) Write to you and maintain our denial - go to step 4; or

c) Ask you or your provider for more information. If we ask your provider, we will send you a copy of our request�go to step 3.

3

You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have.

We will write to you with our decision.

4

If you do not agree with our decision, you may ask OPM to review it.

You must write to OPM within:

90 days after the date of our letter upholding our initial decision; or

120 days after you first wrote to us - if we did not answer that request in some way within 30 days; or

120 days after we asked for additional information.

Write to OPM at: United States Office of Personnel Management, Insurance Services Programs, Health Insurance Group 3, 1900 E Street, NW, Washington, DC 20415-3630.

Send OPM the following information:

A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;

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

Copies of all letters you sent to us about the claim;

Copies of all letters we sent to you about the claim; and

Your daytime phone number and the best time to call.

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

5

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.

If you do not agree with OPM�s 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, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.

You may not sue until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and

a) We haven�t responded yet to your initial request for care or preauthorization/prior approval, then call us at 1-800/537-9384 and we will expedite our review; or

b) We denied your initial request for care or preauthorization/prior approval, then:

If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

You may call OPM�s Health Insurance Group 3 at 202/606-0755 between 8 a.m. and 5 p.m. eastern time.

External 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, after 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 Member Services at 1-800/537-9384.

When you have other health coverage

You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that pays health care expenses without regard to fault. This is called �double coverage.�

When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary payer. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners� guidelines.

When we are the primary payer, we will pay the benefits described in this brochure.

When we are the secondary payer, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up to our regular benefit. We will not pay more than our allowance.

What is Medicare?

Medicare is a Health Insurance Program for:

People 65 years of age or older.

Some people with disabilities under 65 years of age.

People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).

Medicare has two parts:

Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your spouse worked for at least 10 years in Medicare-covered employment, you should be able to qualify for premium-free Part A insurance. (Someone who was a Federal employee on January 1, 1983 or since automatically qualifies.) Otherwise, if you are age 65 or older, you may be able to buy it. Contact 1-800/MEDICARE for more information.

Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social Security check or your retirement check.

Should I enroll in Medicare?

The decision to enroll in Medicare is yours. We encourage you to apply for Medicare benefits 3 months before you turn age 65. It�s easy. Just call the Social Security Administration toll-free number 1-800/772-1213 to set up an appointment to apply. If you do not apply for one or both Parts of Medicare, you can still be covered under the FEHB Program.

If you can get premium-free Part A coverage, we advise you to enroll in it. Most Federal employees and annuitants are entitled to Medicare Part A at age 65 without cost. When you don�t have to pay premiums for Medicare Part A, it makes good sense to obtain the coverage. It can reduce your out-of-pocket expenses as well as costs to the FEHB, which can help keep FEHB premiums down.

Everyone is charged a premium for Medicare Part B coverage. The Social Security Administration can provide you with premium and benefit information. Review the information and decide if it makes sense for you to buy the Medicare Part B coverage.

If you are eligible for Medicare, you may have choices in how you get your health care. Medicare Advantage is the term used to describe the various private health plan choices available to Medicare beneficiaries. The information in the next few pages shows how we coordinate benefits with Medicare, depending on whether you are in the Original Medicare Plan or a private Medicare Advantage Plan.

The Original Medicare Plan (Part A or Part B)

The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share. Some things are not covered under Original Medicare, such as most prescription drugs (but coverage through private prescription drug plans will be available starting in 2006).

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. Your care must continue to be authorized by your Plan PCP or precertified as required. Also, please note that if your Plan physician does not participate in Medicare, you will have to file a claim with Medicare

Claims process when you have the Original Medicare Plan � You probably will never have to file a claim form when you have both our Plan and the Original Medicare Plan.

When we are the primary payer, we process the claim first.

When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. You will not need to do anything. To find out if you need to do something to file your claim, call us at 1-800/537-9384 or see our Web site at www.aetna.com/fed.

We do not waive any costs if the Original Medicare Plan is your primary payer.

{Primary Payer chart is on next page.)

1) Have FEHB coverage on your own as an active employee or through your spouse who is an active employee

2) Have FEHB coverage on your own as an annuitant or through your spouse who is an annuitant

3) Are a reemployed annuitant with the Federal government and your position is excluded from the FEHB (your employing office will know if this is the case) and you are not covered under FEHB through your spouse under #1 above

4) Are a reemployed annuitant with the Federal government and your position is not excluded from the FEHB (your employing office will know if this is the case) and �

You have FEHB coverage on your own or through your spouse who is also an active employee

You have FEHB coverage through your spouse who is an annuitant

5) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired under Section 7447 of title 26, U.S.C. (or if your covered spouse is this type of judge) and you are not covered under FEHB through your spouse under #1 above

6) Are enrolled in Part B only, regardless of your employment status

for Part B services

for other services

7) Are a former Federal employee receiving Workers� Compensation and the Office of Workers� Compensation Programs has determined that you are unable to return to duty

*

1) Have Medicare solely based on end stage renal disease (ESRD) and�

It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)

It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD

2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and�

This Plan was the primary payer before eligibility due to ESRD

for 30-month coordination period

Medicare was the primary payer before eligibility due to ESRD

1) Have FEHB coverage on your own as an active employee or through a family member who is an active employee

2) Have FEHB coverage on your own as an annuitant or through a family member who is an annuitant

Medicare Advantage

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private health care choices (like HMOs) in some areas of the country. In most Medicare Advantage plans, you can only go to doctors, specialists, or hospitals that are part of the plan. Medicare Advantage plans provide all the benefits that Original Medicare covers. Some cover extras, like prescription drugs. To learn more about enrolling in a Medicare Advantage plan, contact Medicare at 1-800/MEDICARE (1-800/633-4227) or at www.medicare.gov.

If you enroll in a Medicare Advantage plan, the following options are available to you:

This Plan and our Medicare Advantage plan: You may enroll in our Medicare Advantage Plan and also remain enrolled in our FEHB Plan. If you are an annuitant or former spouse with FEHBP coverage and are enrolled in Medicare Parts A and B, you may enroll in our Medicare Advantage plan if one is available in your area. We do not waive cost-sharing for your FEHB coverage.

This Plan and another plan�s Medicare Advantage plan: You may enroll in another plan�s Medicare Advantage plan and also remain enrolled in our FEHB plan. We will still provide benefits when your Medicare Advantage plan is primary, even out of the managed care plan�s network and/or service area (if you use our Plan providers), but we will not waive any of our copayments or coinsurance. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare Advantage plan premium.) For information on suspending your FEHB enrollment, 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 unless you involuntarily lose coverage or move out of the Medicare Advantage plan�s service area.

TRICARE and CHAMPVA

TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. IF TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your FEHB enrollment, 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 unless you involuntarily lose coverage under the program.

Workers� Compensation

We do not cover services that:

You need because of a workplace-related illness or injury that the Office of Workers� Compensation Programs (OWCP) or a similar Federal or State agency determines they must provide; or

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 OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care.

Medicaid

When you have this Plan and Medicaid, we pay first.

Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these State programs, eliminating your FEHB premium. For information on suspending your FEHB enrollment, 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 unless you involuntarily lose coverage under the State program.

When other Government agencies are responsible for your care

We do not cover services and supplies when a local, State, or Federal government agency directly or indirectly pays for them.

When others are responsible for injuries

When you receive money to compensate you for medical or hospital care for injuries or illness caused by another person, you must reimburse us for any expenses we paid. However, we will cover the cost of treatment that exceeds the amount you received in the settlement.

The words �Third Party� or �Any party making payments on the third party�s behalf� includes not only the insurance carrier(s) for the responsible party, but also any uninsured motorist coverage, underinsured motorist coverage, personal umbrella coverage, medical payments coverage, workers� compensation coverage, no-fault automobile insurance coverage or any other first party insurance coverage. The words �Member,� �you� and �your� include anyone on whose behalf the Plan pays or provides any benefits.

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.

You specifically acknowledge our right of subrogation. When we provide health care benefits for injuries or illnesses for which a third party is or may be responsible, we shall be subrogated to your rights of recovery against any third party to the extent of the full cost of all benefits provided by us, to the fullest extent permitted by law. We may proceed against any third party with or without your consent.

You also specifically acknowledge our right of reimbursement. This right of reimbursement attaches, to the fullest extent permitted by law, when we have provided health care benefits for injuries or illnesses for which a third party is or may be responsible and you and/or your representative has recovered any amounts from the third party or any party making payments on the third party�s behalf. By providing any benefit under this Plan, we are granted an assignment of the proceeds of any settlement, judgment or other payment received by you to the extent of the full cost of all benefits provided by us. Our right of reimbursement is cumulative with and not exclusive of our subrogation right and we may choose to exercise either or both rights of recovery.

You and your representatives further agree to:

Notify us in writing within 30 days of when notice is given to any third party of the intention to investigate or pursue a claim to recover damages or obtain compensation due to injuries or illnesses sustained by you that may be the legal responsibility of a third party; and

Cooperate with us and do whatever is necessary to secure our rights of subrogation and/or reimbursement under this Plan; and

Give us a first-priority lien on any recovery, settlement or judgment or other source of compensation which may be had from a third party to the extent of the full cost of all benefits provided by us associated with injuries or illnesses for which a third party is or may be responsible (regardless of whether specifically set forth in the recovery, settlement, judgment or compensation agreement); and

Pay, as the first priority, from any recovery, settlement or judgment or other source of compensation, any and all amounts due us as reimbursement for the full cost of all benefits provided by us associated with injuries or illnesses for which a third party is or may be responsible (regardless of whether specifically set forth in the recovery, settlement, judgment, or compensation agreement), unless otherwise agreed to by us in writing; and

Do nothing to prejudice our rights as set forth above. This includes, but is not limited to, refraining from making any settlement or recovery which specifically attempts to reduce or exclude the full cost of all benefits provided by us.

We may recover the full cost of all benefits provided by us under this Plan without regard to any claim of fault on the part of you, whether by comparative negligence or otherwise. We may recover the full cost of all benefits provided by us under this Plan even if such payment will result in a recovery to you which is insufficient to make you whole or fully compensate you for your damages. No court costs or attorney fees may be deducted from our recovery without the prior express written consent of us. In the event you or your representative fails to cooperate with us, you shall be responsible for all benefits paid by us in addition to costs and attorney�s fees incurred by us in obtaining repayment.

Calendar year

January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year.

Coinsurance

Coinsurance is the percentage of our allowance that you must pay for your care. See page 19.

Copayment

A copayment is a fixed amount of money you pay when you receive covered services. See page 19.

Covered services

Care we provide benefits for, as described in this brochure.

Custodial care

Any type of care provided according to Medicare guidelines, including room and board, that a) does not require the skills of technical or professional personnel; b) is not furnished by or under the supervision of such personnel or does not otherwise meet the requirements of post-hospital Skilled Nursing Facility care; or c) is a level such that you have reached the maximum level of physical or mental function and such person is not likely to make further significant improvement. Custodial care includes any type of care where the primary purpose is to attend to your daily living activities which do not entail or require the continuing attention of trained medical or paramedical personnel. Examples include assistance in walking, getting in and out of bed, bathing, dressing, feeding, using the toilet, changes of dressings of noninfected wounds, post-operative or chronic conditions, preparation of special diets, supervision of medication which can be self-administered by you, the general maintenance care of colostomy or ileostomy, routine services to maintain other service which, in our sole determination, is based on medically accepted standards, can be safely and adequately self-administered or performed by the average non-medical person without the direct supervision of trained medical or paramedical personnel, regardless of who actually provides the service, residential care and adult day care, protective and supportive care including educational services, rest cures, or convalescent care. Custodial care that lasts 90 days or more is sometimes known as long term care. Custodial care is not covered.

Detoxification

The process whereby an alcohol or drug intoxicated or alcohol or drug dependent person is assisted, in a facility licensed by the appropriate regulatory authority, through the period of time necessary to eliminate, by metabolic or other means, the intoxicating alcohol or drug, alcohol or drug dependent factors or alcohol in combination with drugs as determined by a licensed Physician, while keeping the physiological risk to the patient at a minimum.

Experimental or investigational services

Services or supplies that are, as determined by us, experimental. A drug, device, procedure or treatment will be determined to be experimental if:

There is not sufficient outcome data available from controlled clinical trials published in the peer reviewed literature to substantiate its safety and effectiveness for the disease or injury involved; or

Required FDA approval has not been granted for marketing; or

A recognized national medical or dental society or regulatory agency has determined, in writing, that it is experimental or for research purposes; or

The written protocol or protocol(s) used by the treating facility or the protocol or protocol(s) of any other facility studying substantially the same drug, device, procedure or treatment or the written informed consent used by the treating facility or by another facility studying the same drug, device, procedure or treatment states that it is experimental or for research purposes; or

It is not of proven benefit for the specific diagnosis or treatment of your particular condition; or

It is not generally recognized by the Medical Community as effective or appropriate for the specific diagnosis or treatment of your particular condition; or

It is provided or performed in special settings for research purposes.

Medical necessity

Also known as medically necessary or medically necessary services. Services that are appropriate and consistent with the diagnosis in accordance with accepted medical standards as described in this document. Medical Necessity, when used in relation to services, shall have the same meaning as Medically Necessary Services. This definition applies only to the determination by us of whether health care services are Covered Benefits under this Plan.

Open Access HMO

This does not apply to the States of California or Washington (Enrollment Codes 2X or 8J). You can go directly to any network specialist for covered services without a referral from your primary care physician. Note: This does not apply to covered mental health services and/or substance abuse services. Referrals must be obtained for those services. Please see Mental Health/Substance Abuse section on page 42. Whether your covered services are provided by your selected primary care physician (for your PCP copay) or by another participating provider in the network (for the specialist copay), you will be responsible for payment which may be in the form of a copay (flat dollar amount) or coinsurance (a percentage of covered expenses). You still must select a PCP and notify Member Services of your selection (1-800/537-9384). If you do not select a participating PCP, the specialist copay will apply. If you go directly to a specialist, you are responsible for verifying that the specialist is participating in our Plan.

Plan allowance

Plan allowance is the amount we use to determine our payment and your coinsurance for the service or supply in the geographic area where it is furnished. Plans determine their allowances in different ways. We determine our allowance as follows: We may take into account factors such as the complexity, degree of skill needed, type or specialty of the provider, range of services provided by a facility, and the prevailing charge in other areas in determining the Plan allowance for a service or supply that is unusual or is not often provided in the area or is provided by only a small number of providers in the area.

Referral

For California and Washington members only: To receive coverage for any non-emergency service and necessary follow-up care outside those provided by the PCP, the member must have a written or electronic referral made by their PCP or no coverage will be provided (with the exception of some direct access providers within the network).

For Open Access members, you do not need a referral for specialist care within our network.

Respite care

Care furnished during a period of time when your family or usual caretaker cannot, or will not, attend to your needs. Respite care is not covered.

Urgent care

Covered benefits required in order to prevent serious deterioration of your health that results from an unforeseen illness or injury if you are temporarily absent from our service area and receipt of the health care service cannot be delayed until your return to our service area.

Us/We

Us and We refer to Aetna.

You

You refers to the enrollee and each covered family member.

No pre-existing condition limitation

We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan solely because you had the condition before you enrolled.

Where you can get information about enrolling in the FEHB Program

See www.opm.gov/insure. Also, your employing or retirement office can answer your questions, and give you a Guide to Federal Employees Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

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

When the next open season for enrollment begins.

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.

Types of coverage available for you and your family

Self Only coverage is for you alone. Self and Family coverage is for you, your spouse, and your unmarried dependent children under age 22, including any foster children or stepchildren your employing or retirement office authorizes coverage for. Under certain circumstances, you may also continue 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 that event. The Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form; benefits will not be available to your spouse until you marry.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits, nor will we. Please tell us immediately when you add or remove family members from your coverage for any reason, including divorce, or when your child under age 22 marries or turns 22.

If you or one of your family members is enrolled in one FEHB plan, that person may not be enrolled in or covered as a family member by another FEHB plan.

Children�s Equity Act

OPM has implemented the Federal Employees Health Benefits Children�s Equity Act of 2000. This law mandates that you be enrolled for Self and Family coverage in the FEHB Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren).

If this law applies to you, you must enroll for Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as follows:

If you have no FEHB coverage, your employing office will enroll you for Self and Family coverage in the Blue Cross and Blue Shield Service Benefit Plan�s Basic Option;

If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self and Family in the same option of the same plan; or

If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self and Family in the Blue Cross and Blue Shield Service Benefit Plan�s Basic Option.

As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that doesn�t serve the area in which your children live, unless you provide documentation that you have other coverage for the children. If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that doesn�t serve the area in which your children live as long as the court/administrative order is in effect. Contact your employing office for further information.

When benefits and premiums start

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be paid according to the 2005 benefits of your old plan or option. However, if your old plan left the FEHB Program at the end of the year, you are covered under that plan�s 2004 benefits until the effective date of your coverage with your new plan. Annuitants� coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

When you retire

When you retire, you can usually stay in the FEHB Program. Generally, you must have been 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 (TCC).

When FEHB coverage ends

You will receive an additional 31 days of coverage, for no additional premium, when:

Your enrollment ends, unless you cancel your enrollment, or

You are a family member no longer eligible for coverage.

You may be eligible for spouse equity coverage or Temporary Continuation of Coverage (TCC), or a conversion policy (a non-FEHB individual policy.)

Spouse equity coverage

If you are divorced from a Federal employee or annuitant, you may not continue to get benefits under your former spouse�s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage to you. But, you may be eligible for your own FEHB coverage under the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse�s employing or retirement office to get RI 70-5, the Guide To Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees, or other information about your coverage choices. You can also download the guide from OPM�s Web site, www.opm.gov/insure.

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 Temporary Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal job, if you are a covered dependent child and you turn 22 or marry, etc.

You may not elect TCC if you are fired from your Federal job due to gross misconduct.

Enrolling in TCC. 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 or from www.opm.gov/insure. It explains what you have to do to enroll.

Converting to individual coverage

You may convert to a non-FEHB individual policy if:

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 of your right to convert. 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.

Getting a Certificate of Group Health Plan Coverage

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal law that offers limited Federal protections for health coverage availability and continuity to people who lose employer group coverage. If you leave the FEHB Program, we will give you a Certificate of Group Health Plan Coverage that indicates how long you have been enrolled with us. You can use this certificate when getting health insurance or other health care coverage. Your new plan must reduce or eliminate waiting periods, limitations, or exclusions for health related conditions based on the information in the certificate, as long as you enroll within 63 days of losing coverage under this Plan. If you have been enrolled with us for less than 12 months, but were previously enrolled in other FEHB plans, you may also request a certificate from those plans.

For more information, get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the FEHB Program. See also the FEHB Web site at www.opm.gov/insure/archive/health; refer to the �TCC and HIPAA� frequently asked questions. These highlight HIPAA rules, such as the requirement that Federal employees must exhaust any TCC eligibility as one condition for guaranteed access to individual health coverage under HIPAA, and information about Federal and State agencies you can contact for more information.

Important information

OPM wants to make sure you are aware of two Federal programs that complement the FEHB Program. First, the Federal Flexible Spending Account (FSA) Program, also known as FSAFEDS, lets you set aside pre-tax money to pay for health and dependent care expenses. The result can be a discount of 20% to more than 40% on services you routinely pay for out-of-pocket. Second, the Federal Long Term Care Insurance Program (FLTCIP) helps cover long term care costs, which are not covered under the FEHB.

What is an FSA?

It is a tax-favored benefit that allows you to set aside pre-tax money from your paychecks to pay for a variety of eligible expenses. By using an FSA, you can reduce your taxes while paying for services you would have to pay for anyway, producing a discount that can be over 40%.

There are two types of FSAs offered by FSAFEDS:

Health Care Flexible Spending Account (HCFSA)

Covers eligible health care expenses not reimbursed by this Plan, or any other medical, dental, or vision care plan you or your dependents may have.

Eligible dependents for this account include anyone you claim on your Federal Income Tax return as a qualified dependent under the U.S. Internal Revenue Service (IRS) definition and/or with whom you jointly file your Federal Income Tax return, even if you don�t have self and family health benefits coverage. Note: The IRS has a broader definition of a �family member� than is used under the FEHB Program to provide benefits by your FEHB Plan.

The maximum annual amount that can be allotted for the HCFSA is $4,000. Note: The Federal workforce includes a number of employees married to each other. If each spouse/employee is eligible for FEHB coverage, both may enroll for a HCFSA up to the maximum of $4,000 each ($8,000 total). Both are covered under each other�s HCFSA. The minimum annual amount is $250.

Dependent Care Flexible Spending Account (DCFSA)

Covers eligible dependent care expenses incurred so you, and your spouse, if married, can work, look for work, or attend school full-time.

Qualifying dependents for this account include your dependent children under age 13, or any person of any age whom you claim as a dependent on your Federal Income Tax return (and who is mentally or physically incapable of self care).

The maximum annual amount that can be allotted for the DCFSA is $5,000. The minimum annual amount is $250. Note: The IRS limits contributions to a DCFSA. For single taxpayers and taxpayers filing a joint return, the maximum is $5,000 per year. For taxpayers who file their taxes separately with a spouse, the maximum is $2,500 per year. The limit includes any child care subsidy you may receive.

Enroll during Open Season

You must make an election to enroll in an FSA during the 2005 FEHB Open Season. Even if you enrolled during 2004, you must make a new election to continue participating in 2005. Enrollment is easy!

Online: visit www.FSAFEDS.com and click on Enroll.

Telephone: call an FSAFEDS Benefits Counselor toll-free at 1-877/FSAFEDS (372-3337), Monday through Friday, from 9 a.m. until 9 p.m., Eastern Time. TTY: 1-800/952-0450.

What is SHPS?

SHPS is a third-party administrator hired by OPM to manage the FSAFEDS Program. SHPS is the largest FSA administrator in the nation and is responsible for enrollment, claims processing, customer service, and day-to-day operations of FSAFEDS.

Who is eligible to enroll?

If you are a Federal employee eligible for FEHB � even if you�re not enrolled in FEHB � you can choose to participate in either, or both, of the FSAs. However, if you enroll in a High Deductible Health Plan (HDHP) with a Health Savings Account (HSA), you are not eligible to participate in an HCFSA.

Almost all Federal employees are eligible to enroll for a DCFSA. The only exception is intermittent (also called �when actually employed� [WAE]) employees expected to work fewer than 180 days during the year.

Note: FSAFEDS is the FSA Program established for all Executive Branch employees and Legislative Branch employees whose employers have signed on to participate. Under IRS law, FSAs are not available to annuitants. Also, the U.S. Postal Service and the Judicial Branch, among others, have their own plans with slightly different rules. However, the advantages of having an FSA are the same regardless of the agency for which you work.

How much should I contribute to my FSA?

Plan carefully when deciding how much to contribute to an FSA. Because of the tax benefits an FSA provides, the IRS places strict guidelines on how the money can be used. Under current IRS tax rules, you are required to forfeit any money for which you did not incur an eligible expense under your FSA account(s) during the Plan Year. This is known as the �use-it-or-lose-it� rule. You will have until April 30, following the end of the Plan Year to submit claims for your eligible expenses incurred from January 1 through December 31. For example if you enroll in FSAFEDS for the 2005 Plan Year, you will have until April 30, 2006 to submit claims for eligible expenses.

The FSAFEDS Calculator at www.FSAFEDS.com will help you plan your FSA allocations and provide an estimate of your tax savings based on your individual situation.

What can my HCFSA pay for?

Every FEHB plan includes cost sharing features, such as deductible s you must meet before the Plan provides benefits, coinsurance or copayments that you pay when you and the Plan share costs, and medical services and supplies that are not covered by the Plan and for which you must pay. These out-of-pocket costs are summarized on page 72 and detailed throughout this brochure. Your HCFSA will reimburse you when those costs are for qualified medical care that you, your spouse and/or your dependents receive that is NOT covered or reimbursed by this FEHB Plan or any other coverage that you have.

Under this plan, typical out-of-pocket expenses include copayments for pharmacy and inpatient/outpatient hospitalization. Expenses not covered by the plan include in vitro fertilization and alternative treatments such as acupuncture and hypnotherapy.

The IRS governs expenses reimbursable by a HCFSA. See Publication 502 for a comprehensive list of tax-deductible medical expenses. Note: While you will see insurance premiums listed in Publication 502, they are NOT a reimbursable expense for FSA purposes. Publication 502 can be found on the IRS Web site at http://www.irs.gov/pub/irs-pdf/p502.pdf . The FSAFEDS Web site also has a comprehensive list of eligible expenses at www.FSAFEDS.com/fsafeds/eligibleexpenses.asp . If you do not see your service or expense listed, please call an FSAFEDS Benefits Counselor at 1-877/FSAFEDS (372-3337), who will be able to answer your specific questions.

Tax savings with an FSA

An FSA lets you allot money for eligible expenses before your agency deducts taxes from your paycheck. This means the amount of income that your taxes are based on will be lower, so your tax liability will be less. Without an FSA, you would still pay for these expenses, but you would do so using money remaining in your paycheck after Federal (and often state and local) taxes are deducted. The following chart illustrates a typical tax savings example:

If your taxable income is:

$50,000

$50,000

And you deposit this amount into an FSA:

$2,000

-$0-

Your taxable income is now:

$48,000

$50,000

Subtract Federal & Social Security taxes:

$13,807

$14,383

If you spend after-tax dollars for expenses:

-$0-

$2,000

Your real spendable income is:

$34,193

$33,617

Your tax savings:

$576

-$0-

Note: This example is intended to demonstrate a typical tax savings based on 27% Federal and 7.65% FICA taxes. Actual savings will vary based upon the retirement system in which you are enrolled (CSRS or FERS), your state of residence, and your individual tax situation. In this example, the individual received $2,000 in services for $1,424 - a discount of almost 36%! You may also wish to consult a tax professional for more information on the tax implications of an FSA.

Tax credits and deductions

You cannot claim expenses on your Federal Income Tax return if you receive reimbursement for them from your HCFSA or DCFSA. Below are some guidelines that may help you decide whether to participate in FSAFEDS.

Health care expenses

The HCFSA is Federal Income Tax-free from the first dollar. In addition, you may be reimbursed from your HCFSA at any time during the year for expenses up to the annual amount you�ve elected to contribute.

Only health care expenses exceeding 7.5% of your adjusted gross income are eligible to be deducted on your Federal Income Tax return. Using the example shown above, only health care expenses exceeding $3,750 (7.5% of $50,000) would be eligible to be deducted on your Federal Income Tax return. In addition, money set aside through an HCFSA is also exempt from FICA taxes. This exemption is not available on your Federal Income Tax return.

Dependent care expenses

The DCFSA generally allows many families to save more than they would with the Federal tax credit for dependent care expenses. Note that you may only be reimbursed from the DCFSA up to your current account balance. If you file a claim for more than your current balance, it will be held until additional payroll allotments have been added to your account.

Visit www.FSAFEDS.com and download the Dependent Care Tax Credit Worksheet from the Forms and Literature page to help you determine what is best for your situation. You may also wish to consult a tax professional for more details.

Does it cost me anything to participate in FSAFEDS?

No. Section 1127 of the National Defense Authorization Act (Public Law 108-136) requires agencies that offer FSAFEDS to employees to cover the administrative fee(s) on behalf of their employees. However, remember that participating in FSAFEDS can cost you money if you don�t spend your entire account balance by the end of the Plan Year, resulting in the forfeiture of funds remaining in your account (the IRS �use-it-or-lose-it� rule).

Contact us

To learn more or to enroll, please visit the FSAFEDS Web site at www.FSAFEDS.com , or contact SHPS directly via email or by phone. FSAFEDS Benefits Counselors are available Monday through Friday, from 9:00 a.m. until 9:00 p.m. Eastern Time.

E-mail: FSAFEDS@shps.net

Telephone: 1-877/FSAFEDS (1-877/372-3337)

TTY: 1-800/952-0450

It�s important protection

Why should you consider applying for coverage under the Federal Long Term Care Insurance Program (FLTCIP)?

FEHB plans do not cover the cost of long term care. Also called �custodial care,� long term care is help you receive to perform activities of daily living � such as bathing or dressing yourself - or supervision you receive because of a severe cognitive impairment. The need for long term care can strike anyone at any age and the cost of care can be substantial.

The Federal Long Term Care Insurance Program can help protect you from the potentially high cost of long term care. This coverage gives you options regarding the type of care you receive and where you receive it. With FLTCIP coverage, you won�t have to worry about relying on your loved ones to provide or pay for your care.

It�s to your advantage to apply sooner rather than later. In order to qualify for coverage under the FLTCIP, you must apply and pass a medical screening (called underwriting). Certain medical conditions, or combinations of conditions, will prevent some people from being approved for coverage. By applying while you�re in good health, you could avoid the risk of having a future change in your health disqualify you from obtaining coverage. Also, the younger you are when you apply, the lower your premiums.

You don�t have to wait for an open season to apply. The Federal Long Term Care Insurance Program accepts applications from eligible persons at any time. You will have to complete a full underwriting application, which asks a number of questions about your health. However, if you are a new or newly eligible employee, you (and your spouse, if applicable) have a limited opportunity to apply using the abbreviated underwriting application, which asks fewer questions. Newly married spouses of employees also have a limited opportunity to apply using abbreviated underwriting.

Qualified relatives are also eligible to apply. Qualified relatives include spouses and adult children of employees and annuitants, and parents, parents-in-law, and stepparents of employees.

To find out more and to request an application

Call 1-800/LTC-FEDS (1-800/582-3337) (TTY 1-800/843-3557) or visit www.ltcfeds.com .

Benefits

You pay

Page

Medical services provided by physicians:

Diagnostic and treatment services provided in the office..................

Office visit copay: $20 primary care; $30 specialist

22

Inpatient

$150 per day up to a maximum of $750 per admission

36

Outpatient

$200 per visit

37

In-area

$100 per visit

40

Out-of-area....................................................................................

$100 per visit

40

Mental health and substance abuse treatment............................

Regular cost sharing

42

Prescription drugs....................................................................

Retail Pharmacy: For up to a 30-day supply per prescription unit or refill

Mail Order Pharmacy: For a 31-day up to a 90-day supply per prescription unit or refill

In no event will the copay exceed the cost of the prescription drug.

Retail Pharmacy: $10 copay per generic formulary drug;

$25 copay per brand name formulary drug; and

$40 copay per non-formulary drug (generic or brand name).

Mail Order Pharmacy: $20 copay per generic formulary drug;

$50 copay per brand name formulary drug; and

$80 copay per non-formulary drug (generic or brand name).

44

Dental care............................................................................. .

Variable copays

48

Vision care............................................................................. .

$30 copay per visit. All charges over $100 for eyeglasses or contacts per 24 month period

28

Special Features: Services for the deaf and hearing-impaired, Informed Health Line, Maternity Management Program, National Medical Excellence Program, and Reciprocity benefit.

Contact Plan

47

Protection against catastrophic costs

(your catastrophic protection out-of-pocket maximum).............

Nothing after $1,500/Self Only or $3,000/Self and Family enrollment per year.

Some costs do not count toward this protection

19