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

1) Precertification

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

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

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

2) Concurrent Review

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

3) Discharge Planning

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

4) Retrospective Record Review

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

Identification cards

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 1-800/537-9384 or request them through our Web site at www.aetna.com/fed.

Where you get covered care

You can get care from any licensed provider or licensed facility. How much we pay � and you pay � depends on whether you use a network or non-network provider or facility. If you use a non-network provider, you will pay more.

� Network providers

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

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

� Network facilities

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

� Non-network providers and facilities

You can access care from any licensed provider or facility. Providers and facilities not in Aetna�s networks are considered non-network providers and facilities.

What you must do to get covered care

It depends on the kind of care you want to receive. You can go to any provider you want, but we must approve some care in advance.

� Traditional care

Specialty care: If you have a chronic or disabling condition and

5) Lose access to your network specialist because we terminate our contract with your specialist for other than cause; or

6) Lose access to your specialist because we drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or

7) Reduce our service area and you enroll in another FEBH plan,

you may be able to continue seeing your specialist and receive any in-network benefits for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the Program, contact your new plan.

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

� Hospital care

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

Note: Non-network physicians will generally also make these arrangements, but you are responsible for any precertification requirements.

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

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

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

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

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

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

How to Get Approval for�

� Your hospital stay

In most cases, your Network physician or hospital will take care of precertification. Because you are still responsible for ensuring that we are asked to precertify your care, you should always ask your physician or hospital whether they have contacted us.

Note: If you go to a Non-network hospital, you are responsible for precertifying your care.

Warning

If you are using a non-network physician or hospital, we will reduce our benefits for the inpatient hospital stay by $500 if no one contacts us for precertification. If the stay is not medically necessary, we will not pay any benefits.

� How to precertify an admission

Certification of days of confinement can be obtained as follows:

If the admission is a non-urgent admission or if you are being admitted to a Non-network hospital, you must get the days certified by calling the number shown on your ID card. This must be done at least 14 days before the date the person is scheduled to be confined as a full-time inpatient. If the admission is an emergency or an urgent admission, you, the person�s physician, or the hospital must get the days certified by calling the number shown on your ID card. This must be done:

11) Before the start of a confinement as a full-time inpatient which requires an urgent admission; or

12) Not later than 48 hours following the start of a confinement as a full-time inpatient which requires an emergency admission; unless it is not possible for the physician to request certification within that time. In that case, it must be done as soon as reasonably possible. In the event the confinement starts on a Friday or Saturday, the 48 hour requirement will be extended to 72 hours.

If, in the opinion of the person�s physician, it is necessary for the person to be confined for a longer time than already certified, you, the physician, or the hospital may request that more days be certified by calling the number shown on your ID card. This must be done no later than on the last day that has already been certified.

Written notice of the number of days certified will be sent promptly to the hospital. A copy will be sent to you and to the physician.

� Maternity care

You do not need to precertify a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional days. Further, if your baby stays after you are discharged, then your physician or the hospital must contact us for precertification of additional days for your baby.

� What happens when you do not follow the precertification rules when using Non-network Facilities

13) If no one contacts us, we will decide whether the hospital stay was medically necessary.

� If we determine that the stay was medically necessary, we will pay the inpatient charges, less the $500 penalty.

� If we determine that it was not medically necessary for you to be an inpatient, we will not pay inpatient hospital benefits. We will only pay for any covered medical supplies and services that are otherwise payable on an outpatient basis.

14) If we denied the precertification request, we will not pay inpatient hospital benefits. We will only pay for any covered medical supplies and services that are otherwise payable on an outpatient basis.

15) When we precertified the admission but you remained in the hospital beyond the number of days we approved and did not get the additional days precertified, then:

� for the part of the admission that was medically necessary, we will pay inpatient benefits, but

� for the part of the admission that was not medically necessary, we will pay only medical services and supplies otherwise payable on an outpatient basis and will not pay inpatient benefits.

Circumstances beyond our control

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

Services requiring our prior approval

Some services require prior approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice. We call this review and approval process precertification.

You must obtain approval for certain services such as:

16) For inpatient mental health and substance abuse care. You must contact Member Services at 1-800/537-9384 or call the behavioral health contractor for information on precertification;

17) For surgical treatment of morbid obesity;

18) For orthognathic surgery and TMJ surgery, and surgery to correct congenital defects;

19) For select outpatient surgery;

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

21) For covered transplant surgery;

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

23) For non-emergent ambulance and air ambulance transportation services;

24) For growth hormone therapy treatment;

25) For intravenous immunoglobulin (IVIG) therapy treatment;

26) For penile implants;

27) For certain durable medical equipment;

28) For all home health care services; and

29) For home intravenous (IV) and antibiotic therapy.

Members must call Member Services at 1-800/537-9384 for authorization.

Copayments

A copay is the fixed amount of money you pay to the pharmacy when you receive services.

Deductible

A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for them.

Consumer Driven Health Plan (CDHP)

After you have exhausted your Medical Fund, you must satisfy your deductible before your Traditional Medical Coverage begins. For the CDHP, your deductible is $1,000 for a Self Only enrollment and $2,000 for a Self and Family enrollment. The Self and Family deductible can be satisfied by one or more members. The full Family deductible must be met for the plan of benefits to apply. There is no individual limit within the Family deductible.

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

And, if you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your new option.

High Deductible Health Plan (HDHP)

You must satisfy your deductible before your Traditional Medical Coverage begins. For the HDHP, your deductible is $2,500 for a Self Only enrollment and $5,000 for a Self and Family enrollment. The Self and Family deductible can be satisfied by one or more members. The full Family deductible must be met for the plan of benefits to apply. There is no individual limit within the Family deductible.

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

And, if you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your new option.

Coinsurance

Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance doesn�t begin until you meet your deductible.

Example: You pay 15% of our Plan allowance for in-network durable medical equipment under CDHP, and 10% under HDHP.

Differences between our Plan allowance and the bill

30) Network Providers agree to accept our Plan allowance so if you use a network provider, you never have to worry about paying the difference between our Plan allowance and the billed amount for covered services.

31) Non-Network Providers: If you use a non-network provider, you will have to pay the difference between our Plan allowance and the billed amount.

Your catastrophic protection out-of-pocket maximum

CDHP

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

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

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

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

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

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

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

35) Copay expenses for prescription drugs

36) Any coinsurance expenses you have paid for infertility services

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

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

39) Expenses in excess of hospice care maximums

HDHP

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

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

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

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

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

42) Any coinsurance expenses you have paid for infertility services

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

44) Expenses in excess of hospice care maximums

Out-of-Pocket Maximums

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

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

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

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Here are some important things you should keep in mind about these in-network medical and dental preventive care benefits:

- The Plan pays 100% for the medical and dental preventive care services listed in this Section as long as you use a network provider.

- If you choose to access preventive care with an out-of-network provider, you will not qualify for 100% preventive care coverage. Please see Section 5.2 � Medical and Dental Fund, Section 5.3 � Traditional Medical Coverage (Subject to the Deductible).

- For preventive care not listed in this Section or preventive care from a non-network provider, please see Section 5.2 � Medical and Dental Funds.

- For all other covered expenses, please see section 5.2 � Medical and Dental Funds and Section 5.3 � Traditional Medical Coverage (Subject to the Deductible).

- Note that the in-network medical and dental preventive care paid under this Section does NOT count against or use up your Medical or Dental Fund.

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

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Benefit Description

You pay

In-Network Medical Preventive Care, adult

Routine screenings, such as:

45) Blood test

46) Urinalysis

47) Total Blood Cholesterol

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

49) Colorectal Cancer Screening, including

� Fecal occult blood test yearly starting at age 50,

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

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

� Colonoscopy screening � every 10 years starting at age 50

50) Routine annual digital rectal exam (DRE) for men age 40 and older

51) Routine well-woman exam including Pap test, one visit every 12 months from last date of service

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

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

� From age 40 through 64, one every calendar year

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

In-network: Nothing at a network provider.

Out-of-network: Nothing at a non-network provider up to your available Medical Fund balance. Charges above the available Medical Fund balance, according to the Traditional Medical Coverage (Section 5.3), and the deductible.

In-Network Medical Preventive Care, adult (continued)

You pay

53) Routine physicals:

� One exam every 24 months up to age 65

� One exam every 12 months age 65 and older

54) Routine immunizations and exams, limited to:

� Tetanus-diphtheria (Td) booster � once every 10 years, ages 19 and over (except as provided for under Childhood immunizations)

� Influenza vaccine, annually

� Pneumococcal vaccine, age 65 and over

� 1 routine eye exam every 12 months

� 1 routine OB/GYN exam every 12 months including 1 Pap smear and related services

� 1 routine hearing exam every 24 months

In-network: Nothing at a network provider.

Out-of-network: Nothing at a non-network provider up to your available Medical Fund balance. Charges above the available Medical Fund balance, according to the Traditional Medical Coverage (Section 5.3), and the deductible.

Not covered:

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

- Immunizations, boosters, and medications for travel or work-related exposure.

All charges.

In-Network Medical Preventive Care, children

55) Childhood immunizations recommended by the American Academy of Pediatrics

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

� 6 exams in the first 12 months of life

� 2 exams in the 13-24th months of life

� 1 exam every 12 months thereafter up to age 18

� 1 exam every 24 months for children age 18 and older

57) 1 routine eye exam every 12 months

58) 1 routine hearing exam every 24 months

In-network: Nothing at a network provider.

Out-of-network: Nothing at a non-network provider up to your available Medical Fund balance. Charges above the available Medical Fund balance, according to the Traditional Medical Coverage (Section 5.3), and the deductible.

Not covered:

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

- Immunizations, boosters, and medications for travel or work-related exposure.

All charges.

In-Network Dental Preventive Care

You pay

Preventive care limited to:

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

60) Fluoride applications (limited to 1 treatment per calendar year and for children under age 16)

61) Sealants � (once every 3 years, from the last date of service, on permanent molars for children under age 16)

62) Space maintainer (primary teeth only)

63) Bitewing x-rays (one set per calendar year)

64) Complete series x-rays (one complete series every 3 years)

65) Periapical x-rays

66) Routine oral evaluations (limited to 2 per calendar year)

In-network: Nothing at a network dentist

Out-of-network: Nothing at a non-network dentist up to your available Dental Fund balance. However, you are responsible for non-network dentist fees that exceed our Plan allowance. See Section 5.2 Dental Fund.

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Here are some important things you should keep in mind about your Medical Fund:

67) All eligible medical care expenses up to the Plan allowance in Section 5.3 (except in-network preventive care) are paid first from your Medical Fund. Traditional Medical Coverage will only start once your Medical Fund is exhausted and your deductible is satisfied.

68) Note that in-network preventive care covered under Section 5.1 does NOT count against your Medical Fund.

69) The Medical Fund provides full coverage for eligible expenses from both in-network and non-network providers. However, your Medical Fund will generally go much further when you use network providers because network providers agree to discount their fees.

70) You have flexibility about how to spend your Medical Fund, and the Plan provides you with the resources to manage your Medical Fund. You can track your Medical Fund on Aetna�s Navigator Web site, by telephone at 1-800/537-9384 (toll-free), or, when you incur claims, with monthly statements mailed directly to you at home.

71) If you join this Plan during Open Season, you receive the full Medical Fund ($1,000 per Self Only or $2,000 per Self and Family enrollment.) as of your effective date of coverage. If you join at any other time during the year, your Medical Fund for your first year will be prorated at a rate of $83 per month for Self Only or $167 per month for Self and Family for each full month of coverage remaining in that calendar year. If your enrollment effective date falls between the first and fifteenth day of the month, you will be given credit as of the first of the month. If your enrollment effective date is the sixteenth or later in the month, you will be given credit as of the first of the following month.

72) Medicare premium reimbursement � Medicare participating annuitants may request reimbursement for Medicare premiums paid if Health Fund dollars are available. Please contact us at 1-800/537-9384 for more information.

73) If you terminate your participation in this Plan, any Medical Fund balance you may have will be lost.

74) YOUR NETWORK PHYSICIAN MUST PRECERTIFY HOSPITAL STAYS FOR IN-NETWORK FACILITY CARE; YOU MUST PRECERTIFY HOSPITAL STAYS FOR NON-NETWORK FACILITY CARE; FAILURE TO DO SO WILL RESULT IN A $500 PENALTY FOR NON-NETWORK FACILITY CARE. Please refer to the precertification information shown in Section 3 to confirm which services require precertification.

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

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Benefit Description

You pay

Medical Fund

A Medical Fund is provided by the Plan for each enrollment. Each year the Plan adds to your account:

76) $1,000 per year for a Self Only enrollment, or;

77) $2,000 per year for a Self and Family enrollment.

The Medical Fund covers eligible expenses at 100%. For example, if you are ill and go to a network doctor for a $60 visit, the doctor will submit your claim and the cost of the visit will be deducted automatically from your Medical Fund; you pay nothing.

Balance in Medical Fund for Self Only $ 1,000

Less: Cost of visit - 60

Remaining Balance in Medical Fund $ 940

Nothing for eligible expenses until you exhaust your Medical Fund. However, you are responsible for non-network medical fees that exceed our Plan allowance.

Medical Fund expenses are the same medical, surgical, hospital, emergency, mental health and substance abuse, and prescription drug services and supplies covered under the Traditional Medical Coverage (see Section 5.3 for details).

To make the most of your Medical Fund, you should:

78) Use the network providers whenever possible; and

79) Use generic prescriptions whenever possible

Medical Fund Rollover

Provided you remain enrolled in the CDHP, any unused, remaining balance in your Medical Fund at the end of the calendar year may be rolled over to subsequent years.

Note: This rollover feature can increase your Medical Fund in the following year(s) up to a maximum rollover of $4,000 for Self Only or $8,000 for a Self and Family enrollment.

Not covered:

- Eyeglasses and contact lenses (see the non-FEHBP page for our Vision One Program)

- Non-network preventive care services not included under Section 5.1

- Services or supplies shown as not covered under Traditional Medical Coverage (see Section 5.3)

- Charges of non-network providers that exceed our Plan allowance.

All charges.

Dental Fund

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Here are some important things you should keep in mind about your Dental Fund:

80) Note that in-network preventive dental care covered under Section 5.1 does NOT count against your Dental Fund.

81) When you join this Plan, you will have access to the entire Dental Fund ($300 for Self Only or $600 for Self and Family to share between you and your enrolled family members).

82) Participating network PPO dentists offer members services at a negotiated rate � so, you are generally charged less for your dental care when you visit a participating network PPO dentist. Refer to our DocFind� online provider directory at www.aetna.com/fed to find a participating network PPO dentist, or call Member Services at 1-800/537-9384.

83) All eligible dental expenses will be paid from your Dental Fund. You can track your Dental Fund on Aetna�s Navigator Web site or by telephone at 1-800/537-9384. Note: Once your fund is exhausted, you will continue to save on the cost of your dental care with access to the negotiated rates offered by participating network PPO dentists.

84) You can visit any licensed dentist for covered services under the Dental Fund. However, you can make your Dental Fund go further by taking advantage of the negotiated rates offered by a participating network PPO dentist. These negotiated rates are generally less than the dentist�s usual fees.

85) REMEMBER: If you terminate your participation in this Plan, any Dental Fund balance you may have will be lost.

86) Any unused, remaining balance in your Dental Fund at the end of your calendar year will not rollover, regardless of whether you stay in the Plan or not.

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

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Benefit Description

You pay

Dental Fund

Dental Fund expenses include dental services up to a maximum of $300 for Self Only or $600 for Self and Family enrollment.

The Dental Fund covers eligible expenses at 100%. For example, if you go to a network dentist for a $125 visit, the doctor will submit your claim and the cost of the visit will be deducted automatically from your Dental Fund; you pay nothing.

Balance in Dental Fund for Self Only $ 300

Less: Cost of visit - 125

Remaining Balance in Dental Fund $ 175

Note: Any unused remaining balance in your Dental Fund at the end of the calendar year cannot be rolled over to the next year.

Eligible dental covered services include:

Diagnostic and Preventive Care From Non-Network Dentists:

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

88) Fluoride applications (limited to 1 treatment per calendar year and for children under age 16)

Nothing for eligible expenses until you exhaust your Dental Fund. However, you are responsible for non-network dentist fees that exceed our Plan allowance.

Note: Once your Dental Fund is exhausted, you pay the negotiated rates offered by participating network PPO dentists. You are responsible for the full charges for services accessed from a non-network dentist.

Dental Fund (continued)

You pay

89) Sealants � (once every 3 years, from the last date of service, on permanent molars for children under age 16)

90) Space maintainer (primary teeth only)

91) Bitewing x-rays (one set per calendar year)

92) Complete series x-rays (one complete series every 3 years)

93) Periapical x-rays

94) Routine oral evaluations (limited to 2 per calendar year)

Nothing for eligible expenses until you exhaust your Dental Fund. However, you are responsible for non-network dentist fees that exceed our Plan allowance.

Note: Once your Dental Fund is exhausted, you pay the negotiated rates offered by participating network PPO dentists. You are responsible for the full charges for services accessed from a non-network dentist.

Restorative Care (Basic and Major):

95) Amalgam and resin-based composite restorations (�fillings�)

96) Inlays and onlays

97) Crowns

98) Fixed partial dentures (�bridgework�)

99) Root canal (�endodontics�) therapy, including necessary x-rays

100) Extractions (oral surgery) such as simple, surgical, soft tissue and bony impacted teeth

101) Osseous surgery (�periodontics�) - one per quadrant every 3 years, from the last date of service

102) General anesthesia and intravenous sedation

103) Repairs to removable partial dentures and complete dentures, within 6 months of installation

104) Occlusal guards (for bruxism only) � limited to one every 3 years, from the last date of service

Nothing for eligible expenses until you exhaust your Dental Fund. However, you are responsible for non-network dentist fees that exceed our Plan allowance.

Note: Once your Dental Fund is exhausted, you pay the negotiated rates offered by participating network PPO dentists. You are responsible for the full charges for services accessed from a non-network dentist.

Not covered:

- Orthodontia

- Dental treatment for cosmetic purposes

- Dental care involved with the treatment of temporomandibular joint (TMJ) pain dysfunction syndrome

- Dental implants

- Replacement of crowns, fixed partial dentures (bridges), removable partial dentures or complete dentures, if the existing crown, fixed partial denture (bridge), removable partial denture or complete denture was originally placed less than 8 years prior to the replacement.

- Charges of non-network providers that exceed our Plan allowance

All charges.

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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.

- In-network preventive care is covered at 100% under Section 5.1 and does not count against your Medical Fund.

- Your Medical Fund of $1,000 for Self Only enrollment and $2,000 for Self and Family enrollment must be used first for eligible health care expenses.

- Once your Medical Fund has been exhausted, you must pay your deductible before your Traditional Medical Coverage may begin. Your deductible is $1,000 for Self Only enrollment and $2,000 for Self and Family enrollment.

- The Medical Fund provides coverage for both network and non-network providers. Under the Traditional Medical Coverage, in-network benefits apply only when you use a network provider. Out-of-network benefits apply when you do not use a network provider.

- Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 10 about coordinating benefits with other coverage, including with Medicare.

- YOUR NETWORK PHYSICIAN MUST PRECERTIFY HOSPITAL STAYS FOR IN-NETWORK FACILITY CARE; YOU MUST PRECERTIFY HOSPITAL STAYS FOR NON-NETWORK FACILITY CARE; FAILURE TO DO SO WILL RESULT IN A $500 PENALTY FOR NON-NETWORK FACILITY CARE. Please refer to the precertification information shown in Section 3 to confirm which services require precertification.

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Benefit Description

You pay

Deductible before Traditional Medical Coverage begins

Once your Medical Fund has been exhausted, you must satisfy your deductible before your Traditional Medical Coverage begins. The Self and Family deductible can be satisfied by one or more family members.

Note: You must use any available Medical Fund amounts, including any amounts rolled over from previous years, before Traditional Medical Coverage begins.

Once your Traditional Medical Coverage begins, you will be responsible for your coinsurance amounts for eligible medical expenses or copayments for eligible prescriptions.

$1,000 per Self Only enrollment or $2,000 per Self and Family enrollment

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

105) The deductible is $1,000 for Self Only enrollment and $2,000 for Self and Family enrollment each calendar year. The Self and Family deductible can be satisfied by one or more family members. The deductible applies to all benefits in Section 5.3.

106) After you have exhausted your Medical Fund and satisfied your deductible, your Traditional Medical Coverage begins.

107) Under your Traditional Medical Coverage, you will be responsible for your coinsurance amounts for eligible medical expenses or copayments for eligible prescriptions.

108) 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.

109) Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 10 about coordinating benefits with other coverage, including with Medicare.

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Benefit Description

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Diagnostic and treatment services

Professional services of physicians

110) In physician�s office

� Office medical consultations

� Second surgical or medical opinion

� Initial examination of a newborn child covered under a family enrollment

111) In an urgent care center for a routine service

112) During a hospital stay

113) In a skilled nursing facility

114) At home

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Lab, X-ray and other diagnostic tests

Tests, such as:

115) Blood tests

116) Urinalysis

117) Non-routine pap tests

118) Pathology

119) X-rays

120) Non-routine Mammograms

121) CT Scans/MRI

122) Ultrasound

123) Electrocardiogram and EEG

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Maternity care

You pay

Complete maternity (obstetrical) care, such as:

124) Prenatal care

125) Delivery

126) Postnatal care

Note: Here are some things to keep in mind:

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

128) You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will cover an extended inpatient stay if medically necessary but you, your representatives, your doctor, or your hospital must recertify the extended stay.

129) 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.

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

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

All charges.

Family Planning

A range of voluntary family planning services, limited to:

131) Voluntary sterilization (See Surgical procedures)

132) Surgically implanted contraceptives

133) Injectable contraceptive drugs (such as Depo Provera)

134) Intrauterine devices (IUDs)

135) Diaphragms

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered: Reversal of voluntary surgical sterilization, genetic counseling

All charges.

Infertility services

You pay

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.

136) Artificial insemination

� Intravaginal insemination (IVI)

� Intracervical insemination (ICI)

� Intrauterine insemination (IUI)

137) Testing for diagnosis and surgical treatment of the underlying cause of infertility.

138) Fertility drugs except injectables

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

139) Assisted reproductive technology (ART) procedures, such as:

� In vitro fertilization

� Embryo transfer including, but not limited to, gamete GIFT and zygote ZIFT

� Services provided in the setting of ovulation induction such as ultrasounds, laboratory studies, and physician services.

� Services and supplies related to the above mentioned services, including sperm processing

140) Reversal of voluntary, surgically-induced sterility.

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

142) Injectable fertility drugs

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

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

All charges.

Allergy care

145) Testing and treatment

146) Allergy injection

147) Allergy serum

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered: Provocative food testing and sublingual allergy desensitization

All charges.

Treatment therapies

You pay

148) Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under Organ/Tissue Transplants on page 39.

149) Respiratory and inhalation therapy

150) Dialysis � hemodialysis and peritoneal dialysis

151) Intravenous (IV) Infusion Therapy � Home IV and antibiotic therapy must be precertified by your attending physician.

152) Growth hormone therapy (GHT)

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.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Physical and occupational therapies

153) 20 visits 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

� 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.

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered: Long-term rehabilitative therapy

All charges.

Pulmonary and cardiac rehabilitation

155) 20 visits per condition per member per calendar year for pulmonary rehabilitation to treat functional pulmonary disability.

156) 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.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered: Long-term rehabilitative therapy

All charges.

Speech therapy

You pay

157) 20 visits per condition per member per calendar year, beginning with the first day of treatment

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Hearing services (testing, treatment and supplies)

158) One hearing exam every 24 months

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered: Hearing aids, testing and examinations for them

All charges.

Vision services (testing, treatment and supplies)

159) Treatment of eye diseases and injury

160) One routine eye refraction every 12-month period

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

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

162) Corrective eyeglasses and frames or contact lenses (also see the non-FEHB page for our Vision One Program)

163) Fitting of contact lenses

164) Eye exercises

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

All charges.

Foot care

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

See Orthopedic and prosthetic devices for more information.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

167) 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

168) 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)

169) Foot orthotics

170) Podiatric shoe inserts

All charges.

Orthopedic and prosthetic devices

You pay

171) Orthopedic devices such as braces and prosthetic devices such as artificial limbs and eyes

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

173) Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following mastectomy, and lenses following cataract removal. See Surgical section for coverage of the surgery to insert the device.

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

175) Orthopedic and corrective shoes not attached to a covered brace

176) Arch supports

177) Foot orthotics

178) Heel pads and heel cups

179) Lumbosacral supports

180) Penile implants

All charges.

Durable medical equipment (DME)

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

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

182) Wheelchairs (motorized wheelchairs and scooters must be preauthorized);

183) Crutches;

184) Walkers; and

185) Insulin pumps and related supplies such as needles and catheters.

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

186) Elastic stockings and support hose

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

188) Home modifications such as stairglides, elevators and wheelchair ramps

189) 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 services

You pay

190) Home health care ordered by your attending Physician and provided by nurses and home health aides. Your attending physician will periodically review the program for continuing appropriateness and need.

191) Services include oxygen therapy, intravenous therapy and medications.

Note: Home health services must be precertified by your attending Physician.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

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

193) Transportation

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

195) Services of a social worker

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

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

All charges.

Chiropractic

No benefit

All charges.

Alternative treatments

No benefit

All charges.

Educational classes and programs

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

198) Chronic heart failure

199) Coronary artery disease

200) Diabetes

201) Asthma

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

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

- The deductible is $1,000 for Self Only enrollment and $2,000 for Self & Family enrollment.

- 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 10 about coordinating benefits with other coverage, including with Medicare.

- YOUR NETWORK PHYSICIAN MUST PRECERTIFY HOSPITAL STAYS FOR IN-NETWORK FACILITY CARE; YOU MUST PRECERTIFY HOSPITAL STAYS FOR NON-NETWORK FACILITY CARE; FAILURE TO DO SO WILL RESULT IN A $500 PENALTY FOR NON-NETWORK FACILITY CARE. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.

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Benefit Description

You pay

Surgical procedures

A comprehensive range of services, such as:

202) Operative procedures

203) Treatment of fractures, including casting

204) Normal pre- and post-operative care by the surgeon

205) Correction of amblyopia and strabismus

206) Endoscopy procedures

207) Biopsy procedures

208) Removal of tumors and cysts

209) Correction of congenital anomalies (see Reconstructive surgery)

210) 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 in advance by Aetna.

211) Insertion of internal prosthetic devices. See 5.3(a) � Orthopedic and prosthetic devices for device coverage information

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

213) Treatment of burns

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Surgical procedures(continued)

You pay

Not covered:

214) Reversal of voluntary surgically-induced sterilization

215) Surgery primarily for cosmetic purposes

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

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

218) Routine treatment of conditions of the foot; see Foot care

All charges.

Reconstructive surgery 

219) Surgery to correct a functional defect

220) 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

221) 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.

222) 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.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

223) 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

224) Surgeries related to sex transformation

All charges.

Oral and maxillofacial surgery 

You pay

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

225) Treatment of fractures of the jaws or facial bones;

226) Removal of stones from salivary ducts;

227) Excision of benign or malignant lesions;

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

229) 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.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

230) Dental implants

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

All charges.

Organ/tissue transplants

National Transplant Program (NTP) - Transplants which are non-experimental or non-investigational are a covered benefit. Covered transplants must be ordered by your attending doctor and plan specialist and approved by our medical director in advance of the surgery. To receive in-network benefits, 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 until discharge from the hospitalization when the donation occurred, to the extent these services are not covered by another plan or program.

Transplants are limited to:

232) Cornea

233) Heart

234) Heart/lung

235) Kidney

236) Liver

237) Lung: Single � Double

238) Pancreas; Pancreas/Kidney (simultaneous)

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Organ/tissue transplants - continued on next page.

Organ/tissue transplants (continued)

You pay

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

240) Skin

241) Tissue

242) Allogeneic (donor) bone marrow/peripheral stem cell transplants

243) 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

244) Autologous tandem transplants for ovarian cancers as well as testicular cancers

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Limited Benefits � Treatment for breast cancer, multiple myeloma and epithelial ovarian cancer and other selected diseases 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.

Not covered:

245) Transplants not listed as covered

246) Implants of artificial organs

247) Donor screening tests and donor search expenses, except those performed for the actual donor

All charges.

Anesthesia 

Professional services provided in �

248) Hospital (inpatient)

249) Hospital outpatient department

250) Skilled nursing facility

251) Ambulatory surgical center

252) Office

Note: If your network provider uses a non-network anesthesiologist, we will pay out-of-network benefits for any anesthesia charges.

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253) The deductible is $1,000 for Self Only enrollment and $2,000 for Self & Family enrollment.

254) 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.

255) Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 10 about coordinating benefits with other coverage, including with Medicare.

256) YOUR NETWORK PHYSICIAN MUST PRECERTIFY HOSPITAL STAYS FOR IN-NETWORK FACILITY CARE; YOU MUST PRECERTIFY HOSPITAL STAYS FOR NON-NETWORK FACILITY CARE; FAILURE TO DO SO WILL RESULT IN A $500 PENALTY FOR NON-NETWORK FACILITY CARE. Please refer to the precertification information shown in Section 3 to confirm which services require precertification.

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Benefit Description

You pay

Inpatient hospital

Room and board, such as

257) Ward, semiprivate, or intensive care accommodations;

258) General nursing care; and

259) 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.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Other hospital services and supplies, such as:

260) Operating, recovery, maternity, and other treatment rooms

261) Prescribed drugs and medicines

262) Diagnostic laboratory tests and X-rays

263) Administration of blood and blood products

264) 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

265) Dressings, splints, casts, and sterile tray services

266) Medical supplies and equipment, including oxygen

267) Anesthetics, including nurse anesthetist services

268) Take-home items

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

Inpatient hospital (continued)

You pay

Not covered:

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

271) Non-covered facilities, such as nursing homes, schools

272) Custodial care, rest cures, domiciliary or convalescent cares

273) Personal comfort items, such as telephone and television

274) Private nursing care

All charges.

Outpatient hospital or ambulatory surgical center

275) Operating, recovery, and other treatment rooms

276) Prescribed drugs and medicines

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

278) Pathology Services

279) Administration of blood, blood plasma, and other biologicals

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

281) Pre-surgical testing

282) Dressings, casts, and sterile tray services

283) Medical supplies, including oxygen

284) 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.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

.

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

All charges.

Extended care benefits/Skilled nursing care facility benefits

Extended care benefit: All necessary services during confinement in a skilled nursing facility with a 60-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.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered: Custodial care

All charges.

Hospice care

You pay

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 your attending Physician, who certifies the patient is in the terminal stages of illness, with a life expectancy of approximately 6 months or less. We allow up to a maximum of $5,000 for outpatient hospice services and a period not to exceed 30 days for inpatient hospice services.

Note: Inpatient hospice services require prior approval.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Ambulance

285) Local professional ambulance service when medically appropriate.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

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

All charges.

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

- The deductible is $1,000 for Self Only enrollment and $2,000 for Self & Family enrollment.

- 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 10 about coordinating benefits with other coverage, including with Medicare.

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

Benefit Description

You pay

Emergency

286) Emergency care at a doctor�s office or urgent care center

287) Emergency care as an outpatient in a hospital, including doctors� services

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

288) Non-emergency use of the Emergency Room

50% of our Plan allowance

Not covered: Elective care or non-emergency care

All charges.

Ambulance

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

See Hospital section for non-emergency service.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered: Air ambulance without prior approval.

All charges.

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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 you should keep in mind about these benefits:

- The deductible is $1,000 for Self Only enrollment and $2,000 for Self & Family enrollment.

- 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 10 about coordinating benefits with other coverage, including with Medicare.

- YOU MUST GET PREAUTHORIZATION FOR INPATIENT SERVICES.

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Benefit Description

You pay

Mental health and substance abuse benefits

Outpatient services include:

289) Individual and group therapy performed by licensed providers such as psychiatrists, psychologists, or clinical social workers

290) Facility based intensive outpatient or partial hospital treatment programs

291) Outpatient services provided by a hospital or other facility

292) Diagnostic tests

293) Medication management

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Inpatient care includes:

294) Both mental health and chemical dependency services provided by an appropriately licensed inpatient facility including licensed residential treatment facilities

Note: All inpatient services are subject to precertification.

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.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Network limitation

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

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

- The deductible is $1,000 for Self Only enrollment and $2,000 for Self & Family enrollment.

- We cover prescribed drugs and medications, as described in the chart beginning on the next page. Copayment levels reflect in-network pharmacies only. If you obtain your prescription at an out-of-network pharmacy (non-preferred), you will be reimbursed at our Plan allowance less 40%. You are responsible for any difference between our Plan allowance and the billed amount.

- Your Medical Fund must be used first for eligible pharmacy expenses and your deductible must be satisfied before your Traditional Medical Coverage begins. You will then pay a copayment at in-network retail pharmacies or mail-order pharmacy for prescriptions under your Traditional Medical Coverage. You will pay 40% coinsurance plus the difference between our Plan allowance and the billed amount at out-of-network retail pharmacies. There is no out-of-network mail order pharmacy program.

Note: The cost of your prescriptions will be deducted from your Medical Fund at the time of the purchase. The cost of your prescription is based on the Aetna contracted rate with network pharmacies. The Aetna contracted rate with the network pharmacy does not reflect or include any rebates Aetna receives from drug manufacturers.

- All eligible prescription drug expenses are first deducted from your Medical Fund. Traditional Medical Coverage will only start once your Medical Fund and deductible are exhausted.

- 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 10 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.

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There are important features you should be aware of which include:

295) Who can write your prescription. A licensed physician, dentist or licensed practitioner (as allowed by law) must write the prescription.

296) Where you can obtain them. Any retail pharmacy can be used for up to a 30-day supply. Our mail-order facility can be utilized 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. If accessing a nonparticipating pharmacy, the member must pay the full cost of the medication at the point of service, then submit a complete paper claim and a receipt for the cost of the prescription to our Direct Member Reimbursement (DMR) unit. Reimbursements are subject to review to determine if the claim meets applicable requirements, and are subject to the terms and conditions of the benefit plan and applicable law.

297) We use a formulary. Drugs are prescribed by attending doctors and covered in accordance with the Plan�s drug formulary; however, coverage is not limited to medications included on the formulary. Many non-formulary drugs are also covered but a higher copayment will apply. Certain drugs require your doctor to get precertification from the Plan before they can be covered under the Plan. Visit our Web site at www.aetna.com/fed to review our Formulary Guide or call 1-800/537-9384.

298) Precertification. We require precertification of growth hormones for all members. Precertification helps promote the appropriate and cost-effective use of growth hormones by providing coverage when certain generally accepted medical criteria are met, such as growth hormone deficiency, Turner's Syndrome and AIDS wasting. Our precertification program is based on current medical findings, manufacturer labeling information, Food and Drug Administration (FDA) guidelines and cost and manufacturer rebate arrangements.

299) When to use a participating retail or mail order pharmacy. 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 (applies to in-network pharmacies only). 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. Drug costs are calculated based on Aetna's contract rate with the pharmacy excluding any drug rebates.

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.

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.

300) 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.

301) 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.

Benefit Description

You pay

Covered medications and supplies

We cover the following medications and supplies prescribed by your attending physician or dentist and obtained from a Plan pharmacy or through our mail order program or an out-of-network retail pharmacy:

302) Drugs and medicines for which a prescription is required by Federal law, except those listed as Not Covered

303) Self-injectable drugs

304) Contraceptive drugs and devices

305) Oral fertility drugs

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

307) Insulin

308) Disposable needles and syringes for the administration of covered medications

In-network:

The full cost of the prescription is applied to the deductible before any benefits are considered for payment under the pharmacy plan. Once the deductible is satisfied, the following will apply:

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.

Out-of-network (retail pharmacies only):

40% plus the difference between our Plan allowance and the billed amount.

Covered medications and supplies (continued)

You pay

Limited benefits:

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

310) Imitrex (limited to 48 kits per calendar year)

311) Depo Provera is limited to 5 vials per calendar year

312) One diaphragm per calendar year

In-network:

50%

$25/kit

$25 copay per vial

$25 per diaphragm

Out-of-network (retail pharmacies only):

40% plus the difference between our Plan allowance and the billed amount, except for drugs to treat sexual dysfunction which are 50% plus the difference between our Plan allowance and the billed amount.

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

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

314) 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 used for the purpose of weight reduction, such as appetite suppressants

- Drugs for cosmetic purposes, such as Rogaine

- Drugs to enhance athletic performance

- Medical supplies such as dressings and antiseptics

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

- Lost, stolen or damaged drugs

- Vitamins and nutritional substances that can be purchased without prescription.

- Smoking-cessation drugs and medication including, but not limited to, nicotine patches and sprays

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

All charges.

Feature

Description

Aetna InteliHealth^�

InteliHealth.com offers comprehensive health information that is interactive and easy-to-use. Harvard Medical School and the University of Pennsylvania School of Dental Medicine help InteliHealth to provide trusted and credible health information to its users. Aetna InteliHealth features include: a Drug Resource Center, Disease and Condition Management tools, the Harvard Symptom Scout (an interactive symptom checker that provides guidance about a variety of symptoms), Daily Health News and much more. Visit InteliHealth at www.aetna.com/fed.

Aetna Navigator�

Aetna Navigator is Aetna�s member and consumer self-service Web site that provides a single source for online benefits and health-related information. As an enrolled Aetna Plan member, you can register for a secure, personalized view of your Aetna benefits through this site.

Once registered, you can: review eligibility, view claim status and Explanation of Benefits (EOB) statements, look up and change provider selections, request member ID cards, receive personalized health and benefits messages, and contact Aetna Member Services at your convenience by sending a secure message.

Registration assistance is available toll free, Monday through Friday, from 7 a.m. to
9 p.m. Eastern Time at 1-800/225-3375. Register today at www.aetna.com/fed.

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.

Services for the deaf and hearing-impaired

1-800/628-3323

Note: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each section. Also read the General Exclusions in Section 7; they apply to the benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about our benefits, contact us at 1-800/537-9384 or at our Web site at www.aetna.com/fed .

Aetna�s high deductible health plan option with an HSA provides comprehensive coverage for high-cost medical events and a tax-advantaged way to help you build savings for future medical expenses. The Plan gives you greater control over how you use your health care benefits.

When you enroll in this HDHP option, we establish either a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA) for you based on your eligibility. Under the HSA, we automatically pass through a portion of the total health Plan premium to your HSA each month, based upon your eligibility. If we establish an HRA for you, we will credit your account with the full amount. If we establish an HSA for you, we will credit your account monthly.

With the HDHP, in-network preventive care is covered in full. As you receive other non-preventive medical care, you must meet the Plan�s deductible before we pay benefits. You can choose to use funds available in your HSA to make payments toward the deductible or you can pay toward your deductible entirely out-of-pocket, allowing your savings to continue to grow.

This HDHP includes five key components: in-network medical and dental preventive care; traditional medical coverage that is subject to the deductible; savings, catastrophic protection for out-of-pocket expenses, and, health education resources and account management tools.

6.1 Savings � Health Savings Account or Health Reimbursement Arrangement............................................ 54

Health Savings Accounts or Health Reimbursement Arrangements provide a means to help you pay out-of-pocket expenses (see Sections 6.1(a), 6.1(b), and 6.1(c) for more details).

6.1(a) Health Savings Account (HSA)............................................................................................................... 55

By law, HSAs are available to members who cannot be claimed as a dependent on someone else�s tax return, have not received VA benefits within the previous three months, and who are not enrolled in Medicare or do not have other health insurance coverage, other than another high deductible health plan. In 2005, for each month you are eligible for the HSA, we will deposit $104.16per month for a Self Only enrollment or $208.33per month for a Self and Family enrollment to your HSA. In addition to our monthly deposit, you have the option to make additional tax-free contributions to your HSA, so long as total contributions do not exceed the limit established by law, which is $1,250 for Self Only enrollment and $2,500 for Self and Family enrollment. See maximum contribution information in Section 6.1(c). You can use funds in your HSA to help pay your health plan deductible and other medical expenses.

Federal tax tip: There are tax advantages to fully funding your HSA as quickly as possible. Your HSA contribution payments are fully deductible on your Federal tax return. By fully funding your HSA early in the year, you have the flexibility of paying medical expenses from tax-free HSA dollars or after tax out-of-pocket dollars. If you don�t deplete your HSA and you allow the contributions and the tax-free interest to accumulate, your HSA grows more quickly for future expenses.

HSA features include:

- Your HSA is administered by Aetna Life Insurance Company

- Your contributions to the HSA are tax deductible

- Your HSA earns tax-free interest

- You can make tax-free withdrawals for qualified medical expenses for you, your spouse and dependents. (See IRS publication 502 for a complete list of eligible expenses.)

- Your unused HSA funds and interest accumulate from year to year

- It�s portable � the HSA is owned by you and is yours to keep, even when you leave Federal employment or retire

316) When you need it, funds up to the actual HSA balance are available.

Important Consideration if you want to participate in a Health Care Flexible Spending Account: if you are enrolled in this HDHP with a Health Savings Account (HSA), you are not able to participate in an FSAFEDS Health Care Flexible Spending Account (HCFSA). See The Federal Flexible Spending Account Program � FSAFEDS in Section 13.

6.1(b) Health Reimbursement Arrangement (HRA)............................................................................................ 58

For members who aren�t eligible for an HSA, are enrolled in Medicare or have another health plan, Aetna will administer and provide an HRA.

In 2005, we will give you an HRA credit of $1,250 per year for a Self Only enrollment and $2,500 for a Self and Family enrollment.  You can use funds in your HRA to help pay your health plan deductible and/or for certain expenses that don�t count toward the deductible.

HRA features include:

- For our HDHP option, the HRA is administered by Aetna Life Insurance Company

- Entire HRA credit (prorated from your effective date to the end of the plan year) is available from your effective date of enrollment

- Tax-free credit can be used to pay for qualified medical expenses for you and any individuals covered by this HDHP

- Unused credits carryover from year to year

- HRA credit does not earn interest

317) HRA credit is forfeited if you leave Federal employment or switch health insurance plans.

318) An HRA does not affect your ability to participate in an FSAFEDS Health Care Flexible Spending Account (HCFSA). However, you must meet FSAFEDS eligibility requirements. See Who Is Eligible to Enroll? in Section 13 under The Federal Flexible Spending Account Program � FSAFEDS.

6.1(c) Savings � HSA and HRA Comparisons.................................................................................................. 60

Important information that compares features of HSAs and HRAs, as well as gives answers to frequently asked questions.

6.2 In-network Medical and Dental Preventive Care........................................................................................ 66

The Plan covers preventive care services, such as periodic health evaluations (e.g., annual physicals), screening services (e.g., routine mammograms), routine prenatal and well-child care, routine child and adult immunizations, disease management and wellness programs. These services are covered at 100% if you use a network provider and are fully described in Section 6.2. You do not have to meet the deductible before using these services. This does not reduce your Account or Fund.

6.3 Traditional Medical Coverage (Subject to the Deductible)......................................................................... 69

After you have paid the Plan�s deductible ($2,500 for Self Only enrollment and $5,000 for Self and Family enrollment), we pay benefits under Traditional Medical Coverage (Subject to the Deductible) described in Section 6.3. The Plan typically pays 90% for in-network and 70% for out-of-network care.

Covered services include:

(a) Medical services and supplies provided by physicians and other health care professionals.............. 70

(b) Surgical and anesthesia services provided by physicians and other health care professionals.......... 77

(c) Hospital services; other facility or ambulance services........................................................................ 81

(d) Emergency services/accidents................................................................................................................ 84

(e) Mental health and substance abuse benefits......................................................................................... 85

(f) Prescription drug benefits........................................................................................................................ 86

(g) Special features........................................................................................................................................ 89

6.4 Catastrophic protection for out-of-pocket expenses.................................................................................... 90

When you use network providers, your annual maximum for out-of-pocket expenses (deductibles, coinsurance and copayments) for covered services is limited to $4,000 per person or $8,000 per family enrollment. However, certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses once you reach your out-of-pocket maximum (such as expenses in excess of the Plan�s allowable amount or benefit maximum). Refer to Section 4 Your catastrophic protection out-of-pocket maximum and Section 6.3 Traditional Medical Coverage (Subject to the Deductible), and Section 6.4 Catastrophic protection for out-of-pocket expenses for more details.

6.5 Health education resources and account management tools....................................................................... 91

Section 6.5 describes the health education resources and account management tools available to you to help you manage your health care and your health care dollars.

Connect to www.aetna.com/fed for access to Aetna Navigator, a secure and personalized member site offering you a single source for health and benefits information. Use it to:

319) Perform self-service functions, like checking your fund and deductible balance or the status of a claim.

320) Gather health-related information from our award-wining Aetna InteliHealth^� website, one of the most comprehensive health sites available today.

Navigator gives you direct access to:

321) The Price-A-Medical Procedure^SM tool, to compare network physician fees for select services to typical fees outside the network.

322) Price-A-Drug^SM tool to estimate the cost of your prescription if obtained at a participating retail or mail order pharmacy.

323) A hospital comparison tool that allows you to see how hospitals in your area rank on measures important to your care.

324) Our DocFind^� online provider directory.

325) Online customer service that allows you to request member ID cards, send secure messages to Member Services, and more.

326) Simple Steps To A Healthier Life^� where you assess your potential health risks, develop a personalized action plan for better health, track your progress and much more.

327) Healthwise^� Knowledgebase where you get information on thousands of health-related topics to help you make better decisions about your health care and treatment options.

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Here are some important things you should keep in mind about a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA):

328) Enrollment in a High Deductible Health Plan (HDHP), with an HSA or HRA, provides health benefits coverage and a tax-advantaged way to help save for future medical expenses.

329) The HDHP/HSA or HRA gives you greater flexibility and discretion over how you use your health care dollars.

330) An HSA is a trust account that you own for the purpose of paying qualified medical expenses for yourself, your spouse, and other dependents. See Sections 6.1(a) and 6.1(c) for greater detail.

331) An HRA is an employer-funded account that automatically reimburses allowable medical expenses, and is administered by the health plan. See Sections 6.1(b) and 6.1(c) for greater detail.

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Here are some important things you should keep in mind about your HSA:

332) You can choose how to use your HSA. You can save your HSA for future expenses while utilizing other funds. Or you can use your HSA account to pay for claims (subject to the deductible).

333) You must participate in the Aetna HealthFund High Deductible Health Plan (HDHP) option, have no other insurance coverage other than that permitted, and not be claimed as a dependent on someone else�s tax return, in order to be eligible for an HSA. Some examples of other coverage that would cause ineligibility are: enrollment in a health care spending account component of a flexible spending account (FSA), a spouse�s FSA, enrollment in a spouse�s health care spending account component of an HMO, other non-high deductible health coverage, TRICARE, Medicare Part A or B or receipt of VA benefits within the previous three months. You are responsible for notifying us of any changes that would cause you to become ineligible.

334) All eligible medical expenses in Section 6.3 (except in-network preventive care ) are applied to your deductible. Traditional Medical Coverage (Subject to the Deductible) will only start once your deductible is satisfied.

335) Your HSA can be used to pay for �qualified medical expenses,� as defined by IRS Code 213(d). These expenses include, but are not limited to, medical plan deductibles, diagnostic services covered by your plan, long-term care premiums, health insurance premiums if you are receiving federal unemployment compensation, over-the-counter drugs, LASIK surgery and some nursing services. When you enroll in Medicare, you can use the account to purchase any health insurance other than a Medigap policy. You may not, however, continue to make contributions to your HSA once you enroll in Medicare. For a list of IRS-allowable expenses, you can request a copy of IRS Publication 502 by calling 1-800/829-3676, or visit the IRS website at www.irs.gov and click on �Forms and Publications.�

336) You have flexibility about how to spend your dollars, and the Plan provides you with the resources to manage your HDHP. You can track your HDHP on Aetna�s Navigator Web site or by telephone at
1-800/537-9384 (toll-free).

337) You may contribute to your HSA by submitting a lump sum payment via a check in any amount, up to the maximum allowed. To make a lump sum contribution, complete an HSA Contribution form and submit it along with your check to the address listed on the form. The deadline for HSA contributions is April 15 following the year for which contributions are made. When you submit the HSA Contribution form, please be sure to indicate whether your contribution is for the current tax year or the previous tax year. You can obtain additional HSA forms by logging into the Aetna Navigator website at www.aetnanavigator.com , enrolling as a member, and selecting from the �Forms Library.�

338) If you join this Plan during Open Season, you receive the full HSA ($1,250 for Self Only or $2,500 for Self and Family enrollment) as of your effective date of coverage. If you join at any other time during the year, your permitted HSA contribution levels are prorated by month. If you join other than the first of the month, you are eligible to contribute to your HSA at the beginning of the first full month of coverage.

339) If you change from Self Only enrollment to Self and Family enrollment mid-year, you can credit amounts incurred against your individual deductible toward your family deductible.

340) You may not contribute to an HSA once you are enrolled in Medicare. Please contact us at 1-800/537-9384 for more information.

341) 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.

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Benefit Description

You pay

Health Savings Account

A Health Savings Account is administered by the Plan for each enrollment. Each year the Plan adds to your HSA:

342) $1,250 per year for a Self Only enrollment, or;

343) $2,500 per year for a Self and Family enrollment.

You may also contribute the following to your HSA:

344) Up to $1,250 per year for a Self Only enrollment, or

345) Up to $2,500 per year for a Self and Family enrollment.

Note: If you join the Plan other than the first of the month, you are eligible to contribute to your HSA at the beginning of the first full month of coverage.

Computing the Maximum Allowable Contribution to an HSA Account

The annual deductible is divided by 12. The result is multiplied by the number of full months remaining in the year after the effective date of the HDHP.

- Example #1: Effective date of enrollment in the Aetna HDHP is 1/9/05. The annual family deductible is $5,000. The maximum allowable 2005 contribution to an HSA account for the enrollee is $5,000 x 11/12 = $4,583.33. You may make a contribution of up to $2,083.33
($4,583.33 � $2,500 automatic Plan contribution from premium).

- Example #2: Effective date of enrollment in Aetna HDHP is 7/6/05. The annual Self Only deductible is $2,500. The maximum allowable 2005 contribution to an HSA account for the enrollee is $2,500 x 5/12 = $1,041.67. You may make a contribution of up to $520.87 ($1,041.67 - $520.80 automatic Plan contribution from premium).

Reimbursement of Medical Expenses from HSA

To be a �qualified medical expense,� eligible for reimbursement from the HSA, the medical expense must be incurred on or following the effective date of the HSA. The HSA effective date is the day the account is established, but not before the first day of the month on or following the effective date of the HDHP.

- Example #1: Effective date of HDHP enrollment is 1/9/05 and HSA is established on 1/11/05. Therefore, the HSA effective date is 2/1/05. Only medical expenses incurred on or after 2/1/05 are reimbursable from the HSA. If the effective date of the HDHP were instead 1/1/05, then the HSA would be effective on the date it was established and medical expenses incurred on or after 1/11/05 would be reimbursable from the HSA.

- Example #2: Effective date HDHP enrollment is 1/9/05 and HSA is established on 2/5/05. Only medical expenses incurred on or after 2/5/05 are reimbursable.

Under the HSA, you can choose to pay from other funds and allow your HSA to grow over time.

Nothing for eligible expenses

Health Savings Account (continued)

You pay

To make the most of your eligible expenses, you should:

346) Use the network providers whenever possible; and

347) Use generic prescriptions whenever possible

Nothing for eligible expenses

HSA Rollover

Any unused, remaining balance in your HSA at the end of the calendar year carries over to the next year. You own your account, so you keep your HSA account even if you change health plans or jobs. If you no longer are enrolled in a high deductible health plan, you are not eligible to make new contributions to your HSA, but you may request a withdrawal for qualified medical expenses.

Note: There is no rollover maximum.

Not covered:

- Non-network preventive care services not included under Section 6.1

- Services or supplies shown as not covered under Traditional Medical Coverage (see Section 6.3)

- Charges of non-network providers that exceed our Plan allowance.

All charges.

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Here are some important things you should keep in mind about your HRA:

- Members must be enrolled in Medicare.

- The Plan provides an HRA Fund for each enrollment for members enrolled in Medicare. Each year, the Plan provides $1,250 for a Self Only enrollment or $2,500 for a Self and Family enrollment. The HRA covers 100% of your eligible medical expenses, and applies to your deductible of $2,500 for Self Only enrollment and $5,000 for Self and Family enrollment.

- All eligible health care expenses in Section 6.3 (except in-network preventive care) are paid first from your HRA. Traditional Medical Coverage will only start once your HRA Fund is exhausted and your deductible is satisfied.

- If you have an unused HRA Fund balance at the end of the calendar year, you will rollover that balance so you can use it in the future with no maximum rollover amount, as long as you continue to participate in the Plan. If you terminate your participation in the Plan, your HRA balance is lost.

Note: In-network Preventive Care benefits paid under Section 6.2 do NOT account against your HRA.

- Medicare premium reimbursement � Medicare participating annuitants may request reimbursement for Medicare premiums paid if HRA dollars are available. Please contact us at 1-800/537-9384 for more information.

- You have flexibility about how to spend your HRA Fund, and the Plan provides you with the resources to manage your HRA Fund. You can track your HRA Fund on Aetna�s Navigator Web site at www.aetna.com/fed or by telephone at 1-800/537-9384 (toll-free).

348) If you join this Plan during Open Season, you receive the full HRA Fund ($1,250 per Self Only or $2,500 per Self and Family enrollment) as of your effective date of coverage. If you join at any other time during the year, your HRA Fund for your first year will be prorated at a rate of $104.16 per month for Self Only or $208.33 per month for Self and Family for each full month of coverage remaining in that calendar year. If your enrollment effective date falls between the first and fifteenth day of the month, you will be given credit as of the first of the month. If your enrollment effective date is the sixteenth or later in the month, you will be given credit as of the first of the following month.

349) YOUR NETWORK PHYSICIAN MUST PRECERTIFY HOSPITAL STAYS FOR IN-NETWORK FACILITY CARE; YOU MUST PRECERTIFY HOSPITAL STAYS FOR NON-NETWORK FACILITY CARE; FAILURE TO DO SO WILL RESULT IN A $500 PENALTY FOR NON-NETWORK FACILITY CARE. Please refer to the precertification information shown in Section 3 to confirm which services require precertification.

- 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.

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Benefit Description

You pay

Health Reimbursement Arrangement

An HRA Fund is provided by the Plan for each enrollment. Each year the Plan adds to your HRA:

350) $1,250 per year for a Self Only enrollment, or;

351) $2,500 per year for a Self and Family enrollment.

The HRA Fund covers eligible expenses at 100%. For example, if you are ill and go to a network doctor for a $60 visit, the doctor will submit your claim and the cost of the visit will be deducted automatically from your HRA; you pay nothing.

Balance in HRA Fund for Self Only $ 1,250

Less: Cost of visit - 60

Remaining Balance in HRA Fund $ 1,190

Nothing for eligible expenses.

To make the most of your eligible expenses, you should:

352) Use the network providers whenever possible; and

353) Use generic prescriptions whenever possible.

HRA Rollover

Provided you remain enrolled in the HRA, any unused, remaining balance in your HRA Fund at the end of the calendar year may be rolled over to subsequent years.

Note: There is no rollover maximum.

Not covered:

- Non-network preventive care services not included under Section 6.1

- Services or supplies shown as not covered under Traditional Medical Coverage (see Section 6.3)

- Charges of non-network providers that exceed our Plan allowance.

All charges.

Feature Comparison

Health Savings Account (HSA)

Health Reimbursement Arrangement (HRA)

Provided when you are
ineligible for an HSA

Administrator

The Plan will establish an HSA for you with Aetna Life Insurance Company, this HDHP�s fiduciary (an administrator, trustee or custodian as defined by Federal tax code and approved by IRS).

Aetna Life Insurance Company

920B Harvest Drive, U40A

Blue Bell, PA 19422

1-800/537-9384 www.aetna.com/fed

Aetna Life Insurance Company is the HRA fiduciary for this Plan.

Aetna Life Insurance Company

920B Harvest Drive, U40A

Blue Bell, PA 19422

1-800/537-9384 www.aetna.com/fed

Fees

Set-up fee is paid by the Plan.

The administrative fee is covered in the premium while the member is covered under the HDHP. If you are no longer covered under the HDHP, there is a $0.75 administrative fee that will be deducted from your HSA until it reaches zero.

None.

Eligibility

- You must be enrolled in the Aetna HealthFund High Deductible Health Plan (HDHP).

- You must not be enrolled in Medicare Part A or Part B or have other general medical insurance coverage.

- You must not be a dependent on someone else�s tax return.

- You must not have received VA benefits in the last 3 months.

- You must be enrolled in the Aetna HealthFund High Deductible Health Plan (HDHP).

- If you enroll in Aetna�s HSA and do not qualify for an HSA, we will establish an HRA for you.

- You must be enrolled in Medicare.

- Eligibility is determined on the first day of the month.

Feature Comparison

Health Savings Account (HSA)

Health Reimbursement Arrangement (HRA)

Provided when you are
ineligible for an HSA

Funding

354) Self Only coverage

$1,250 annually � prorated monthly and deposited by the Plan directly into your account. The Plan will make a monthly deposit of $104.16. Your annual maximum contribution cannot exceed $2,500.

$1,250 annual credit provided by the HDHP upon effective date.

355) Self and Family coverage

$2,500 annually � prorated monthly and deposited by the Plan directly into your account. The Plan will make a monthly deposit of $208.33. Your annual maximum contribution cannot exceed $5,000.

$2,500 annual credit provided by the HDHP upon effective date.

Eligibility for contributions will be determined on the first day of the month following your effective date of coverage and will be prorated for length of enrollment.

Eligibility for annual credit will be determined on the first day of the month and will be prorated for length of enrollment.

Contributions/credits

The maximum that can be contributed to your HSA is an annual combination of the automatic contribution from the Plan which is deposited into the Account and voluntary enrollee contributions, which when combined, cannot exceed the amount of the deductible, which is $2,500 for Self Only coverage and $5,000 for Self and Family coverage.

The full HRA credit will be available, subject to proration, on the effective date of enrollment. The HRA does not earn interest. You cannot contribute to the HRA.

If you choose to contribute to your HSA,

� You must deduct 1/12 of total annual maximum contribution for every month you are not eligible for the HDHP the whole month. For instance, if your enrollment in this Plan was not effective on January 1, 2005, you cannot receive a credit for January and you would need to deduct 1/12 of the annual maximum contribution.

� You may rollover funds you have in other HSAs to this HDHP HSA (rollover funds do not affect your annual maximum contribution under this HDHP).

� Your HSA will earn tax-free interest (does not affect your annual maximum contribution).

Feature Comparison

Health Savings Account (HSA)

Health Reimbursement Arrangement (HRA)

Provided when you are
ineligible for an HSA

Access funds

You can access your HSA by the following methods:

- Withdrawal form

OR

- Streamlining (all eligible medical expenses would automatically flow to the HSA and payment would be made directly to the account holder). (Note: member needs to enroll in this option.)

For qualified medical expenses under your HDHP, claims will be paid automatically by your HRA when claims are submitted to Aetna, if there is money available in your HRA.

Distributions/withdrawals

356) Medical

After meeting the deductible, pay the out-of-pocket expenses for yourself, your spouse or your dependents even if they are not covered by the HDHP from the funds available in your HSA.

Medical expenses are not allowable if they occur before the first full month your enrollment is effective, and they are not reimbursable from your HSA until the first of the month following the effective date of your enrollment in this HDHP and the date your HSA account is established.

For most Federal enrollees (those not paid on a monthly basis), the earliest date medical expenses will be allowable is February 1, 2005.

See IRS Publication 502 for a complete list of eligible expenses.

After meeting the deductible, pay the out-of-pocket expenses for qualified medical expenses for individuals covered under the HDHP.

Non-reimbursed qualified medical expenses are allowable if they occur after the effective date of your enrollment in this Plan.

See Availability of funds below for information on when funds are available in the HRA.

See IRS Publication 502 for a complete list of eligible expenses.

� Non-medical

If you are under age 65, withdrawal of funds for non-medical expenses will create a 10% income tax penalty in addition to any other income taxes you may owe on the accumulated funds.

When you turn age 65, distributions can be used for any reason without being subject to the 10% penalty.

Not applicable � distributions will not be made for anything other than non-reimbursed qualified medical expenses.

Feature Comparison

Health Savings Account (HSA)

Health Reimbursement Arrangement (HRA)

Provided when you are
ineligible for an HSA

Availability of Account or Fund

Funds are not available until:

� Your enrollment in this HDHP is effective (effective date is determined by your agency in accord with the event permitting the enrollment change).

� The HDHP receives record of your enrollment and initially establishes your HSA account with the fiduciary by providing information it must furnish and by contributing the minimum amount required to establish an HSA.

� Aetna sends out HSA enrollment forms and Disclosure Statement paperwork for the enrollee to complete and the plan administrator receives the completed paperwork.

After the plan administrator receives enrollment and contributions from OPM, the enrollee can withdraw funds up to the amount contributed for any expenses incurred on or after the date the HSA was initially established.

Funds are not available until:

� Your enrollment in this HDHP is effective (effective date is determined by your agency in accord with the event permitting the enrollment change).

Account owner

FEHB enrollee

HDHP

Portable

Yes, you can take this account with you when you separate or retire.

If you retire and remain in this HDHP, you may continue to use and accumulate credits in your HRA.

If you terminate employment or change health plans, only eligible expenses incurred while covered under the HDHP will be eligible for reimbursement subject to timely filing requirements. Unused funds are forfeited.

Annual rollover

Yes, accumulates without a maximum annual cap.

Yes, accumulates without a maximum annual cap.

HSAs

Is the �premium pass through� to my HSA considered taxable income?

�Premium pass through� contributions by the HDHP are not considered taxable income.

Can I contribute to my HSA?

Yes. All contributions are aggregated and cannot exceed the annual maximum contribution. You may contribute your own money to your account through payroll deductions (if available), or you may make a lump sum contribution at any time, in any amount up to an annual maximum limit. Others can also make contributions to your HSA on your behalf. If you (or someone on your behalf) contribute a lump-sum, you can claim the total amount contributed for the year as a tax deduction when you file your income taxes. You receive tax advantages in any case. You have until April 15 of the following year to make HSA contributions for the current year.

IRS contribution rules reduce the total annual maximum contribution if you are not eligible for the HDHP during the whole month. For instance, if your enrollment in this Plan was not effective on January 1, 2005, you cannot receive a credit for January and you would need to deduct 1/12 of the annual maximum contribution. Contact Aetna for more details.

Catch-up contributions

If you are age 55 or older, the IRS permits you to make additional catch-up contributions to your HSA. In 2005, you may contribute up to $600 in �catch-up� contributions. Catch-up contributions in later years increase up to a maximum of $1,000 in 2009 and beyond. Contributions must stop once an individual is enrolled in Medicare. Additional details are available on the IRS Web site at www.irs.gov .

Rate of interest earned

Depending on how you choose to invest your HSA savings, the interest rate and payment of interest will vary.

What happens to my HSA if I leave my health plan or job?

You own your account, so you keep your HSA even if you change health plans, leave Federal employment, enroll in Medicare, or any of the other events which may make you ineligible for further contributions to your HSA. Even when you are not eligible to make contributions to your HSA, you may request withdrawals.

What happens to my HSA if I die?

Your HSA would pass to your surviving spouse or named beneficiary tax-free. If you do not have a named beneficiary, the money is disbursed to your estate and is taxable.

What expenses can I pay for with my HSA?

You can pay for �qualified medical expenses,� as defined by IRS Code 213(d). These expenses include, but are not limited to, medical plan deductibles, diagnostic services covered by your plan, long-term care premiums, and health insurance premiums if you are receiving Federal unemployment compensation, over-the-counter drugs, LASIK surgery, and some nursing services.

When you enroll in Medicare, you can use the account to purchase any health insurance other than a Medigap policy. You may not, however, continue to make contributions to your HSA once you are enrolled in Medicare.

For the complete list of IRS-allowable expenses, request a copy of IRS Publication 502 by calling 1-800-829-3676, or visit the IRS Web site at www.irs.gov and click on �Forms and Publications.�

Non-qualified health expenses

You may withdraw money from your HSA for items other than qualified health expenses, but it will be subject to income tax and if you are under 65 years old, an additional 10% penalty tax on the amount withdrawn.

HRAs

How do I know if I qualify for an HRA?

If you don�t qualify for an HSA when you enroll, or later become ineligible for an HSA, the HDHP will establish an HRA for you. If you are enrolled in Medicare, you are ineligible for an HSA and your HDHP will establish an HRA for you.

HRA and HSA differences

Please review the chart at the beginning of this Section which details the differences. The major differences are:

357) you cannot make contributions to an HRA

358) HRA funds are forfeited if you leave the HDHP

359) an HRA does not earn interest, and

360) HRAs can only pay for qualified medical expenses, such as deductibles, copayments, and coinsurance expenses, for individuals covered by the HDHP.

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Here are some important things you should keep in mind about these in-network medical and dental preventive care benefits:

- The Plan pays 100% for the medical and dental preventive care services listed in this Section as long as you use a network provider.

- If you choose to access preventive care from a non-network provider, you will not qualify for 100% preventive care coverage. Please see Section 6.2 � HSA, and HRA or Section 6.3 � Traditional Medical Coverage (Subject to the Deductible ).

- For preventive care not listed in this Section, preventive care from a non-network provider, or any other covered expenses, please see Section 6.3 � Traditional Medical Coverage.

- Note that the in-network preventive care paid under this Section does NOT count against or use up your HSA or HRA.

- 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.

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Benefit Description

You pay

In-Network Medical Preventive Care, adult

HSA

HRA

Routine screenings, such as:

361) Blood tests

362) Urinalysis

363) Total Blood Cholesterol

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

365) Colorectal Cancer Screening, including

� Fecal occult blood test yearly starting at age 50,

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

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

� Colonoscopy screening � every 10 years starting at age 50

366) Routine annual digital rectal exam (DRE) for men age 40 and older

367) Routine well-woman exam including Pap test , one visit every 12 months from last date of service

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

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

� From age 40 through 64, one every calendar year

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

In-network: Nothing at a network provider.

Out-of-network: All charges until you satisfy your deductible, then 30% of our Plan allowance and any difference between our allowance and the billed amount under Traditional Medical Coverage (Section 6.3). However, you may elect to use your HSA account to pay the bill, up to your HSA balance.

In-network: Nothing at a network provider.

Out-of-network: Nothing at a non-network provider up to your available HRA Fund balance. Charges above the available HRA Fund balance, according to the Traditional Medical Coverage (Section 6.3), and the deductible.

In-Network Medical Preventive Care, adult (continued)

You pay
HSA

You pay
HRA

369) Routine physicals:

� One exam every 24 months up to age 65

� One exam every 12 months age 65 and older

370) Routine immunizations , exams and eyewear limited to:

� Tetanus-diphtheria (Td) booster � once every 10 years, ages 19 and over (except as provided for under Childhood immunizations )

� Influenza vaccine, annually

� Pneumococcal vaccine, age 65 and over

� 1 routine eye exam every 12 months

� 1 routine OB/GYN exam every 12 months including 1 Pap smear and related services

� 1 routine hearing exam every 24 months

� Corrective eyeglasses and frames or contact lenses (hard or soft) per 24-month period up to a Plan allowance of $100.

In-network: Nothing at a network provider.

Out-of-network: All charges until you satisfy your deductible, then 30% of our Plan allowance and any difference between our allowance and the billed amount under Traditional Medical Coverage (Section 6.3). However, you may elect to use your HSA account to pay the bill, up to your HSA balance.

In-network: Nothing at a network provider

Out-of-network: Nothing at a non-network provider up to your available HRA Fund balance. Charges above the available HRA Fund balance, according to the Traditional Medical Coverage (Section 6.3), and the deductible.

Not covered:

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

- Immunizations, boosters, and medications for travel or work-related exposure.

All charges.

All charges.

In-Network Medical Preventive Care, children

� Childhood immunizations recommended by the American Academy of Pediatrics

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

� 6 exams in the first 12 months of life

� 2 exams in the 13-24th months of life

� 1 exam every 12 months thereafter up to age 18

� 1 exam every 24 months for children age 18 and older

372) 1 routine eye exam every 12 months

� 1 routine hearing exam every 24 months

In-network: Nothing at a network provider

Out-of-network: All charges until you satisfy your deductible, then 30% of our Plan allowance and any difference between our allowance and the billed amount under Traditional Medical Coverage (Section 6.3). However, you may elect to use your HSA account to pay the bill, up to your HSA balance.

In-network: Nothing at a network provider

Out-of-network: Nothing at a non-network provider up to your available HRA Fund balance. Charges above the available HRA Fund balance, according to the Traditional Medical Coverage (Section 6.3), and the deductible.

In-Network Medical Preventive Care, children (continued)

You pay
HSA

You pay
HRA

Not covered:

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

- Immunizations, boosters, and medications for travel or work-related exposure.

All charges.

All charges.

In-Network Dental Preventive Care

Preventive care limited to:

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

374) Fluoride applications (limited to 1 treatment per calendar year and for children under age 16)

375) Sealants � (once every 3 years, from the last date of service, on permanent molars for children under age 16)

376) Space maintainer (primary teeth only)

377) Bitewing x-rays (one set per calendar year)

378) Complete series x-rays (one complete series every 3 years)

379) Periapical x-rays

380) Routine oral evaluations (limited to 2 per calendar year)

Participating network PPO dentists offer members services at a negotiated rate � so, you are generally charged less for your dental care when you visit a participating network PPO dentist. Refer to our DocFind online provider directory at www.aetna.com/fed to find a participating network PPO dentist, or call Member Services at 1-800/537-9384.

In-network: Nothing at a network dentist

Out-of-network: All charges

In-network: Nothing at a network dentist

Out-of-network: All charges

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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.

- In-network preventive care is covered at 100% under Section 6.2 and does not count against your deductible.

- The deductible is $2,500 per person or $5,000 per family enrollment. The family deductible can be satisfied by one or more family members. You must pay your deductible before your Traditional Medical Coverage may begin.

- Under Traditional Medical Coverage, in-network benefits apply only when you use a network provider. Out-of-network benefits apply when you do not use a network provider. Your dollars will generally go further when you use network providers because network providers agree to discount their fees.

- Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 10 about coordinating benefits with other coverage, including with Medicare.

- YOUR NETWORK PHYSICIAN MUST PRECERTIFY HOSPITAL STAYS FOR IN-NETWORK FACILITY CARE; YOU MUST PRECERTIFY HOSPITAL STAYS FOR NON-NETWORK FACILITY CARE; FAILURE TO DO SO WILL RESULT IN A $500 PENALTY FOR NON-NETWORK FACILITY CARE. Please refer to the precertification information shown in Section 3 to confirm which services require precertification.

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Benefit Description

You pay

Deductible before Traditional Medical Coverage begins

HSA

HRA

You must satisfy your deductible before your Traditional Medical Coverage begins. The Self and Family deductible can be satisfied by one or more family members.

Once your Traditional Medical Coverage begins, you will be responsible for your coinsurance amounts for eligible medical expenses or copayments for eligible prescriptions, until you reach the annual catastrophic protection out-of-pocket maximum. At that point, we pay eligible medical expenses for the remainder of the calendar year at 100%.

100% of allowable charges until you meet the deductible of $2,500 per Self Only enrollment or $5,000 per Self and Family enrollment. You can use HSA to help satisfy your deductible.

100% of allowable charges until you meet the deductible of $2,500 per Self Only enrollment or $5,000 per Self and Family enrollment. Your HRA Fund counts towards your deductible.

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

381) The deductible is $2,500 for Self Only enrollment and $5,000 for Self & Family enrollment.

382) After you have satisfied your deductible , your Traditional Medical Coverage begins.

383) Under your Traditional Medical Coverage, you will be responsible for your coinsurance amounts for eligible medical expenses or copayments for eligible prescriptions.

384) 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.

385) Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 10 about coordinating benefits with other coverage, including with Medicare.

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Benefit Description

You pay

Diagnostic and treatment services

Professional services of physicians

386) In physician �s office

� Office medical consultations

� Second surgical or medical opinion

� Initial examination of a newborn child covered under a family enrollment

387) In an urgent care center for a routine service

388) During a hospital stay

389) In a skilled nursing facility

390) At home

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

Lab, X-ray and other diagnostic tests

Tests, such as:

391) Blood tests

392) Urinalysis

393) Non-routine pap tests

394) Pathology

395) X-rays

396) Non-routine Mammograms

397) CT Scans/MRI

398) Ultrasound

399) Electrocardiogram and EEG

Maternity care

You pay

Complete maternity (obstetrical) care, such as:

400) Prenatal care

401) Delivery

402) Postnatal care

Note: Here are some things to keep in mind:

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

404) You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will cover an extended inpatient stay if medically necessary but you, your representatives, your doctor, or your hospital must recertify the extended stay.

405) 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.

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

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

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

All charges.

Family Planning

A range of voluntary family planning services, limited to:

407) Voluntary sterilization (See Surgical procedures)

408) Surgically implanted contraceptives

409) Injectable contraceptive drugs (such as Depo Provera)

410) Intrauterine devices (IUDs)

411) Diaphragms

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

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered: Reversal of voluntary surgical sterilization, genetic counseling

All charges.

Infertility services

You pay

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.

412) Artificial insemination

� Intravaginal insemination (IVI)

� Intracervical insemination (ICI)

� Intrauterine insemination (IUI)

413) Testing for diagnosis and surgical treatment of the underlying cause of infertility.

414) Fertility drugs except injectables

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

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

415) Assisted reproductive technology (ART) procedures, such as:

� In vitro fertilization

� Embryo transfer including, but not limited to, gamete GIFT and zygote ZIFT

� Services provided in the setting of ovulation induction such as ultrasounds, laboratory studies, and physician services.

� Services and supplies related to the above mentioned services, including sperm processing

416) Reversal of voluntary, surgically-induced sterility.

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

418) Injectable fertility drugs

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

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

All charges.

Allergy care

421) Testing and treatment

422) Allergy injection

423) Allergy serum

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered: Provocative food testing and sublingual allergy desensitization

All charges.

Treatment therapies

You pay

424) Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under Organ/Tissue Transplants on page 79.

425) Respiratory and inhalation therapy

426) Dialysis � hemodialysis and peritoneal dialysis

427) Intravenous (IV) Infusion Therapy � Home IV and antibiotic therapy must be precertified by your attending physician .

428) Growth hormone therapy (GHT)

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.

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

Physical and occupational therapies

429) 20 visits 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

� 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.

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

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered: Long-term rehabilitative therapy

All charges.

Pulmonary and cardiac rehabilitation

431) 20 visits per condition per member per calendar year for pulmonary rehabilitation to treat functional pulmonary disability.

432) 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.

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered: Long-term rehabilitative therapy

All charges.

Speech therapy

You pay

433) 20 visits per condition per member per calendar year, beginning with the first day of treatment

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

Hearing services (testing, treatment and supplies)

434) One hearing exam every 24 months

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered: Hearing aids, testing and examinations for them

All charges.

Vision services (testing, treatment and supplies)

435) Treatment of eye diseases and injury

436) One routine eye refraction every 12-month period

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

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

438) Fitting of contact lenses

439) Eye exercises

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

All charges.

Foot care

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

See Orthopedic and prosthetic devices for more information.

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

442) 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

443) 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)

444) Foot orthotics

445) Podiatric shoe inserts

All charges.

Orthopedic and prosthetic devices

You pay

446) Orthopedic devices such as braces and prosthetic devices such as artificial limbs and eyes

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

448) Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following mastectomy, and lenses following cataract removal. See Surgical section for coverage of the surgery to insert the device.

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

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

450) Orthopedic and corrective shoes not attached to a covered brace

451) Arch supports

452) Foot orthotics

453) Heel pads and heel cups

454) Lumbosacral supports

455) Penile implants

All charges.

Durable medical equipment (DME)

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

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

457) Wheelchairs (motorized wheelchairs and scooters must be preauthorized);

458) Crutches;

459) Walkers; and

460) Insulin pumps and related supplies such as needles and catheters.

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

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

461) Elastic stockings and support hose

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

463) Home modifications such as stairglides, elevators and wheelchair ramps

464) 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 services

You pay

465) Home health care ordered by your attending physician and provided by nurses and home health aides. Your attending physician will periodically review the program for continuing appropriateness and need.

466) Services include oxygen therapy, intravenous therapy and medications.

Note: Home health services must be precertified by your attending Physician.

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

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

468) Transportation

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

470) Services of a social worker

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

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

All charges.

Chiropractic

No benefit

All charges.

Alternative treatments

No benefit

All charges.

Educational classes and programs

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

473) Chronic heart failure

474) Coronary artery disease

475) Diabetes

476) Asthma

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

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

- The deductible is $2,500 for Self Only enrollment and $5,000 for Self & Family enrollment.

- 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 10 about coordinating benefits with other coverage, including with Medicare.

- YOUR NETWORK PHYSICIAN MUST PRECERTIFY HOSPITAL STAYS FOR IN-NETWORK FACILITY CARE; YOU MUST PRECERTIFY HOSPITAL STAYS FOR NON-NETWORK FACILITY CARE; FAILURE TO DO SO WILL RESULT IN A $500 PENALTY FOR NON-NETWORK FACILITY CARE. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.

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Benefit Description

You pay

Surgical procedures

A comprehensive range of services, such as:

477) Operative procedures

478) Treatment of fractures, including casting

479) Normal pre- and post-operative care by the surgeon

480) Correction of amblyopia and strabismus

481) Endoscopy procedures

482) Biopsy procedures

483) Removal of tumors and cysts

484) Correction of congenital anomalies (see Reconstructive surgery )

485) 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 in advance by Aetna.

486) Insertion of internal prosthetic devices . See 6.3(a) � Orthopedic and prosthetic devices for device coverage information

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

488) Treatment of burns

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

Surgical procedures(continued)

You pay

Not covered:

489) Reversal of voluntary surgically-induced sterilization

490) Surgery primarily for cosmetic purposes

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

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

493) Routine treatment of conditions of the foot; see Foot care

All charges.

Reconstructive surgery

494) Surgery to correct a functional defect

495) 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

496) 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.

497) 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.

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

498) 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

499) Surgeries related to sex transformation

All charges.

Oral and maxillofacial surgery

You pay

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

500) Treatment of fractures of the jaws or facial bones;

501) Removal of stones from salivary ducts;

502) Excision of benign or malignant lesions;

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

504) 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.

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

505) Dental implants

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

All charges.

Organ/tissue transplants

National Transplant Program (NTP) - Transplants which are non-experimental or non-investigational are a covered benefit. Covered transplants must be ordered by your attending doctor and plan specialist and approved by our medical director in advance of the surgery. To receive in-network benefits, 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 until discharge from the hospitalization when the donation occurred, to the extent these services are not covered by another plan or program.

Transplants are limited to:

507) Cornea

508) Heart

509) Heart/lung

510) Kidney

511) Liver

512) Lung: Single � Double

513) Pancreas; Pancreas/Kidney (simultaneous)

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

515) Skin

516) Tissue

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

Organ/tissue transplants (continued)

You pay

517) Allogeneic (donor) bone marrow/peripheral stem cell transplants

518) Autologous bone marrow transplant s (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

519) Autologous tandem transplants for ovarian cancers as well as testicular cancers

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

Limited Benefits � Treatment for breast cancer, multiple myeloma and epithelial ovarian cancer and other selected diseases 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.

Not covered:

520) Transplants not listed as covered

521) Implants of artificial organs

522) Donor screening tests and donor search expenses, except those performed for the actual donor

All charges.

Anesthesia

Professional services provided in �

523) Hospital (inpatient)

524) Hospital outpatient department

525) Skilled nursing facility

526) Ambulatory surgical center

527) Office

Note: If your network provider uses a non-network anesthesiologist, we will pay out-of-network benefits for any anesthesia charges.

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

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

528) The deductible is $2,500 for Self Only enrollment and $5,000 for Self & Family enrollment.

529) 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.

530) Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 10 about coordinating benefits with other coverage, including with Medicare.

531) YOUR NETWORK PHYSICIAN MUST PRECERTIFY HOSPITAL STAYS FOR IN-NETWORK FACILITY CARE; YOU MUST PRECERTIFY HOSPITAL STAYS FOR NON-NETWORK FACILITY CARE; FAILURE TO DO SO WILL RESULT IN A $500 PENALTY FOR NON-NETWORK FACILITY CARE. Please refer to the precertification information shown in Section 3 to confirm which services require precertification.

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Benefit Description

You pay

Inpatient hospital

Room and board , such as

532) Ward, semiprivate, or intensive care accommodations;

533) General nursing care; and

534) 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.

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

Other hospital services and supplies, such as:

535) Operating, recovery, maternity, and other treatment rooms

536) Prescribed drugs and medicines

537) Diagnostic laboratory tests and X-rays

538) Administration of blood and blood products

539) 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

540) Dressings, splints, casts, and sterile tray services

541) Medical supplies and equipment, including oxygen

542) Anesthetics, including nurse anesthetist services

543) Take-home items

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

Inpatient hospital (continued)

You pay

Not covered:

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

546) Non-covered facilities, such as nursing homes, schools

547) Custodial care, rest cures, domiciliary or convalescent cares

548) Personal comfort items, such as telephone and television

549) Private nursing care

All charges.

Outpatient hospital or ambulatory surgical center

550) Operating, recovery, and other treatment rooms

551) Prescribed drugs and medicines

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

553) Pathology Services

554) Administration of blood, blood plasma , and other biologicals

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

556) Pre-surgical testing

557) Dressings, casts , and sterile tray services

558) Medical supplies, including oxygen

559) 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.

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

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

All charges.

Extended care benefits/Skilled nursing care facility benefits

Extended care benefit: All necessary services during confinement in a skilled nursing facility with a 60-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.

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered: Custodial care

All charges.

Hospice care

You pay

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 your attending Physician, who certifies the patient is in the terminal stages of illness, with a life expectancy of approximately 6 months or less. We allow up to a maximum of $5,000 for outpatient hospice services and a period not to exceed 30 days for inpatient hospice services.

Note: Inpatient hospice services require prior approval .

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

Ambulance

560) Local professional ambulance service when medically appropriate.

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

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

All charges.

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

� The deductible is $2,500 for Self Only enrollment and $5,000 for Self & Family enrollment.

- 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 10 about coordinating benefits with other coverage, including with Medicare.

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

Benefit Description

You pay

Emergency

561) Emergency care at a doctor�s office or urgent care center

562) Emergency care as an outpatient in a hospital, including doctors� services

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

563) Non-emergency use of the Emergency Room

50% of our Plan allowance

Not covered: Elective care or non-emergency care

All charges.

Ambulance

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

See Hospital section for non-emergency service.

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered: Air ambulance without prior approval .

All charges.

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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 you should keep in mind about these benefits:

� The deductible is $2,500 for Self Only enrollment and $5,000 for Self & Family enrollment.

- 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 10 about coordinating benefits with other coverage, including with Medicare .

- YOU MUST GET PREAUTHORIZATION FOR INPATIENT SERVICES.

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Benefit Description

You pay

Mental health and substance abuse benefits

Outpatient services include:

564) Individual and group therapy performed by licensed providers such as psychiatrists, psychologists, or clinical social workers

565) Facility based intensive outpatient or partial hospital treatment programs

566) Outpatient services provided by a hospital or other facility

567) Diagnostic tests

568) Medication management

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

Inpatient care includes:

569) Both mental health and chemical dependency services provided by an appropriately licensed inpatient facility including licensed residential treatment facilities

Note: All inpatient services are subject to precertification.

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.

In-network: 10% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

Network limitation

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

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

- The deductible is $2,500 for Self Only enrollment and $5,000 for Self & Family enrollment.

- We cover prescribed drugs and medications, as described in the chart beginning on the next page. Copayment levels reflect in-network pharmacies only. If you obtain your prescription at an out-of-network pharmacy (non-preferred), you will be reimbursed at our Plan allowance less 30%. You are responsible for any difference between our Plan allowance and the billed amount.

� Your deductible must be satisfied before your Traditional Pharmacy Coverage begins. After your deductible is satisfied, you will pay a copayment at an in-network retail or mail order pharmacy for prescriptions under your Traditional Pharmacy Coverage; you will pay 30% coinsurance plus the difference between our Plan allowance and the billed amount at an out-of-network retail pharmacy. There is no out-of-network mail order pharmacy program. Your HRA must be used to help you satisfy your deductible. Note: The cost of your prescription is based on the Aetna contracted rate with network pharmacies. The Aetna contracted rate with the network pharmacy does not reflect or include any rebates Aetna receives from drug manufacturers.

- 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 10 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.

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