guide to federal benefits - office of personnel management

The 2014

Guide To Federal Benefits

Healthcare and Insurance RI 70-10Revised November 2013

bull Federal Employees Health Benefits (FEHB) Program p 8

bull Federal Employees Dental and Vision Insurance Program

(FEDVIP) p 12

bull Federal Flexible Spending Account Program (FSAFEDS) p 16

bull Federal Employeesrsquo Group Life Insurance (FEGLI) Program p 20

bull Federal Long Term Care Insurance Program (FLTCIP) p 22

For Federal Civilian Employees

Visit us at wwwopmgovhealthcare-insurance

The information contained in this Guide to Federal Benefits is only

a summary of the benefits available under each plan Before you

select a plan or option please read the Planrsquos Federal brochure

as it is the official statement of benefits

All benefits are subject to the definitions limitations and

exclusions set forth in the Planrsquos Federal brochure

The Federal Employees Dental and Vision Insurance

Program (FEDVIP) is adding three new dental plans and

one new vision plan for 2014 See page 105 for details

Summary Information

New Hires Can Enroll

Federal Benefits Open Season

How to Enroll OPMrsquos Program Website

FEHB Within 60 days from new hire date

Annual ndash November 11 to December 9 2013

Varies by agency automated enrollment or via SF 2809

wwwopmgovhealthcareshyinsurancehealthcare

FEDVIP Within 60 days from new hire date


Go to wwwBENEFEDScom or call 1shy877shy888shy3337

wwwopmgovhealthcareshyinsurancedentalshyvision

FSAFEDS Within 60 days from new hire date


Go to wwwFSAFEDScom or call 1shy877shy372shy3337

wwwopmgovhealthcareshyinsuranceflexibleshyspendingshyaccounts

FEGLI Within 60 days from new hire date for optional insurance automatically enrolled in Basic insurance until you take action to cancel

No annual Open Season

Varies by agency automated enrollment or via SF 2817 for new hires

Others provide medical information on SF 2822

wwwopmgovhealthcareshyinsurancelifeshyinsurance

FLTCIP Apply (not necessarily enroll) within 60 days from new hire date with abbreviated underwriting


Go to wwwLTCFEDScom or call 1shy800shy582shy3337

wwwopmgovhealthcareshyinsurancelongshytermshycare

Table of Contents

Page

Introduction to Federal Benefits and This Guide 2

Federal Benefits Snapshot 3

Federal Benefits Open Season Snapshot 4

Thinking About Retiring 5

Federal Employees Health Benefits (FEHB) Program 8

FEHB Program Health Information Technology and PriceCost Transparency 11

Federal Employees Dental and Vision Insurance Program (FEDVIP) 12

Federal Flexible Spending Account Program (FSAFEDS) 16

Federal Employeesrsquo Group Life Insurance (FEGLI) Program 20

Federal Long Term Care Insurance Program (FLTCIP) 22

Appendix A FEHB Program Features 25

Appendix B Choosing an FEHB Plan 26

Appendix C Qualifying Life Events that May Permit you to Enroll or Change Your FEHB Enrollment 29

Appendix D FEHB Member Survey Results 30

Appendix E FEHB Plan Comparison Charts 31

bull Nationwide FeeshyforshyService Plans 32

bull Health Maintenance Organization Plans and Plans Offering a PointshyofshyService Product 37

bull High Deductible and ConsumershyDriven Health Plans 76

Appendix F FEDVIP Program Features 101

Appendix G FEDVIP Definitions 102

Appendix H FEDVIP Qualifying Life Events for Enrollment Changes 103

Appendix I FEDVIP Plan Comparison Charts 104

bull Nationwide and International Dental Plans Open to All 105

bull Regional Dental Plans 107

bull Nationwide and International Vision Plans Open to All 108

Appendix J FEDVIP Dental Rating Regional Chart 110

Appendix K FEDVIP Premium Rate Charts 113

Medicaid and the Childrenrsquos Health Insurance Program (CHIP) 116

1

Introduction to Federal Benefits and This Guide

As a Federal employee the benefits available to you represent a significant piece of your compensation package They may provide important insurance coverage to protect you and your family and in some cases offer tax advantages that reduce the burden in paying for some health products and services or dependent or elder care services

The purpose of this Guide is to provide you basic information about the benefits offered to you as a Federal employee and assist you in making informed choices about these benefits as you move through your career and prepare for retirement

Benefits Programs included in this Guide

In addition to your Civil Service or Federal Employees Retirement System benefits and the Thrift Savings Plan the Federal government offers five benefits programs to eligible employees and retirees This Guide includes information on the five programs

bull Federal Employees Health Benefits Program (FEHB) bull Federal Employees Dental and Vision Insurance Program (FEDVIP) bull Federal Flexible Spending Account Program (FSAFEDS) bull Federal Employeesrsquo Group Life Insurance Program (FEGLI) bull Federal Long Term Care Insurance Program (FLTCIP)

If you are a new Federal employee or have recently become eligible for benefits this Guide will walk you through the benefits offered and provide information on how and when to make your choices If you are a current employee this Guide will provide the most current information regarding the benefit programs and will support you as you make decisions during the annual Federal Benefits Open Season or experience life events that cause you to reconsider previous choices

This Guide also contains some tips on what to consider as you make your decisions For instance did you know that the Federal Employees Health Benefits (FEHB) Program the Federal Employees Dental and Vision Insurance Program (FEDVIP) and the Federal Flexible Spending Account Program (FSAFEDS) can potentially provide you with greater benefits without costing you much more As a Federal employee you can choose to pay the FEDVIP and FEHB premiums with preshytax dollars and you can use preshytax FSA dollars to pay for eligible expenses including FEDVIP and FEHB copays and deductibles Dental and vision care are also eligible FSA expenses whether combined with FEDVIP coverage or not Please take a moment to review the information in this Guide and decide upon the right choices for you

Additional Information

You will find references throughout this Guide to websites or other locations to obtain more detailed information than is available here We encourage you to access these sites to become a more educated decisionshymaker and consumer of Federal benefit programs

2

Federal Benefits Snapshot

New or Newly Eligible Employees

As a new or newly eligible employee you may have the opportunity to enroll in the benefit programs noted below Use this chart to assist you with the decisionshymaking process of selecting and enrolling in the benefit programs below that meet your needs The chart gives you things to consider as you make your decisions

FEHB 1 See page 8 for general information on FEHB (including eligibility) and for guidance on choosing a plan

2 If you decide to enroll examine the 2014 brochure of each plan you consider to ensure the benefits and premiums meet your needs and the plan is available in your area

3 Contact the human resources office of your agency for information on how to enroll

FEDVIP 1 See page 12 for general information on FEDVIP (including eligibility) and guidance on choosing a FEDVIP dental plan andor vision plan


3 See page 14 for information on how to enroll

FSAFEDS 1 See page 16 for general information on FSAFEDS (including eligibility) and for guidance on making a decision whether to participate


FEGLI 1 See page 20 for general information on FEGLI (including eligibility) and for guidance on making a decision whether to select optional insurance (Basic FEGLI is automatic)


FLTCIP 1 See page 22 for general information on FLTCIP (including eligibility) and for guidance on making a decision whether to apply

2 See page 23 for information on how to apply for coverage

3

Federal Benefits Open Season Snapshot

Current Employees

During Open Season you have the opportunity to enroll or make changes in the Federal Employees Health Benefits (FEHB) Program the Federal Employees Dental and Vision Insurance Program (FEDVIP) and the Federal Flexible Spending Account Program (FSAFEDS) You can use this chart to assist you with the decisionshymaking process of selecting plans and enrolling in these benefit programs

If Currently Enrolled in the Program If Not Enrolled in the Program

FEHB 1 Check your planrsquos 2014 premiums and satisfaction survey results in Appendix E

2 Examine your planrsquos 2014 brochure for benefit and enrollmentservice area changes

3 Check Appendix E for any new plans and plan options available to you

4 If satisfied with your planrsquos rates survey results and benefits for 2014 do nothing ndash your enrollment will continue automatically

5 If not satisfied with your current plan for 2014 see Appendix B for guidance on choosing another plan

6 See page 5 for information on FEHB and retirement

1 See page 8 for general information on FEHB (including eligibility) and Appendix B for guidance on choosing a plan



FEDVIP 1 Check your planrsquos 2014 premiums in Appendix K and examine your planrsquos 2014 brochure for benefit and enrollmentservice area changes

2 If also enrolled in FEHB check your 2014 FEHB brochure for any changes in dental andor vision benefits

3 Check Appendix I for new plans available to you

4 If satisfied with your planrsquos rates and benefits for 2014 do nothing ndash your enrollment will continue automatically

5 If not satisfied with your current plan for 2014 see page 12 for guidance on choosing another plan and for information on how to change your enrollment

6 If you no longer want FEDVIP you must cancel during Open Season by contacting BENEFEDS After Open Season you cannot cancel see Appendix H for details

7 See page 6 for information on FEDVIP and retirement

1 See page 12 for general information on FEDVIP (including eligibility) and for guidance on choosing a FEDVIP plan

2 If you decide to enroll examine the 2014 brochure of the plans in which you are interested to ensure the benefits and premiums meet your needs and the plan is available in your area

3 If enrolled in FEHB check your 2014 FEHB brochure for any changes in dental andor vision benefits


FSAFEDS 1 If you want to participate in 2014 you must make a new election Keep in mind your election and enrollment do not carry over from year to year see page 19 for information on how to enroll

2 Check your 2014 FEHB and 2014 FEDVIP plan brochures to see how any benefit changes may affect your outshyofshypocket health care expenses

3 See page 17 for any updated information about the Program

1 See page 16 for general information on FSAFEDS (including eligibility) and for guidance on making a decision whether to participate


4

Thinking About Retiring

Federal Benefits Facts

FEHB bull When you retire you are eligible to continue health benefits coverage if you meet all of the following requirements

ndash you are entitled to retire on an immediate annuity under a retirement system for civilian employees (including the Federal Employees Retirement System (FERS) Minimum Retirement Age (MRA) + 10 retirement) and

ndash you have been continuously enrolled (or covered as a family member) in any FEHB plan(s) for the 5 years of service immediately before your retirement date or for the full period(s) of service since your first opportunity to enroll (if less than 5 years)

bull The 5 year requirement period can include the following

ndash the time you are covered as a family member under another persons FEHB enrollment or

ndash the time you are covered under the Uniformed Services Health Benefits Program (also known as TRICARE) as long as you were covered under an FEHB enrollment at the time of your retirement

bull As an annuitant you are entitled to the same benefits and Government contributions as Federal employees enrolled in the same plan

bull The event of retirement is not a qualifying life event (QLE) however there are other opportunities to change FEHB enrollment including during Open Season or when you experience a QLE

bull If you retire with a Self Only enrollment and later want to cover eligible family members you can change to a Self and Family enrollment during the annual Open Season or when you experience certain QLEs

bull If you are not enrolled in FEHB (or covered as a family member) at the time of your retirement you cannot enroll when you retire

bull If you are enrolled in a High Deductible Health Plan (HDHP) with a Health Savings Account (HSA) at the time of your retirement you can still contribute to your HSA provided you have no other insurance coverage other than those specifically allowed and are not claimed as a dependent on someone elsersquos tax return Some examples of other coverage that would cause ineligibility are Medicare TRICARE other nonshyhigh deductible health insurance or having received VA benefits within the previous three months If you donrsquot qualify for an HSA your plan will enroll you in a Health Reimbursement Arrangement (HRA)

bull If you cancel your FEHB enrollment as an annuitant you will never be able to reshyenroll in FEHB unless you had suspended your FEHB enrollment because you are now covered by a Medicare Advantage plan TRICARE or CHAMPVA Medicaid or similar Stateshysponsored program of medical assistance or Peace Corps Volunteer coverage

bull If you want your surviving family members to continue your health benefits enrollment after your death you must be enrolled for Self and Family at the time of your death and at least one family member must be entitled to an annuity as your survivor

bull Consider whether you need to sign up for Medicare when you become eligible

5


Federal Benefits Facts continued

FEDVIP bull There is no 5 year requirement for continuing FEDVIP coverage into retirement

bull Your coverage will continue as a retiree Retirees may also enroll during the annual Federal Benefits Open Season or when you experience a qualifying life event (QLE) Keep in mind that retirement is not a QLE

bull In most cases changing from payroll deduction to annuity deduction is automatic but may take several months to occur It is advised that you contact BENEFEDS at 1shy877shy888shy3337 prior to retirement in order to eliminate any suspension in coverage

bull BENEFEDS cannot deduct premiums from your annuity while you are receiving ldquospecialrdquo or ldquointerimrdquo pay Once your annuity is finalized premium deductions will begin If you miss one or more premium payments before your annuity is final BENEFEDS will make double deductions until any balance due is paid They will notify you before deducting this additional premium amount Once there is no past due balance the amount of premium deducted will return to the regular monthly premium

FSAFEDS

bull When you retire you will no longer be able to participate in FSAFEDS Your FSA will terminate as of the date of your retirement and you will not be eligible to enroll as an annuitant When you make your annual election for the year that you plan to retire keep in mind that any remaining funds for which you have not incurred eligible expenses while employed will be forfeited

bull You can still submit claims for eligible medical expenses incurred prior to the date of your retirement

bull You can continue to use the remaining balance in your Dependent Care Flexible Spending Account (DCFSA) to pay for eligible dependent care expenses until the end of the Benefit Period or until your account balance is used up whichever comes first

6



FEGLI

bull When you retire you are eligible to continue your FEGLI life insurance coverage(s) if you retire on an immediate annuity and had the coverage for

ndash the five years of service immediately before the starting date of your annuity or for annuitants retiring under FERS who postpone receiving their annuity the five years immediately before their separation date for annuity purposes or

ndash all period(s) of service during which that coverage was available to you if it is less than five years and

ndash you (or your assignees) do not convert the coverage to a private policy

bull If you are eligible you will choose how you wish your coverage(s) to continue during your retirement by submitting a standard form (SF) 2818 Continuation of Life Insurance

bull If you are not enrolled in FEGLI at the time of your retirement you cannot enroll when you retire

bull You cannot newly elect or increase existing coverage after you retire You may only reduce or cancel coverage

bull Your premiums are subject to change in the future Your premium could change based on your age and the experience of the Program You will be notified if there is any change in your deductions from your annuity

FLTCIP bull Your coverage continues into retirement provided you continue to pay premiums

bull If you pay premiums via payroll deduction then shortly before you retire you should notify Long Term Care Partners (LTCP) at 1shy800shy582shy3337 to make other arrangements for premium payment

bull You may elect annuity deduction if you desire LTCP cannot deduct your premium from ldquospecialrdquo or ldquointerimrdquo pay LTCP will send you a direct bill during this time Premium deduction will begin from your annuity once it is finalized

7

Federal Employees Health Benefits (FEHB) Program

What does this Program offer

The FEHB Program offers a wide variety of plans and coverage to help you meet your health care needs It is group coverage available to employees retirees and their eligible family members If you continuously maintain your FEHB enrollment or are covered by another FEHB enrollment as a family member or a combination of both for the five years of service immediately preceding your retirement or the full period(s) of service since your first opportunity to enroll if less than five years and you retire on an immediate annuity you can continue to participate in the FEHB Program after retirement The benefits you receive as a retiree are the same coverage Federal employees receive and at the same cost If you leave government employment before retiring the Program offers temporary continuation of coverage (TCC) and an opportunity to convert your enrollment to nonshygroup (private) coverage

If you are currently enrolled in the FEHB Program and do not want to change plans or enrollment type during Open Season you do not need to do anything Your enrollment will continue automatically

Appendix E includes a comparison chart of all the plans in the FEHB Program with information comparing basic benefits and costs

Key FEHB facts

bull The FEHB Program is part of the annual Federal Benefits Open Season

bull FEHB coverage continues each year You do not need to reshyenroll each year If you are happy with your current coverage do nothing Please note that your premiums and benefits may change

bull You can choose from ConsumershyDriven and High Deductible plans that offer catastrophic risk protection with higher deductibles health savingsreimbursement accounts and lower premiums or Health Maintenance Organizations or FeeshyforshyService plans with comprehensive coverage and higher premiums

bull There are no waiting periods and no preshyexisting condition limitations even if you change plans

bull If you are an active Federal employee you can use your Health Care Flexible Spending Account or Limited Expense Health Care Flexible Spending Account with your FEHB plan

bull If you participate in premium conversion enrollment changes can only be made during Open Season or if you experience a qualifying life event Premium conversion allows Federal employees to use preshytax dollars to pay their FEHB premiums If you do not participate in premium conversion you may change to Self Only or cancel at any time

bull All nationwide FEHB plans offer international coverage

bull There are separate andor different provider networks for each plan

bull Utilizing an inshynetwork provider will reduce your outshyofshypocket costs

What enrollment types are available

bull Self Only which covers only the enrolled employee or

bull Self and Family which covers the enrolled employee and all eligible family members

8


Which family members are eligible

Family Members covered under your Self and Family enrollment are

bull Your spouse (including a valid common law marriage) and

bull Children under age 26 including recognized natural children legally adopted children and stepchildren

Foster children are included if they meet certain requirements A child age 26 or over who is incapable of selfshysupport because of a mental or physical disability that existed before age 26 is also an eligible family member

Contact your employing office for additional information In determining whether the child is a covered family member your employing office will look at the childrsquos relationship to you as an enrollee

How much does it cost

The premiums for your enrollment are shared by you and your Federal agency or retirement system The government pays the lesser of 72 of the average total premium of all plans weighted by the number of enrollees in each or 75 of the premium for the specific plan you choose If you are an employee you automatically pay your share of the premium through a payroll deduction using preshytax dollars unless you elect not to participate in Premium Conversion The charts in Appendix E provide cost information for all plans in the FEHB Program

Am I eligible to enroll

Most employees are eligible If you have an appointment other than a career or career conditional appointment and your agency has not provided you information about enrollment you should contact your human resources office for information

When you retire you are eligible to continue health benefits coverage if you retire on an immediate annuity under a retirement system for civilian employees (including FERS MRA + 10 retirement) and you have been continuously enrolled (or covered as a family member) in any FEHB plan(s) for the 5 years of service immediately before your retirement date or for the full period(s) of service since your first opportunity to enroll (if less than 5 years)

If you suspend your FEHB coverage as a retiree because you are covered by TRICARE or CHAMPVA a Medicare Advantage Plan Medicaid or Peace Corps volunteer coverage you may reenroll under certain conditions (You should contact your retirement system for information on your eligibility) If you are not enrolled in or covered as a family member under FEHB when you retire you will not be able to enroll after retirement

9


When can I enroll or change my enrollment

If you are a new employee who is eligible for FEHB or an employee who has become newly eligible to enroll you may enroll within 60 days of becoming eligible You may also enroll during the annual Open Season held from the Monday of the second full work week in November through the Monday of the second full work week in December Furthermore you may enroll change your enrollment type or change plans outside of Open Season if you experience a qualifying life event such as a change in family or other insurance coverage status Appendix C contains more specific information about qualifying life events that permit employees to enroll or change enrollment in the FEHB Program

For new or newly eligible employees who elect to enroll coverage will be effective on the first day of the first pay period that begins after your agency receives your enrollment An Open Season enrollment or change is effective on the first day of the first full pay period that begins in January

Note Certain pay status requirements may also apply Your Human Resources Office can advise you of your specific effective date

How do I enroll or change my enrollment

You may be able to enroll or change your enrollment using the Health Benefits Election Form (SF 2809) or through an agency selfshyservice system such as Employee Express MyPay Employee Personal Page or EBIS Contact the human resources office of your employing agency for details

How do I get more information about this Program

Visit the FEHB Program online at wwwopmgovhealthcareshyinsurancehealthcare for information including bull How to compare and choose among health plans bull Health plan websites and plan brochures bull How to file a disputed claim request bull Getting quality healthcare bull Medicare and FEHB

10

FEHB Program Health Information Technology and PriceCost Transparency

Did You Knowhellip Health Information Technology can improve your health

What is Health Information Technology Health Information Technology (HIT) allows doctors and hospitals to manage medical information and to securely exchange information among patients and providers In a variety of ways HIT has a demonstrated benefit in improving health care quality preventing medical errors reducing costs and decreasing paperwork

What are examples of HIT at work

bull You can go online to review your medical pharmacy and laboratory claims information

bull If you complete a Health Risk Assessment (HRA) your health plan can identify you as a candidate for case management or disease management and offer suggestions on healthy lifestyle strategies and how to reduce or eliminate health risks Health plans can provide you with tips and educational material about good health habits information about routine care that is age and gender appropriate

bull Physicians can have the very best clinical guidelines at their fingertips for managing and treating diseases

bull While with a patient a physician can enter a prescription on a computer where potential allergies and adverse reactions are shown immediately

bull Computer alerts are sent to physicians to remind them of a patientrsquos preventive care needs and to track referrals and test results

One feature of HIT is the Personal Health Record (PHR) The electronic version of your medical records allows you to maintain and manage health information for yourself and your family in a private and secure electronic environment Some health plans include your medical claims data in your PHR which gives a more complete picture of your health status and history

You can also find a PHR on OPMrsquos website at wwwopmgovhealthcareshyinsurancespecialshyinitiativesmanagingshymyshyownshyhealth This PHR is a fillable and downloadable form that you complete yourself and save on your home computer We encourage you to take a look at this PHR option and if you determine it will fulfill your recordshykeeping needs take advantage of this opportunity

Pricecost transparency is another element of health information technology For example many health plans allow you to use online tools that will show what the plan will pay on average for a specific procedure or for a specific prescription drug You can also review healthcare quality indicators for physician and hospital services

The health plans listed on our HIT website at wwwopmgovhealthcareshyinsurancehealthcarereferenceshymaterialsurl=HIT have taken steps to help you become a better consumer of health care and have met OPMrsquos HIT quality and pricecost transparency standards

No one is more responsible for your health care than you ndash HIT tools can help

11

Federal Employees Dental and Vision Insurance Program (FEDVIP)


The Federal Employees Dental and Vision Insurance Program provides comprehensive dental and vision insurance at competitive group rates There are ten dental plans and four vision plans from which to choose FEDVIP features nationwide international and regional plans

A dental or vision insurance plan is much like a health insurance plan you may be required to meet a deductible and provide a copay or coinsurance payments for your dental or vision services With any plan choice you should look at all the information and find a plan that will best fit your needs You should also review your FEHB plan brochure to determine what dental andor vision coverage the FEHB plan provides

If you are currently enrolled in FEDVIP and you take no action during Open Season your current coverage will continue in 2014 provided you remain eligible for the program Enrollment continues year to year automatically Please Note your premiums and benefits may change for 2014

Key FEDVIP facts

bull FEDVIP is part of the annual Federal Benefits Open Season

bull FEDVIP is separate and different from the FEHB Program

bull The health care law does not change the age or unmarried requirement for dependents in FEDVIP

bull FEDVIP coverage continues each year You do not need to reshyenroll each year If you do not want to change plans or enrollment type do nothing

bull You can only cancel FEDVIP coverage during Open Season upon deployment of yourself or spouse to active military duty or upon transfer to another agency where you enroll in their dental andor vision plan and the agency pays at least 50 of the premium You cannot cancel just because you retire or because you can no longer afford the premiums

bull If you are enrolled in an FEHB plan it is a requirement under the FEDVIP law that your FEHB plan function as the first payer The FEDVIP plan is always the secondary payer to the FEHB plan

bull You can use your Flexible Spending Account (FSAFEDS) with FEDVIP You can submit your FEDVIP copayments and deductibles as eligible expenses against your FSA account

bull All nationwide FEDVIP plans provide international coverage



bull There are no preshyexisting condition limitations for enrollment

bull There is no opportunity to convert to a private plan when your FEDVIP coverage ends There is no 31shyday extension of coverage Temporary Continuation of Coverage (TCC) Spouse Equity coverage or right to convert to an individual policy (conversion policy)

12



bull Self Only which covers only the enrolled employee or retiree

bull Self Plus One which covers the enrolled employee or retiree plus one eligible family member specified by the enrollee and

bull Self and Family which covers the enrolled employee or retiree and all eligible family members listed on the coverage

Appendix I lists the available dental and vision insurance plans along with basic benefit information


Eligible family members include your spouse and unmarried dependent children under age 22 This includes legally adopted children and recognized natural children who meet certain dependency requirements This also includes stepchildren and foster children who live with you in a regular parentshychild relationship Under certain circumstances you may also continue coverage for a disabled child 22 years of age or older who is incapable of selfshysupport In order to determine whether your dependent child age 22 or over is incapable of selfshysupport you may be asked to provide a medical certificate that describes a disability with onset prior to age 22 or acceptable documentation that the medical condition is not compatible with employment that there is a medical reason to restrict your child from working or that heshe may suffer injury or harm by working

FEDVIP rules and FEHB rules for family member eligibility are NOT the same

Note Changes in dependent eligibility under healthcare reform (Affordable Care Act) do not affect eligibility for children under FEDVIP


You pay the entire premium There is no government contribution to the premium If you are an active employee your premiums are taken from your salary on a preshytax basis if your salary is sufficient to make the premium withholding When you retire premiums are withheld from your monthly annuity check on a postshytax basis if your annuity is sufficient

Premiums for the nationwide dental plans and three regional dental plans are based on where you live This is called your rating region Your home ZIP code is used to find your rating region Rating regions vary by carrier The vision plans do not have rating regions Enrolling in a FEDVIP plan will not reduce your FEHB premium

See Appendices J and K to find 1) the rating region assigned to the area where you live by the different dental plans and 2) the related premium you will pay You may also go to our website at wwwopmgovhealthcareshyinsurancedentalshyvision for premium and rating region information


If you are a Federal or US Postal Service employee eligible for the FEHB Program or the Health Insurance Marketplace (Exchange) you are eligible to enroll in FEDVIP It does not matter if you are actually enrolled in FEHB or the Health Insurance Marketplace (Exchange) shy eligibility is the key Former spouses and deferred annuitants are NOT eligible to enroll Anyone receiving an insurable interest annuity who is not also an eligible family member is NOT eligible to enroll

13



If you are a new employee eligible for FEDVIP or an employee who has become newly eligible to enroll you may enroll within 60 days of first becoming eligible This is a oneshytime opportunity outside of Open Season to enroll There is a separate 60shyday enrollment period for dental and vision For example you may enroll in a dental plan on day 30 and a vision plan on day 59 Once you enroll your 60shyday opportunity for that type of plan ends

An eligible employee or retiree may also enroll during the annual Federal Benefits Open Season which runs from the Monday of the second full work week in November through the Monday of the second full work week in December An eligible employee or retiree may enroll cancel or change enrollment type or options during Open Season They may enroll or make changes outside of Open Season if they experience a qualifying life event (QLE) such as a change in family or other insurance coverage status Please see Appendix H for more information about QLEs that permit employees and retirees to enroll or make changes in FEDVIP

If you enroll during Open Season premiums are deducted beginning the first full pay period on or after January 1 For new or newly eligible employees who elect to enroll coverage is effective the first day of the pay period following the one in which BENEFEDS receives your enrollment An Open Season enrollment or change is effective January 1


You may enroll on the Internet at wwwBENEFEDScom BENEFEDS is a secure enrollment website sponsored by OPM For those without access to a computer please call 1shy877shy888shyFEDS (1shy877shy888shy3337) (TTY number 1shy877shy889shy5680)

You cannot enroll in a FEDVIP plan using the Health Benefits Election Form (SF 2809) or through an agency selfshyservice system such as Employee Express MyPay or Employee Personal Page However those sites may provide a link to BENEFEDS

What should I consider in making my decision to participate in this Program

There are questions you should ask yourself when deciding to enroll in FEDVIP or selecting a FEDVIP plan By considering these questions thoroughly you will be able to determine if FEDVIP is a good option for you

1 Does my FEHB plan provide dental or vision coverage

2 Does the FEDVIP plan coordinate benefits with the FEHB plan and how is the coordination of benefits calculated

3 How affordable is the plan bull How much will it cost me on a bishyweekly or monthly basis Can I afford that for the entire year bull Must I pay a deductible bull If I use a FEDVIP provider outside of the network how much will I pay to get care bull How frequently can I visit the dentist and how much do I have to pay at each visit bull Will the plan provide benefits if I am also covered by another dental or vision plan

14


4 Do I have access to any provider bull Does the plan give me the freedom to choose my own dentist or am I restricted to a panel of dentists selected by the plan

bull Are there enough of the kinds of dentists I want to see bull Where will I go for care Are these places near where I work or live bull Do I need to get permission before I see a dental specialist bull Will the plan allow referrals to specialists Will my dentist and I be able to choose the specialist

5 Does the plan provide coverage for specialty services bull Are dentures orthodontics implants or replacement of missing teeth covered bull What are the planrsquos limitations or exclusions bull Are there annual limits on the types of services included

How do I find my premium rate

If you live outside the United States Go to Appendix K for your dental and vision premium rates

If you live inside the United States Go to Appendix K for your vision premium rate To find your bishyweekly or monthly dental premium you must first find your rating area on the chart in Appendix J Some plans may have changed their rating regions for the upcoming plan year

Please Note If you are currently enrolled and have moved or your postal service has assigned you a new ZIP code your rating region may have changed

1 To find your dental rating area a Go to the chart in Appendix J b Find your state and your corresponding Zip code (1st 3 digits) c Look under the plan name and you will find your rating area

2 To find your bishyweekly or monthly dental premium match your rating area with your desired FEDVIP plan on the chart in Appendix K

Making an informed choice

bull Before selecting a plan that best suits your needs ask your carrier or access the OPM website for a copy of the plan brochure

bull If you have questions about coverage exclusions limitations or payment of benefits ask the plan before making your plan selection

bull Find out which plan your provider participates in and why Keep in mind that if your provider leaves the plan this is not a qualifying life event allowing a change or cancellation


Visit FEDVIP online at wwwopmgovhealthcareshyinsurancedentalshyvision for information including bull How to enroll bull Dental premium rates bull FEDVIP plan websites brochures and provider searches bull Vision premium rates

15

Federal Flexible Spending Account Program (FSAFEDS)


A way to SAVE MONEY The Federal Flexible Spending Account Program known as FSAFEDS is a benefit that can save you money It offers accounts where you contribute money from your salary BEFORE taxes are withheld incur eligible expenses and get reimbursed Itrsquos a way to save money on dependent care and health care services and items for you and your family Itrsquos a way to pay less tax and save money

The money contributed to your FSAFEDS account is set aside before taxes are deducted so in most cases you save about 30 on your Federal taxes The average tax savings for a person earning $50000 who contributes $2000 into an FSA account is approximately $600 That means you get $2000 worth of FSA eligible purchasing power PLUS pay about $600 LESS in Federal taxes

Key FSAFEDS facts

bull FSAFEDS is part of the annual Federal Benefits Open Season

bull Retirees cannot enroll in FSAFEDS

bull Employees MUST reshyenroll each year ndash coverage does not automatically carry over to the next benefit period

bull If you enroll during Open Season you will have 14shy12 months to spend your annual election

bull Enrollees must incur eligible expenses for their current benefit period by March 15th of the following year

bull Enrollees must file claims for their current benefit period by April 30th of the following year

bull Enrollees can use FSAFEDS accounts for copayments and deductibles from their FEHB andor FEDVIP enrollments

bull Plan your contribution carefully and conservatively ndash you will lose any money in your account(s) for which you do not incur eligible expenses and timely file claims

bull Eligible health care expenses of an employeersquos child are covered through the end of the year in which the child turns 26 without regard to residency or tax dependency

16



There are three types of FSAs Each type has a minimum annual election of $250 and the Dependent Care FSA has a maximum of $5000 per household The Health Care FSA and Limited Expense FSA have a maximum annual election of $2500 per enrollee

bull Dependent Care FSA (DCFSA) ndash Used for eligible dependent care (nonshymedical) expenses that allow you and your spouse (if married) to work look for work (as long as you have earned income at some point during the year) or attend school fullshytime Eligible expenses include child care before and after school care late pickshyup fees and adult daycare Dependents covered under a DCFSA include your children before their 13th birthday and may also include any person you claim as a dependent on your Federal Income Tax return who is mentally or physically incapable of self care

bull Health Care FSA (HCFSA) ndash Used for eligible health care expenses for you your spouse your tax dependents and your adult children through the end of the calendar year in which they turn age 26 without regard to residency or tax dependency that are not covered or reimbursed by FEHB FEDVIP or other insurance Common expenses that are reimbursable by an HCFSA include

shy Chiropractic services shy Coinsurance copays and deductibles (but not insurance premiums) shy Contact lenses solutions and cleaners and cases shy Dental care and procedures shy Eye surgery shy Eyeglasses and prescription sunglasses shy Hearing aids and batteries shy Infertility treatments

An HCFSA is not health insurance and does not replace your insurance plan It is a separate program that reimburses you for eligible outshyofshypocket health care expenses

bull Limited Expense Health Care FSA (LEX HCFSA) ndash Designed for employees enrolled in or covered by a High Deductible Health Plan with a Health Savings Account Eligible expenses are limited to dental and vision care expenses for you your spouse your tax dependents and your adult children through the end of the calendar year in which they turn age 26 without regard to residency or tax dependency that are not covered or reimbursed by FEHB FEDVIP or other insurance By opening a Limited Expense Health Care FSA you can save money on taxes by using your LEX HCFSA dollars for dental and vision care while preserving your Health Savings Account funds for other purposes

Eligible expenses include your outshyofshypocket costs for services and products related to

ndash Dental care (eg cleanings fillings crowns orthodontics etc) ndash Vision care (eg contact lenses eyeglasses refractions vision correction procedures etc)


Most Federal employees in the Executive branch and many in nonshyExecutive branch agencies are eligible For specifics on eligibility visit wwwFSAFEDScom or call an FSAFEDS Benefits Counselor tollshyfree at 1shy877shyFSAFEDS (1shy877shy372shy3337) TTY 1shy800shy952shy0450 Monday through Friday 9 am until 9 pm Eastern Time Retirees cannot enroll

17



Enrollees in FSAFEDS may request reimbursement for eligible health care expenses incurred by a spouse tax dependent natural child stepchild adopted child eligible foster child or a child who is placed with the enrollee for legal adoption


If you are a new or newly eligible employee or experience a qualifying life event (QLE) such as a change in family status you have 60 days from your hire date (QLE date) to enroll in a HCFSA or LEX HCFSA andor DCFSA but you must enroll before October 1 If you are hired or become eligible or experience a QLE on or after October 1 you must wait and enroll during the Federal Benefits Open Season held each fall which runs from the Monday of the second full work week in November to the Monday of the second full work week in December You can find more information about qualifying life events at wwwFSAFEDScom

Enrollment does not carry over from year to year ndash you must make an election every year to participate

An election made during Open Season is effective on January 1 of the benefit year If you are a newly hired or newly eligible employee enrolling outside of Open Season your effective date is the day after your election is accepted by FSAFEDS

Qualifying Life Events (QLEs) that May Permit a Change in Your Flexible Spending Account Participation

The following QLEs may allow you to enroll cancel increase or even decrease your election amount

bull A change in your legal marital status (ie marriage legal separation divorce or death of your spouse)

bull The birth or adoption of your child or placement for adoption bull The death of a dependent bull Other changes in the number of your tax dependents (eg parents now reside with you because they are incapable of selfshycare)

bull A change in employment status (for you your spouse or your dependent) that affects eligibility for health insurance benefits

bull Leave Without Pay (LWOP) due to military deployment bull A change in your dependentrsquos eligibility (eg your child reaches age 13 when heshe is no longer eligible for coverage under a Dependent Care Flexible Spending Account)

bull A change in cost or coverage for daycare or elder care (eg a significant cost increase charged by your current daycare provider or a change in your provider ndash for Dependent Care Flexible Spending Account only)

18


How do I enroll

You enroll at wwwFSAFEDScom or by calling 1shy877shy372shy3337


bull Do I want to participate this year You must make a new election every year Enrollment does not carry over from year to year

bull What do my annual medicaldependent care outshyofshypocket expenses run each year

bull Will my health dental or vision insurance coverage be different this year Am I changing plans or adding other coverage Are my copayments changing

bull Will I still have the same number of dependents



Call 1shy877shy372shy3337 TTY 1shy800shy952shy0450 or visit wwwFSAFEDScom

19

Federal Employeesrsquo Group Life Insurance (FEGLI) Program


The FEGLI Program offers group term life insurance

Key FEGLI facts

bull The FEGLI Program is not part of the annual Federal Benefits Open Season

bull Employees in eligible positions are automatically covered under Basic life insurance unless they choose to waive that coverage

bull Employees must have Basic insurance in order to have or elect Optional insurance

bull Employees must take action within strict time limits to elect Optional insurance Coverage is not automatic

bull The Government pays oneshythird of the cost of Basic insurance Enrollees pay 100 of the cost of Optional insurance

bull FEGLI does not have any cash or paidshyup value You cannot get a loan by borrowing from this insurance

bull Retirees and compensationers may be able to continue their FEGLI coverage into retirement or while receiving compensation from the Office of Workersrsquo Compensation Programs (OWCP) but they cannot newly elect FEGLI coverage as a retiree

bull Living benefits are life insurance benefits paid to you while you are still living rather than paid to a beneficiary or survivor when you die You are eligible to elect a living benefit if you are an employee retiree or compensationer covered under the FEGLI Program who has been diagnosed as terminally ill with a life expectancy of nine months or less and you have not assigned your insurance

What coverage is available

Basic insurance ndash your annual salary rounded up to the next even $1000 plus $2000 Basic insurance includes accidental death and dismemberment coverage for employees (not for retirees)

Optional insurance bull Option A shy Standard ndash $10000 of insurance Option A includes accidental death and dismemberment coverage for employees (not for retirees)

bull Option B shy Additional ndash 1 2 3 4 or 5 times your annual rate of basic pay after rounding it up to the next even $1000

bull Option C shy Family ndash coverage for your spouse and all of your eligible dependent children You can elect 1 2 3 4 or 5 multiples Each multiple is equal to $5000 for your spouse and $2500 for each eligible child


You pay twoshythirds of the premium for Basic life insurance and the Government pays oneshythird Your cost for Basic life insurance is $015 biweekly per $1000 of coverage Your age does not affect the cost of Basic insurance

You pay 100 of the premium for Optional insurance The cost depends on your age based on 5shyyear age groups


Most Federal employees are eligible to enroll in FEGLI unless they are excluded by law or regulation Federal retirees are eligible to carry their FEGLI into retirement if they meet the following requirements eligible to retire on an immediate annuity (including FERS MRA+10 retirement) have not converted the coverage to a private plan and have been insured under FEGLI for the five years immediately preceding retirement or for all periods of service during which FEGLI was available to them if they have been covered for less than five years There is no waiver of this fiveshyyear rule

20



Eligible FEGLI family members include a spouse and eligible dependent children Eligible dependent children must be unmarried and under age 22 or if age 22 or over incapable of selfshysupport because of a mental or physical disability that existed before the child reached age 22 Eligible dependent children include your natural children adopted children stepchildren (if they live with you in a regular parentshychild relationship) recognized natural children and foster children (if they live with you in a regular parentshychild relationship) Stillborn children are not covered


The FEGLI Program is not part of the annual Federal Benefits Open Season

If you are a new employee who is eligible for FEGLI or an employee who has become newly eligible to enroll you will be automatically enrolled in Basic If you do not want Basic you must file a waiver with your agency

As a new or newly eligible employee you may enroll in Optional insurance within 60 days of becoming eligible If you take no action you will have Basic and will not have any Optional insurance

If you are not a new employee or newly eligible you may enroll in Basic life insurance and if you wish Option A andor Option B coverage by providing satisfactory medical information at your own expense using the Request for Life Insurance (Standard Form 2822) You cannot enroll in Option C this way

You may elect Basic Option A Option B and Option C within 60 days of a FEGLI qualifying life event In addition you may increase the number of multiples of Option B andor Option C You may elect any number of multiples for Option B and Option C as long as the total number of multiples for each option does not exceed 5

You may also enroll during a FEGLI Open Season which is held infrequently You will receive plenty of notice when there is a FEGLI Open Season The most recent FEGLI Open Season was held in 2004

How do I enroll

You may be able to enroll using the Life Insurance Election Form (Standard Form 2817) or through an agency selfshyservice system such as EBIS Contact the human resources office of your employing agency for details on how you can enroll

Who gets the benefits paid after my death

When you die the Office of Federal Employeesrsquo Group Life Insurance (OFEGLI) an administrative unit of Metropolitan Life Insurance Company (MetLife) will pay life insurance benefits in a particular order set by law The FEGLI Program Booklet available from your human resources office and at wwwopmgovhealthcareshyinsurancelifeshyinsurance contains more details

How does my beneficiary file a claim

He or she must use a specific form called the Claim for Death Benefits (FEshy6) to claim FEGLI benefits available from your human resources office or retirement system or at wwwopmgovhealthcareshyinsurancelifeshyinsurance


Contact your agency human resources office If you are retired contact OPMrsquos Retirement Operations Center at retireopmgov or by calling 1shy888shy767shy6738 Neither OFEGLI nor OPMrsquos Insurance Operations offices maintain records for active Federal employees or retirees

21

Federal Long Term Care Insurance Program (FLTCIP)


The FLTCIP offers insurance that helps cover the costs of certain long term care services Long term care is the assistance you receive to perform activities of daily living ndash such as bathing or dressing yourself ndash or supervision you receive because of a severe cognitive impairment such as Alzheimerrsquos disease Long term care can be provided in a facility like a nursing home but is most often provided at home

Key FLTCIP facts

bull The FLTCIP is not part of the annual Federal Benefits Open Season

bull You must apply and answer questions about your health to find out if you are approved to enroll

bull You can apply for coverage at any time using the full underwriting application you do not have to wait for an Open Season

bull Newnewly eligible employees and their spouses and newly married spouses of employees can apply with abbreviated underwriting (fewer questions about their health) within 60 days of becoming eligible

bull Qualified family members including sameshysex domestic partners can also apply with full underwriting

bull Once enrolled you can keep your coverage even if you are no longer in an eligible group (for example you leave your job with the Federal Government)


If you are approved for coverage your premium is based on your age on the date your application is received and on the benefit options you select You may pay your premiums through deductions from pay or annuity by automatic bank withdrawal or by direct bill

Please Note Your premiums do not change because you get older or your health changes after your coverage becomes effective However premiums are not guaranteed We may only increase premiums if you are among a group of enrollees whose premium is determined to be inadequate

Am I eligible to apply

Most Federal employees are eligible to apply for coverage those who are not eligible usually have limited appointments of short duration or work sporadically only during certain seasons or when needed by their Federal agency If you are a Federal or US Postal Service employee eligible for the FEHB Program or the Health Insurance Marketplace (Exchange) you are eligible to apply for coverage under FLTCIP It does not matter if you are actually enrolled in FEHB or the Health Insurance Marketplace (Exchange) shy eligibility is the key

22



Enrollment in the FLTCIP is on an individual basis If you are eligible as a Federal employee or annuitant your spouse sameshysex domestic partner and your adult children at least 18 years old are eligible to apply for coverage even if you do not If you are a Federal employee your parents parentsshyinshylaw and step parents are also eligible to apply

For more information on eligibility visit wwwltcfedscomeligibility

How do I apply

You apply by completing an application found at wwwltcfedscom or by calling 1shy800shyLTCshyFEDS You must pass a medical screening (called underwriting) Certain medical conditions or combinations of conditions will prevent some people from being approved for coverage By applying while yoursquore in good health you could avoid the risk of having a future change in your health disqualify you from obtaining coverage Also the younger you are when you apply the lower your premiums

If you are a new or newly eligible employee you (and your spouse if applicable) have 60 days to apply using the abbreviated underwriting application which asks fewer questions about your health Newly married spouses of employees also have 60 days to apply using abbreviated underwriting You and your qualified relatives including sameshysex domestic partners may apply anytime using the full underwriting application


Remember that FEHB plans do not cover the cost of long term care While Medicare covers some care in nursing homes and at home it does so only for a limited time subject to restrictions The need for long term care can strike anyone at any age and the cost of care can be substantial

Be sure to visit wwwltcfedscom for the most upshytoshydate information about the FLTCIP before deciding whether to apply


Call 1shy800shyLTCshyFEDS (1shy800shy582shy3337) (TTY 1shy800shy843shy3557) or visit wwwltcfedscom

23

This page intentionally left blank

24

Appendix A FEHB Program Features

No waiting periods You can use your benefits as soon as your coverage becomes effective There are no preshyexisting condition limitations even if you change plans

A choice of coverage You can choose Self Only coverage just for you or Self and Family coverage for you your spouse and children under age 26 Under certain circumstances your FEHB enrollment may cover your disabled child 26 years old or older who is incapable of selfshysupport

A choice of plans and options The FEHB Program offers FeeshyforshyService plans plans offering a PointshyofshyService product Health Maintenance Organizations High Deductible Health Plans and ConsumershyDriven Health Plans

A Government contribution The Government pays 72 percent of the average premium of all plans toward the total cost of your premium but not more than 75 percent of the total premium for any plan

Salary deduction You pay your share of the premium through a payroll deduction and have the choice of doing so using preshytax dollars

Enrollment opportunities Each year you can enroll or change your health plan enrollment during Open Season Open Season runs from the Monday of the second full work week in November through the Monday of the second full work week in December Also Qualifying Life Events (QLEs) allow for certain types of changes throughout the year see your human resources office or retirement system for details

Continued group coverage The FEHB Program offers continued FEHB coverage

bull for you and your family when you retire from Federal service (normally you need to be covered under the FEHB Program for the five years of service immediately before you retire)

bull for your former spouse if you divorce and he or she has a qualifying court order (see your human resources office for more information)

bull for your family if you die or

bull for you and your family when you move transfer go on leave without pay or enter military service (certain rules about coverage and premium amounts apply see your human resources office)

Coverage after FEHB ends The FEHB Program offers temporary continuation of coverage (TCC) and conversion to nonshygroup (private) coverage

bull for you and your family if you leave Federal service (including when you are not eligible to carry FEHB into retirement)

bull for your covered child if he or she turns age 26 or

bull for your former spouse if you divorce and he or she does not have a qualifying court order (see your human resources office for more information)

If you lose coverage under the FEHB Program you should automatically receive a Certificate of Group Health Plan Coverage from the last FEHB plan to cover you If not the plan must give you one on request This certificate may be important to qualify for benefits if you join a nonshyFEHB plan

25

Appendix B Choosing an FEHB Plan

What type of health plan is best for you You have some basic questions to answer about how you pay for and access medical care Here are the different types of plans from which to choose

Types of Plans Choice of doctors hospitals pharmacies and other providers

Specialty care Outshyofshypocket costs Paperwork

FeeshyforshyService You must use the planrsquos Referral not required You pay fewer costs if Some if you donrsquot use wPPO (Preferred network to reduce your to get benefits you use a PPO network providers Provider outshyofshypocket costs For provider than if you Organization) BCBS Basic Option you

must use Preferred providers for your care to be eligible for benefits

donrsquot

Health Maintenance You generally must Referral generally Your outshyofshypocket Little if any Organization use the planrsquos network

to reduce your outshyofshypocket costs

required from primary care doctor to get benefits

costs are generally limited to copayments

PointshyofshyService You must use the planrsquos network to reduce your outshyofshypocket costs You may go outside the network but you will pay more

Referral generally required to get maximum benefits

You pay less if you use a network provider than if you donrsquot

Little if you use the network You have to file your own claims if you donrsquot use the network

ConsumershyDriven Plans

You may use network and nonshynetwork providers You will pay more by not using the network

Referral not required to get maximum benefits from PPOs

You will pay an annual deductible and costshysharing You pay less if you use the network

Some if you donrsquot use network providers You file a claim to obtain reimbursement from your HRA

High Deductible Health Plans wHealth Savings Account (HSA) or Health Reimbursement Arrangement (HRA)

Some plans are network only others pay something even if you do not use a network provider



Some if you donrsquot use network providers If you have an HSA or HRA account you may have to file a claim to obtain reimbursement

26


What should you consider when choosing a plan Having a variety of plans to choose from is a good thing but it can make the process confusing We have a tool on our website that will help you narrow your plan choice based on the benefits that are important to you go to wwwopmgovhealthcareshyinsurancehealthcareplanshyinformationcompareshyplans You can also find help in selecting a plan using tools provided by PlanSmartChoice and Consumerrsquos Checkbook at wwwopmgovhealthcareshyinsurancehealthcareplanshyinformation

Ask yourself these questions

1 How much does the plan cost This includes the premium you pay

2 What benefits does the plan cover Make sure the plan covers the services or supplies that are important to you and know its limitations and exclusions

3 What are my outshyofshypocket costs Does the plan charge a deductible (the amount you must first pay before the plan begins to pay benefits) What is the copayment or coinsurance (the amount you share in the cost of the service or supply)

4 Who are the doctors hospitals and other care providers I can use Your costs are lower when you use providers who are part of the plan these are ldquoinshynetworkrdquo providers

5 How well does my plan provide quality care Quality care varies from plan to plan and here are three sources for reviewing quality

bull Member survey results ndash evaluations by current plan members are posted within the health plan benefit charts in this Guide

bull Effectiveness of care ndash how a plan performs in preventing or treating common conditions is measured by the Healthcare Effectiveness Data and Information Set and is found at httpwwwopmgovhealthcareshyinsurancehealthcareplanshyinformationqualityshyhealthcareshyscores

bull Accreditation ndash evaluations of health plans by independent accrediting organizations Check the cover of your health planrsquos brochure for its accreditation level or go to httpreportcardncqaorgplanexternalplansearchaspx

27


Definitions

Brand name drug shy A prescription drug that is protected by a patent supplied by a single company and marketed under the manufacturerrsquos brand name

Coinsurance shy The amount you pay as your share for the medical services you receive such as a doctorrsquos visit Coinsurance is a percentage of the planrsquos allowance for the service (you pay 20 for example)

Copayment shy The amount you pay as your share for the medical services you receive such as a doctorrsquos visit A copayment is a fixed dollar amount (you pay $15 for example)

Deductible shy The dollar amount of covered expenses an individual or family must pay before the plan begins to pay benefits There may be separate deductibles for different types of services For example a plan can have a prescription drug benefit deductible separate from its calendar year deductible

Formulary or Prescription Drug List shy A list of both generic and brand name drugs often made up of different costshysharing levels or tiers that are preferred by your health plan Health plans choose drugs that are medically safe and cost effective A team including pharmacists and physicians determines the drugs to include in the formulary

Generic Drug shy A generic medication is an equivalent of a brand name drug A generic drug provides the same effectiveness and safety as a brand name drug and usually costs less A generic drug may have a different color or shape than the brand name but it must have the same active ingredients strength and dosage form (pill liquid or injection)

InshyNetwork shy You receive treatment from the doctors clinics health centers hospitals medical practices and other providers with whom your plan has an agreement to care for its members

OutshyofshyNetwork shy You receive treatment from doctors clinics health centers hospitals and medical practices other than those with whom the plan has an agreement at additional cost Members who receive services outside the network may pay all charges

Premium Conversion shy A program to allow Federal employees to use preshytax dollars to pay insurance premiums to the FEHB Program Based on Federal tax rules employees can deduct their share of health insurance premiums from their taxable income which reduces their taxes

Provider shy A doctor hospital health care practitioner pharmacy or health care facility

Qualifying Life Events shy An event that may allow enrollees in the FEHB Program to change their health benefits enrollment outside of an Open Season These events also apply to employees under premium conversion and include such events as change in family status loss of FEHB coverage due to termination or cancellation and change in employment status

Additional definitions are located at the beginning of the sections introducing the different types of health plans

28

Appendix C Qualifying Life Events (QLEs)

that May Permit You to Enroll or Change Your FEHB Enrollment

Premium Conversion allows employees who are eligible for FEHB the opportunity to pay their share of FEHB premiums with preshytax dollars Premium conversion plans are governed by the Internal Revenue Code and IRS rules govern when a participant may change his or her enrollment outside of the annual Open Season When an employee experiences a QLE changes to the employeersquos FEHB enrollment may be permitted Individuals who donrsquot participate in Premium Conversion (employees who waived participation and retirees) may cancel their enrollment or change to Self Only at any time

Below is a brief list of the more common QLEs Be aware that time limits apply for requesting changes A complete listing of QLEs can be found at wwwopmgovformspdf_fillsf2809pdf For more details about these and other QLEs contact the human resources office of your employing agency

From Not Enrolled to Enrolled

From Self Only to Self and Family

From One Plan or Option to Another

Cancel or Change to Self Only

Change in family status that results in increase or decrease in number of eligible family members

Any change in employeersquos employment status that could result in entitlement to coverage

Employee restored to civilian position after serving in uniformed services

Employee (or covered family member) enrolled in an FEHB health maintenance organization (HMO) moves or becomes employed outside the geographic area from which the FEHB carrier accepts enrollment or if already outside the area moves further from this area

Employee or eligible family member loses coverage under FEHB or another group insurance plan

Enrolled employee or eligible family member gains coverage under FEHB or another group insurance plan

Yes

Yes

Yes

Not Applicable

Yes

No

Yes

Not Applicable

Yes

Yes

Yes

No

Yes

Not Applicable

Yes

Yes

Yes

No

Yes1

Not Applicable

Yes

Not Applicable

Yes

Yes2

1 Employees may change to Self Only outside of Open Season only if the QLE caused the enrollee to be the last eligible family member under the FEHB enrollment Employees may cancel enrollment outside of Open Season only if the QLE caused the enrollee and all eligible family members to acquire other health insurance coverage

2 Employees may change to Self Only outside of Open Season only if the QLE caused all eligible family members to acquire other health insurance coverage Employees may cancel enrollment outside of Open Season only if the QLE caused the enrollee and all eligible family members to acquire other health insurance coverage

29

Appendix D FEHB Member Survey Results

Each year FEHB plans with 500 or more subscribers mail the Consumers Assessment of Healthcare Providers and Systems (CAHPS)1 to a random sample of plan members For Health Maintenance Organizations (HMO)PointshyofshyService (POS) and High Deductible Health Plans (HDHP) and ConsumershyDriven Health Plans (CDHP) the sample includes all commercial plan members including nonshyFederal members For FeeshyforshyService (FFS)Preferred Provider Organization (PPO) plans the sample includes Federal members only The CAHPS survey asks questions to evaluate membersrsquo satisfaction with their health plans Independent vendors certified by the National Committee for Quality Assurance administer the surveys

OPM reports each planrsquos scores on the various survey measures by showing the percentage of satisfied members on a scale of 0 to 100 Also we list the national average for each measure Since we offer HMO plans FFSPPO plans HDHP and CDHP plans we compute a separate national average for each plan type

Survey findings and member ratings are provided for the following key measures of member satisfaction

bull Overall Plan Satisfaction ndash This measure is based on the question ldquoUsing any number from 0 to 10 where 0 is the worst health plan possible and 10 is the best health plan possible what number would you use to rate your health planrdquo We report the percentage of respondents who rated their plan 8 or higher

bull Getting Needed Care ndash How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan

bull Getting Care Quickly ndash When you needed care right away how often did you get care as soon as you thought you needed Not counting the times you needed care right away how often did you get an appointment at a doctors office or clinic as soon as you thought you needed

bull How Well Doctors Communicate ndash How often did your personal doctor explain things in a way that was easy to understand How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you

bull Customer Service ndash How often did the written materials or the Internet provide the information you needed about how your health plan works How often did your health planrsquos customer service give you the information or help you needed How often were the forms from your health plan easy to fill out

bull Claims Processing ndash How often did your health plan handle your claims quickly and correctly

bull Plan Information on Costs ndash How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines

In evaluating plan scores you can compare individual plan scores against other plans and against the national averages Generally new plans and those with fewer than 500 FEHB subscribers do not conduct CAHPS Therefore some of the plans listed in the Guide will not have survey data 1 CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

30

Appendix E FEHB Plan Comparison Charts

Nationwide FeeshyforshyService Plans (Pages 32 through 35 )

FeeshyforshyService (FFS) plans with a Preferred Provider Organization (PPO) ndash A FeeshyforshyService plan provides flexibility in using medical providers of your choice You may choose medical providers who have contracted with the health plan to offer discounted charges You may also choose medical providers who do not contract with the plan but you will pay more of the cost

Medical providers who have contracts with the health plan (Preferred Provider Organization or PPO) have agreed to accept the health planrsquos reimbursement You usually pay a copayment or a coinsurance amount and do not file claims or other paperwork Going to a PPO hospital does not guarantee PPO benefits for all services received in the hospital however Lab work radiology and other services from independent practitioners within the hospital are frequently not covered by the hospitalrsquos PPO agreement If you receive treatment from medical providers who are not contracted with the health plan you either pay them directly and submit a claim for reimbursement to the health plan or the health plan pays the provider directly according to plan coverage and you pay a deductible coinsurance or the balance of the billed charge In any case you pay a greater amount in outshyofshypocket costs

PPOshyonly ndash A PPOshyonly plan provides medical services only through medical providers that have contracts with the plan With few exceptions there is no medical coverage if you or your family members receive care from providers not contracted with the plan

FeeshyforshyService plans open only to specific groups ndash Several FeeshyforshyService plans that are sponsored or underwritten by an employee organization strictly limit enrollment to persons who are members of that organization If you are not certain if you are eligible check with your human resources office first

The Health Maintenance Organization (HMO) and PointshyofshyService (POS) section begins on page 38

The High Deductible Health Plan (HDHP) and ConsumershyDriven Health Plan (CDHP) section begins on page 80

The tables on the following pages highlight selected features that may help you narrow your choice of health plans The tables do not show all of your possible outshyofshypocket costs All benefits are subject to the definitions limitations and exclusions set forth in each planrsquos Federal brochure which is the official statement of benefits available under the planrsquos contract with the Office of Personnel Management Always consult plan brochures before making your final decision

31

Nationwide FeeshyforshyService Plans

How to read this chart

The table below highlights selected features that may help you narrow your choice of health plans Always consult plan brochures before making your final decision The chart does not show all of your possible outshyofshypocket costs

The Deductibles shown are the amount of covered expenses that you pay before your health plan begins to pay

Calendar Year deductibles for families are two or more times the per person amount shown

In some plans your combined Prescription Drug purchases from Mail Order and local pharmacies count toward the deductible In other plans only purchases from local pharmacies count Some plans require each family member to meet a per person deductible

The Hospital Inpatient deductible is what you pay each time you are admitted to a hospital

Doctors shows what you pay for inpatient surgical services and for office visits

Your share of Hospital Inpatient Room and Board covered charges is shown

Plan Name Open to All

Your Share of Premium Enrollment

Code Monthly Biweekly

Telephone Number

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

APWU Health Plan (APWU) shyhigh

Blue Cross and Blue Shield Service Benefit Plan (BCBS) shystd

Blue Cross and Blue Shield Service Benefit Plan (BCBS) shybasic

GEHA Benefit Plan (GEHA) shyhigh

GEHA Benefit Plan (GEHA) shystd

MHBP shystd

MHBP shyValue Plan

NALC shyhigh

NALC Value Option

SAMBA shyhigh

SAMBA shystd

Compass Rose Health Plan (CRHP) shyhigh

Foreign Service Benefit Plan (FS) shyhigh

Panama Canal Area Benefit Plan (PCABP) shyhigh

Rural Carrier Benefit Plan (Rural) shyhigh

Plan Name Open Only to Specific Groups

800shy222shy2798

Local phone

Local phone

800shy821shy6136

800shy821shy6136

800shy410shy7778

800shy410shy7778

888shy636shy6252

888shy636shy6252

800shy638shy6589

800shy638shy6589

888shy438shy9135

202shy833shy4910

800shy424shy8196

800shy638shy8432

471

104

111

311

314

454

414

321

KM1

441

444

421

401

431

381

472

105

112

312

315

455

415

322

KM2

442

445

422

402

432

382

13670

19028

13209

20317

10418

20913

11302

16122

9001

27523

13171

15613

12535

11170

18913

30910

44412

30930

48310

23691

50565

26946

32727

19546

70356

30081

39039

30885

23316

30210

6309

8782

6096

9377

4808

9652

5216

7441

4154

12703

6079

7206

5785

5155

8729

14266

20498

14275

22297

10934

23338

12436

15105

9021

32472

13884

18018

14255

10761

13943

The information contained in this Guide is not the official statement of benefits Each planrsquos Federal brochure is the official statement of benefits

32

Prescription Drugs ndash Prescription Drug Payment Levels Plans use terms such as Level (L I L II) or Tier (T1 T2) to show what you pay for generic or brand name prescription drugs The payment levels that plans use follow L I or Tier 1 includes generic drugs but may include some preferred brands L II or Tier 2 includes preferred brands and may include some generics L III or Tier 3 includes nonshypreferred brands other covered drugs and with some exceptions specialty drugs L IV or Tier 4 includes mostly preferred specialty drugs L V or Tier 5 generally includes nonshypreferred specialty drugs

Mail Order Discounts ndash If your plan has a Mail Order program (typically for maintenance drugs) and its response is ldquoYesrdquo in general its Mail Order program is superior to its retail pharmacy benefit (eg you obtain a greater quantity for less cost than retail pharmacy purchases) If your plan does not have a Mail Order program or it does not offer a superior benefit to retail pharmacy purchases the response will be ldquoNordquo

The prescription drug copayments or coinsurances described in this chart do not represent the complete range of costshysharing under these plans Many plans have variations in their prescription drug benefits (eg you pay the greater of a dollar amount or a percentage or you pay one amount for your first prescription and then a different amount for refills) You must read the plan brochure for a complete description of prescription drug and all other benefits

APWU shyhigh

BCBS shystd

BCBS shybasic

GEHA shyhigh

GEHA shystd

MHBP shystd

MHBP shyValue

NALC shyhigh

NALC Value

SAMBA shyhigh

SAMBA shystd

CRHP

FS

PCABP

Rural

Plan

PPO NonshyPPO

PPO NonshyPPO

PPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

NonshyPPO PPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

Benefit Type

$275 None None $500 None $300

$350 None $250 $350 None $350 + 35+

None None $175day $875 Max

$350 None $100 $350 None $300

$350 None None $350 None None

$400 None $200 $600 None $500

$600 None None $900 Not Covered None

$300 None $200 $300 None $350

$4000 None 50 $2000 None 20

$300 None $200 $300 None $300

$350 None $150 up to $450 $350 None $200 up to $600

$350 None $200 $400 None $400

$250 None Nothing $300 None $200

None None $25 None None $100

$350 $200 $100 $400 $200 $300

Deductible

Calendar Year

Prescription Drug

Hospital Inpatient

Per Person

$18 10 10 $8 2525 Yes 30+diff 30+diff 30 50 5050 Yes

$20 15 Nothing 2015 Medicare B T2 30$80 T3 45$105 Yes 35+ 35+ Nothing 45+ T1shyT5 T4 30$35$95 T5 30$55$155 Yes

$25 $200 Nothing $1030day $3090day NA

$20 10 Nothing $10 25 Max $150NA Yes 25 25 Nothing $10 25 Max $150 +NA Yes

$10 15 15 $10 50 Max $200NA Yes 35 35 35 $10 50 Max $200 +NA Yes

$20 10 Nothing $5 30($200 max)50($200 max) Yes 30 30 30 50 5050 Yes

$30 20 20 $10 4575 Yes 40 40 40 Not Covered Not Covered Yes

$20 15 Nothing 20 3045 Yes 30 30 30 45+ 45+45+ Yes

50 50 50 50 5050+ No 20 20 20 $10 $40$60 No

$20 10 Nothing $8 20($55 max)35($100 max) Yes 30 30 30 $8 20($55 max)35($100 max) Yes


$15 10 Nothing $5 $3530 or $50 Yes 30 30 30 $5 $3530 or $50 Yes

10 10 Nothing $10 25$30min30$50min Yes 30 30 20 $10 25$30min30$50min Yes

$5 Nothing Nothing 20 2020 No 50 50 50 20 2020 No

$20 10 Nothing 30 3030 Yes 25 25 25 30 3030 Yes

Copay ($)Coinsurance ()

Doctors Hospital Inpatient

RampB

Prescription Drugs

MedicalshySurgical ndash You Pay

Level I Level II Level III Mail Order Discounts

Office Visits

Inpatient Surgical Services

T2 $45 T3 50($55Min) T4 $50to$140 T5 $70to$195

The Panama Canal Area Plan provides a PointshyofshyService product within the Republic of Panama

33


Member Survey results are collected scored and reported by an independent organization ndash not by the health plans See Appendix D for a fuller explanation of each survey category

Overall Plan Satisfaction bull How would you rate your overall experience with your health plan

Getting Needed Care bull How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan

Getting Care Quickly bull When you needed care right away how often did you get care as soon as you thought you needed bull Not counting the times you needed care right away how often did you get an appointment at a doctorrsquos office or clinic

as soon as you thought you needed

How Well Doctors bull How often did your personal doctor explain things in a way that was easy to understand Communicate bull How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you

Customer Service bull How often did written materials or the Internet provide the information you needed about how your health plan works bull How often did your health planrsquos customer service give you the information or help you needed bull How often were the forms from your health plan easy to fill out

Claims Processing bull How often did your health plan handle your claims quickly and correctly

Plan Information on Costs bull How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines


Member Survey Results

Plan Code

Overall plan satisfaction

Getting needed care

Getting care quickly

How well doctors

communicate Customer service

Claims processing

Plan Information on Costs

FFS National Average 805 927 917 951 911 934 716

APWU Health Plan shyhigh 47 772 927 935 951 89 921 682

Blue Cross and Blue Shield Service Benefit Plan shystd

47

10 835 946 917 955 926 956 703

Blue Cross and Blue Shield Service Benefit Plan shybasic

GEHA Benefit Plan shyhigh

10

11

31

757

838

896

934

891

922

95

961

921

912

936

929

643

699

GEHA Benefit Plan shystd

31

31 725 907 895 949 875 926 688

MHBP shystd

31

45 84 938 916 935 906 954 696

MHBP shyValue Plan

45

41 63 908 857 929 866 887 636

NALC shyhigh

41

32 856 936 922 959 934 965 771

NALC shyValue Option

32

KM

SAMBA shyhigh

KM

44 897 947 943 96 946 953 789

SAMBA shystd

44

44 816 93 905 956 911 946 757

Compass Rose Health Plan

Plan Name Open Only to Specific GFFS National A

44

42

roups

verage

837

805

941

927

945

917

962

951

94

911

927

934

747

716

Foreign Service Benefit Plan

42

40 798 898 909 935 892 889 721

Panama Canal Area Benefit Plan

40

43

Rural Carrier Benefit Plan

43

38 865 946 947 967 928 966 773 38

34

FeeshyforshyService Plans ndash Blue Cross and Blue Shield Service Benefit Plan ndash Member Survey Results for Select States

Again this year we are providing more detailed information regarding the quality of services provided by our health plans We are including the results of the Member Satisfaction survey at the state level for eight local Blue Cross Blue Shield (BCBS) Plans

Plan Name Location


Plan Code


Getting needed care


How well doctors


Claims processing



Blue Cross and Blue Shield Service shy Standard Benefit Plan shy Basic

Arizona 10 11

851 747

905 898

919 884

933 923

938 914

969 928

724 680


California 10 11

809 705

915 873

897 840

954 943

881 910

937 912

677 616


District of Columbia 10 11

768 691

935 893

930 874

951 940

882 881

898 922

657 622


Florida 10 11

864 806

942 916

922 894

952 947

934 916

954 937

733 660


Illinois 10 11

861 796

933 912

934 881

955 950

901 936

972 938

712 653


Maryland 10 11

857 770

931 897

917 898

954 940

897 921

956 967

713 666


Texas 10 11

887 825

934 898

931 883

950 955

936 910

957 967

721 617


Virginia 10 11

871 782

924 901

929 894

966 962

914 917

959 960

708 681

35


36


Health Maintenance Organization Plans and Plans Offering a PointshyofshyService Product

(Pages 38 through 75)

Health Maintenance Organization (HMO) ndash A Health Maintenance Organization provides care through a network of physicians and hospitals in particular geographic or service areas HMOs coordinate the health care service you receive and free you from completing paperwork or being billed for covered services Your eligibility to enroll in an HMO is determined by where you live or for some plans where you work

bull The HMO provides a comprehensive set of services ndash as long as you use the doctors and hospitals affiliated with the HMO HMOs charge a copayment for primary physician and specialist visits and sometimes a copayment for inshyhospital care

bull Most HMOs ask you to choose a doctor or medical group as your primary care physician (PCP) Your PCP provides your general medical care In many HMOs you must get authorization or a ldquoreferralrdquo from your PCP to see other providers The referral is a recommendation by your physician for you to be evaluated andor treated by a different physician or medical professional The referral ensures that you see the right provider for the care appropriate to your condition

bull Medical care from a provider not in the planrsquos network is not covered unless itrsquos emergency care or your plan has an arrangement with another plan

Plans Offering a PointshyofshyService (POS) Product ndash A PointshyofshyService plan is like having two plans in one ndash an HMO and an FFS plan A POS allows you and your family members to choose between using (1) a network of providers in a designated service area (like an HMO) or (2) OutshyofshyNetwork providers (like an FFS plan) When you use the POS network of providers you usually pay a copayment for services and do not have to file claims or other paperwork If you use nonshyHMO or nonshyPOS providers you pay a deductible coinsurance or the balance of the billed charge In any case your outshyofshypocket costs are higher and you file your own claims for reimbursement

The tables on the following pages highlight what you are expected to pay for selected features under each plan Always consult plan brochures before making your final decision

Primary careSpecialist office visit copay ndash Shows what you pay for each office visit to your primary care doctor and specialist Contact your plan to find out what providers it considers specialists

Hospital per stay deductible ndash Shows the amount you pay when you are admitted into a hospital

Prescription drug Payment Levels ndash Plans use terms such as Level (L I L II) or Tier (T1 T2) to show what you pay for generic or brand name prescription drugs The payment levels that plans use follow L I or Tier 1 includes generic drugs but may include some preferred brands L II or Tier 2 includes preferred brands and may include some generics L III or Tier 3 includes nonshypreferred brands other covered drugs and with some exceptions specialty drugs L IV or Tier 4 includes mostly preferred specialty drugs L V or Tier 5 generally includes nonshypreferred specialty drugs

Mail Order Discounts If your plan has a Mail Order program (typically for maintenance drugs) and its response is ldquoYesrdquo in general its Mail Order program is superior to its retail pharmacy benefit (eg you obtain a greater quantity for less cost than retail pharmacy purchases) If your plan does not have a Mail Order program or it does not offer a superior benefit to retail pharmacy purchases the response will be ldquoNordquo

Member Survey Results ndash See Appendix D for a description

37

Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 37 for an explanation of the columns on these pages

Your Share of Premium

Enrollment Code

Monthly Biweekly

Plan Name ndash Location Telephone

Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Alabama

Aetna Value Planshy Most of Alabama 877shy459shy6604 F54 F55 13058 29656 6027 13687

Alaska

Aetna Value Planshy Most of Alaska 877shy459shy6604 JS4 JS5 17258 41140 7965 18988

Arizona

Aetna Value Planshy All of Arizona 877shy459shy6604 G54 G55 12822 29119 5918 13440

Aetna Open AccessshyHighshyPhoenix and Tucson Areas 877shy459shy6604 WQ1 WQ2 33482 89188 15453 41164

Health Net of Arizona Inc shyhighshy MaricopaPimaOther AZ counties 800shy289shy2818 A71 A72 26548 80303 12253 37063

Health Net of Arizona Inc shystdshy MaricopaPimaOther AZ counties 800shy289shy2818 A74 A75 19509 62476 9004 28835

Humana Health Plan Inc shyHighshy Phoenix 888shy393shy6765 BF1 BF2 13880 30882 6406 14253

Humana Health Plan Inc shyStdshy Phoenix 888shy393shy6765 BF4 BF5 12491 27794 5765 12828

Humana Health Plan Inc shyHighshy Tucson 888shy393shy6765 C71 C72 15825 35210 7304 16251

Humana Health Plan Inc shyStdshy Tucson 888shy393shy6765 C74 C75 13149 29256 6069 13503

Arkansas

Aetna Value Planshy Most of Arkansas 877shy459shy6604 F54 F55 13058 29656 6027 13687

QualChoice shyHighshy All of Arkansas 800shy235shy7017 DH1 DH2 30353 76056 14009 35103

QualChoice shyStdshy All of Arkansas 800shy235shy7017 DH4 DH5 14296 38452 6598 17747


38

Plan Name ndash Location

Primary care

Specialist office copay

Hospital per stay

deductible

Prescription Drugs


Level I Level II Level III

Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Alabama

HMOPOS National Average 679 864 849 942 877 875 649

Aetna Value Plan InshyNetwork $25$40 20 $10 30to$60050

to$1200 Yes Aetna Value Plan OutshyNetwork

Alaska

4040 40 50+ 50+50+ No

Aetna Value Plan InshyNetwork $25$40 20 $10 30to$60050 to$1200 Yes

Aetna Value Plan OutshyNetwork

Arizona

4040 40 50+ 50+50+ No


Aetna Value Plan OutshyNetwork 4040 40 50+ 50+50+ No

Aetna Open AccessshyHigh $20$35 $250day x 4 $10 $35$100 Yes 602 838 861 923 849 918 636

Health Net of Arizona IncshyHigh $20$40 $250dayx5 $10 $3050 Yes 676 888 843 939 884 921 686

Health Net of Arizona IncshyStandard $25$50 25 $10 $4050 Yes 676 888 843 939 884 921 686

Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes

Humana Health Plan IncshyStandard $25$40 $500day x 3 $10 $40$60 Yes


Humana Health Plan IncshyStandard

Arkansas

$25$40 $500day x 3 $10 $40$60 Yes



QualChoice InshyNetwork $20$30 $100max$500 $0 $40$60 Yes QualChoice OutshyNetwork 4040 40 NA NA NA

QualChoice InshyNetwork $20$40 $200max$1000 $5 $40$60 Yes

39



Enrollment Code

Monthly Biweekly


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

California

Aetna Value Planshy Most of California 877shy459shy6604 JS4 JS5 17258 41140 7965 18988

Aetna HMO shy Los Angeles and San Diego Areas 877shy459shy6604 2X1 2X2 15940 41769 7357 19278

Anthem Blue Cross Select HMO shyHighshy Southern California 800shy235shy8631 B31 B32 18194 43825 8397 20227

Blue Shield of CA Access+HMO shyHighshy Southern Region 800shy880shy8086 SI1 SI2 18445 42566 8513 19646

Health Net of California shyHighshy Northern Region 800shy522shy0088 LB1 LB2 77474 182834 35757 84385

Health Net of California shyStdshy Northern Region 800shy522shy0088 LB4 LB5 71405 168807 32956 77911

Health Net of California shyHighshy Southern Region 800shy522shy0088 LP1 LP2 30687 74663 14163 34460

Health Net of California shyStdshy Southern Region 800shy522shy0088 LP4 LP5 27027 66198 12474 30553

Kaiser Foundation Health Plan shy Basic Option shy Northern California 800shy464shy4000 KC1 KC2 18293 47705 8443 22018

Kaiser Foundation Health Plan of California shyHighshy Northern California 800shy464shy4000 591 592 35345 91275 16313 42127

Kaiser Foundation Health Plan of California shyStdshy Northern California 800shy464shy4000 594 595 22772 58183 10510 26854

Kaiser Foundation Health Plan of California shyHighshy Southern California 800shy464shy4000 621 622 14073 35293 6495 16289

Kaiser Foundation Health Plan of California shyStdshy Southern California 800shy464shy4000 624 625 9019 20845 4162 9621

UnitedHealthcare of California shyHighshy Central and Southern California 866shy546shy0510 CY1 CY2 22819 54699 10532 25246

UnitedHealthcare of California shyStdshy Central and Southern California 866shy546shy0510 CY4 CY5 13109 30036 6050 13863

Colorado

Aetna Value Planshy All of Colorado 877shy459shy6604 G54 G55 12822 29119 5918 13440

Kaiser Foundation Health Plan of Colorado shyHighshy DenverBoulderSouthern Colorado areas 800shy632shy9700 651 652 23933 55581 11046 25653

Kaiser Foundation Health Plan of Colorado shyStdshy DenverBoulderSouthern Colorado areas 800shy632shy9700 654 655 9887 22345 4563 10313

Connecticut

Aetna Value Planshy All of Connecticut 877shy459shy6604 EP4 EP5 12694 28827 5859 13305

Delaware

Aetna Value Planshy All of Delaware 877shy459shy6604 EP4 EP5 12694 28827 5859 13305

Aetna Open Access shyHighshy KentNew CastleSussex areas 877shy459shy6604 P31 P32 64801 164359 29908 75858

Aetna Open Access shyBasicshy KentNew CastleSussex areas 877shy459shy6604 P34 P35 49560 118027 22874 54474


40


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

California

HMOPOS National 679 864 849 942 877 875 649


to$1200 Yes

Average



Anthem Blue Cross Select HMOshyHigh $25$35 $250max4days $5$40$60 $5$40$70$60 Yes

Blue Shield of CA Access+HMOshyHigh $20$30 $200 x 3 days $10 $3550 Yes 726 844 802 937 90 855 646

Health Net of CaliforniashyHigh $20$30 $150dayx5 $10 $35$60 Yes 67 816 81 93 831 841 638

Health Net of CaliforniashyStandard $30$50 $750 $15 $35$65 Yes 67 816 81 93 831 841 638



Kaiser Foundation HP shy Basic Option $25$35 20 $15 $35$35 Yes

Kaiser Foundation HP of CaliforniashyHigh $15$25 $250 $10 $30$30 Yes 798 884 848 925 872 793 63

Kaiser Foundation HP of CaliforniashyStandard $30$40 $500 $15 $35$35 Yes 798 884 848 925 872 793 63



UnitedHealthcare of CaliforniashyHigh $20$35 $150day x 4 $10 $35$60 Yes 701 80 804 923 825 889 57

UnitedHealthcare of CaliforniashyStandard

Colorado

$25$40 30 $10 $25$50 Yes 701 80 804 923 825 889 57


to$1200 Yes Aetna Value Plan OutshyNetwork 4040 40 50+ 50+50+ No

Kaiser Foundation HP of ColoradoshyHigh $20$40 $250x3 $10 $35$60 Yes 722 884 873 936 876 879 622

Kaiser Foundation HP of ColoradoshyStandard

Connecticut

$20$40 10 $15 $40$80 Yes 722 884 873 936 876 879 622



Delaware

4040 40 50+ 50+50+ No




Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$100 Yes 602 862 855 972 865 872 618

41


District of Columbia

Aetna Value Planshy All of Washington DC 877shy459shy6604 F54 F55 13058 29656 6027 13687

Aetna Open Access shyHighshy Washington DC Area 877shy459shy6604 JN1 JN2 46867 105610 21631 48743

Aetna Open Access shyBasicshy Washington DC Area 877shy459shy6604 JN4 JN5 14021 31351 6471 14470

CareFirst BlueChoice shyHighshy Washington DC Metro Area 888shy789shy9065 2G1 2G2 21177 48693 9774 22474

CareFirst BlueChoice shyStdshy Washington DC Metro Area 888shy789shy9065 2G4 2G5 15284 35429 7054 16352

Kaiser Foundation Health Plan MidshyAtlantic States shyHighshy Washington DC area 877shy574shy3337 E31 E32 16926 42124 7812 19442

Kaiser Foundation Health Plan MidshyAtlantic States shyStdshy Washington DC area 877shy574shy3337 E34 E35 9646 22186 4452 10240

MD IPA shyHighshy Washington DC area 877shy835shy9861 JP1 JP2 20245 50123 9344 23134

Florida

Aetna Value Planshy Most of Florida 877shy459shy6604 F54 F55 13058 29656 6027 13687

AvMed Health Plans shyHighshy Broward Dade and Palm Beach 800shy882shy8633 ML1 ML2 20336 56279 9386 25975

AvMed Health Plans shyStdshy Broward Dade and Palm Beach 800shy882shy8633 ML4 ML5 12604 30253 5817 13963

Capital Health Plan shyHighshy Tallahassee area 850shy383shy3311 EA1 EA2 11679 30949 5390 14284

Coventry Health Plan of Florida shyHighshy Southern Florida 800shy441shy5501 5E1 5E2 16664 47450 7691 21900

Coventry Health Plan of Florida shyStdshy Southern Florida 800shy441shy5501 5E4 5E5 12501 30003 5770 13848

Humana Value Plan shy Tampa Area 888shy393shy6765 MJ4 MJ5 10247 22697 4729 10476

Humana Value Plan shy South Florida Area 888shy393shy6765 QP4 QP5 10247 22697 4729 10476

Humana Medical Plan Inc shyHighshy Orlando 888shy393shy6765 E21 E22 13149 29256 6069 13503

Humana Medical Plan Inc shyStdshy Orlando 888shy393shy6765 E24 E25 11834 26331 5462 12153

Humana Medical Plan Inc shyHighshy South Florida 888shy393shy6765 EE1 EE2 23153 51514 10686 23776

Humana Medical Plan Inc shyStdshy South Florida 888shy393shy6765 EE4 EE5 15825 35210 7304 16251

Humana Medical Plan Inc shyHighshy Daytona 888shy393shy6765 EX1 EX2 13880 30882 6406 14253

Humana Medical Plan Inc shyStdshy Daytona 888shy393shy6765 EX4 EX5 12491 27794 5765 12828

Humana Medical Plan Inc shyHighshy Tampa 888shy393shy6765 LL1 LL2 48720 108398 22486 50030

Humana Medical Plan Inc shyStdshy Tampa 888shy393shy6765 LL4 LL5 15825 35208 7304 16250


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



42


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs


Aetna Value Plan InshyNetwork $25$40 20 $10

HMOPOS Nationa

30to$60050 to$1200 Yes

l Average 679 864 849 942 877 875 649


Aetna Open AccessshyHigh

Aetna Open AccessshyBasic

CareFirst BlueChoiceshyHigh

CareFirst BlueChoice InshyNetwork

4040

$15$30

$20$35

$25$35

Nothing$35

40

$150day x3

10 Plan Allow

$200

$200

50+

$5

$10

Nothing

Nothing

50+50+

$35$100

$35$100

$35$65

$35$65

No

Yes

Yes

Yes

Yes

69

69

648

648

844

844

86

86

872

872

833

833

942

942

925

925

865

865

846

846

914

914

902

902

567

567

54

54 CareFirst BlueChoice OutshyNetwork

Kaiser Foundation HP MidshyAtlantic StatesshyHigh

Kaiser Foundation HP MidshyAtlantic StatesshyStandard

MD IPAshyHigh

Florida

Aetna Value Plan InshyNetwork

$70$70

$10$20

$20$30

$25$40

$25$40

$500

$100

$250dayx3

$150day x 3

20

Nothing

$7$17 Net

$12$22Net

$7

$10

$35$65

$30$50$45$65

$35$55$50$70

$30$60

30to$60050 to$1200

Yes

Yes

Yes

Yes

Yes

83

83

583

867

867

846

831

831

876

927

927

937

813

813

867

836

836

841

702

702

677


AvMed Health PlansshyHigh

AvMed Health PlansshyStandard

Capital Health PlanshyHigh

Coventry Health Plan of FloridashyHigh

Coventry Health Plan of FloridashyStandard

Humana Value Plan InshyNetwork

4040

$15$40

$25$45

$15$25

$15$30

$20$50

$35$55

40

$250dayx3

$300dayx3

$250

Ded + $150x3

Ded + $150x5

20

50+

$5

$10

$15 Tier 1

$3$20

$3$10

$10

50+50+

$30$5030

$40$6030

$30 Tier 2$50 Tier 3

$40$6020

$50$7020

$40$60

No

No

No

No

No

No

Yes

746

746

855

514

514

877

877

905

808

808

847

847

905

764

764

957

957

953

921

921

919

919

938

827

827

87

87

946

783

783

68

68

755

535

535

Humana Value Plan OutshyNetwork


5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No

Yes Humana Value Plan OutshyNetwork

Humana Medical Plan IncshyHigh

Humana Medical Plan IncshyStandard







5050

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

50

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$10+

$10

$10

$10

$10

$10

$10

$10

$10

$40+$60+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

529

529

86

86

824

824

937

937

846

846

843

843

687

687

43


Georgia

Aetna Value Planshy All of Georgia 877shy459shy6604 F54 F55 13058 29656 6027 13687

Aetna Open Access shyHighshy Atlanta and Athens Areas 877shy459shy6604 2U1 2U2 44133 104232 20369 48107

Humana Value Plan shy Atlanta Area 888shy393shy6765 AD4 AD5 10247 22697 4729 10476

Humana Value Plan shy Macon Area 888shy393shy6765 LM4 LM5 10247 22697 4729 10476

Humana Employers Health of Georgia Inc shyHighshy Columbus 888shy393shy6765 CB1 CB2 15825 35210 7304 16251

Humana Employers Health of Georgia Inc shyStdshy Columbus 888shy393shy6765 CB4 CB5 13880 30882 6406 14253

Humana Employers Health of Georgia Inc shyHighshy Atlanta 888shy393shy6765 DG1 DG2 15825 35210 7304 16251

Humana Employers Health of Georgia Inc shyStdshy Atlanta 888shy393shy6765 DG4 DG5 13149 29256 6069 13503

Humana Employers Health of Georgia Inc shyHighshy Macon 888shy393shy6765 DN1 DN2 15825 35210 7304 16251

Humana Employers Health of Georgia Inc shyStdshy Macon 888shy393shy6765 DN4 DN5 13880 30882 6406 14253

Kaiser Foundation Health Plan of Georgia shyHighshy Atlanta AthensColumbusMaconSavannah 888shy865shy5813 F81 F82 15015 36863 6930 17014

Kaiser Foundation Health Plan of Georgia shyStdshy Atlanta AthensColumbusMaconSavannah 888shy865shy5813 F84 F85 10047 22957 4637 10596

Guam

Calvos Selectcare shyHighshy Guam Northern Mariana Islands Palau 671 479shy7982 B41 B42 11949 31399 5515 14492

TakeCare shyHighshy GuamNMarianaIslandsBelau(Palau) 671shy647shy3526 JK1 JK2 12447 36018 5745 16624

TakeCare shyStdshy GuamNMarianaIslandsBelau(Palau) 671shy647shy3526 JK4 JK5 10209 26960 4712 12443

Hawaii Aetna Value Planshy All of Hawaii 877shy459shy6604 JS4 JS5 17258 41140 7965 18988

HMSA shyHighshy All of Hawaii 800shy776shy4672 871 872 11377 25325 5251 11688

Kaiser Foundation Health Plan of Hawaii shyHighshy HawaiiKauaiLanaiMauiMolokaiOahu 808shy432shy5955 631 632 14515 32578 6699 15036

Kaiser Foundation Health Plan of Hawaii shyStdshy HawaiiKauaiLanaiMauiMolokaiOahu 808shy432shy5955 634 635 7553 16846 3486 7775


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



44


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Georgia


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649




4040

$20$35

$35$55

40

$250day x 4

20

50+

$10

$10

50+50+

$35$100

$40$60

No

Yes

Yes

59 90 878 941 86 857 62



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No


Humana Employers Health of Georgia shyHigh

Humana Employers Health of Georgia shyStandard





Kaiser Foundation HP of GeorgiashyHigh

Kaiser Foundation HP of GeorgiashyStandard

Guam

Calvos Selectcare InshyNetwork

5050

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$30

$20$35

$15$40

50

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250dayx3

$250dayx3

$200

$10+

$10

$10

$10

$10

$10

$10

$10$20 Comm

$15$25 Comm

$10

$40+$60+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$50 Comm

$40$50 Comm

$2550 of AWP

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

514

794

794

883

845

845

837

85

85

941

935

935

859

884

884

849

839

839

556

625

625

Calvos Selectcare OutshyNetwork

TakeCareshyHigh

TakeCareshyStandard

Hawaii Aetna Value Plan InshyNetwork

3030

$5 at FHP$40

$5 at FHP$40

$25$40

30

$100day for 5

$150day for 5

20

NA

$10

$15

$10

NA

$25$50

$40$80

30to$60050 to$1200

NA

Yes

Yes

Yes

687

687

669

669

686

686

904

904

792

792

786

786

571

571


HMSA InshyNetwork

4040

$15$15

40

$100

50+

$7

50+50+

$30$65

No

Yes 842 914 884 955 878 931 628 HMSA OutshyNetwork

Kaiser Foundation HP of HawaiishyHigh

Kaiser Foundation HP of HawaiishyStandard

3030

$20$20

$30$30

30

$100

10

$7 + 20

$10

$15

$45$45

$50$50

$30 + 20$65 + 20 No

Yes

Yes

754

754

826

826

815

815

94

94

875

875

811

811

613

613

45


Idaho

Aetna Value Planshy Most of Idaho 877shy459shy6604 H44 H45 13093 29732 6043 13722

Altius Health Plans shyHighshy Southern Region 800shy377shy4161 9K1 9K2 19819 42542 9147 19635

Altius Health Plans shyStdshy Southern Region 800shy377shy4161 DK4 DK5 11798 25954 5445 11979

Group Health Cooperative shyHighshy most of Washington StateampNorthern Idaho 888shy901shy4636 541 542 27070 55009 12494 25389

Group Health Cooperative shyStdshy most of Washington StateampNorthern Idaho 888shy901shy4636 544 545 11742 26509 5419 12235

SelectHealth shyHighshy Idaho 801shy442shy7497 SF1 SF2 19210 43095 8866 19890

SelectHealth shyStdshy Idaho 801shy442shy7497 SF4 SF5 12435 27741 5739 12803

Illinois

Aetna Value Planshy Most of Illinois 877shy459shy6604 H44 H45 13093 29732 6043 13722

Blue Cross and Blue Shield of Illinois shyHighshy Illinois 855shy676shy4482 A21 A22 30483 71121 14069 32825

Blue Preferred Plus POS shyHighshy Madison and St Clair counties 888shy811shy2092 9G1 9G2 32158 67069 14842 30955

Health Alliance HMO shyHighshy CentralECentralNCentSouthWest Ill 800shy851shy3379 FX1 FX2 26932 67294 12430 31059

Health Alliance HMO shyStdshy CentralECentralNCentSouthWest Ill 800shy851shy3379 K84 K85 20323 51891 9380 23950

Humana Benefit Plan of Illinois Inc shyHighshy Central and Northwestern Illinois 888shy393shy6765 9F1 9F2 51805 115264 23910 53199

Humana Benefit Plan of Illinois Inc shyStdshy Central and Northwestern Illinois 888shy393shy6765 AB4 AB5 15825 35210 7304 16251

Humana Value Plan shy Central Illinois 888shy393shy6765 GB4 GB5 10247 22697 4729 10476

Humana Value Plan shy Chicago Area 888shy393shy6765 MW4 MW5 10247 22697 4729 10476

Humana Health Plan Inc shyHighshy Chicago 888shy393shy6765 751 752 40638 90413 18756 41729

Humana Health Plan Inc shyStdshy Chicago 888shy393shy6765 754 755 15825 35210 7304 16251

Union Health Service shyHighshy Chicago area 312shy423shy4200 761 762 14109 33787 6512 15594

United Healthcare of the Midwest Inc shyHighshy Southwest Illinois 877shy835shy9861 B91 B92 33072 74273 15264 34280

UnitedHealthcare Plan of the River Valley Inc shyHighshy West Central Illinois 800shy747shy1446 YH1 YH2 14091 38330 6503 17691


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



46


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

6

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Idaho


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649


Altius Health PlansshyHigh

Altius Health PlansshyStandard

Group Health CooperativeshyHigh

Group Health CooperativeshyStandard

SelectHealthshyHigh

SelectHealthshyStandard

Illinois


4040

$20$30

$20$40

$25$25

$25$35

$15$25

$20$30

$25$40

40

$200

None

$350

$500

$100

$100 after

20

50+

$7

$7

$20

$20

$5 $25$50

$5

$10

50+50+

$25$50

$35$60

$40$60

$40$60

$25$50$50

$25$50

30to$60050 to$1200

No

No

None

Yes

Yes

Yes

Yes

Yes

552

552

659

659

629

629

852

852

86

86

876

876

813

813

869

869

851

851

948

948

941

941

958

958

883

883

912

912

912

912

895

895

881

881

903

903

588

588

692

692

64

64


Blue Cross and Blue Shield of IllinoisshyHigh

Blue Preferred Plus POS InshyNetwork

4040

$20$35

$25$35

40

Nothing

$500

50+

$10 copay

$5

50+50+

$40$60

$40$6025 $6025

No

Yes

Yes 647 891 861 961 84 864 685 Blue Preferred Plus POS OutshyNetwork

Health Alliance HMOshyHigh

Health Alliance HMOshyStandard

Humana Benefit Plan of Illinois IncshyHigh

Humana Benefit Plan of Illinois IncshyStandard


30 after ded

$25$50

$25$50

$20$35

$25$40

$35$55

30 after ded

$200day x 5

20

$250day x 3

$500day x 3

20

NA

$7

$7

$10

$10

$10

NA

$35$70

$35$70

$40$60

$40$60

$40$60

NA

Yes

Yes

Yes

Yes

Yes

745 915 88 962 878 868 67



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No


Humana Health Plan IncshyHigh


Union Health ServiceshyHigh

United Healthcare of the Midwest IncshyHigh

UnitedHealthcare Plan of the River Valley shyHigh

5050

$20$35

$25$40

$15$15

$25$40

$25$50

50

$250day x 3

$500day x 3

None

$450

20

$10+

$10

$10

$10

$7

$10

$40+$60+

$40$60

$40$60

$35$60

$30$60

$35$50

No

Yes

Yes

Yes

Yes

Yes

647

647

665

577

822

822

919

896

788

788

902

86

943

943

957

956

859

859

892

914

834

834

898

918

66

66

732

623

47


Indiana

Aetna Value Planshy All of Indiana 877shy459shy6604 JS4 JS5 17258 41140 7965 18988

Health Alliance HMO shyHighshy Western Indiana 800shy851shy3379 FX1 FX2 26932 67294 12430 31059

Health Alliance HMO shyStdshy Western Indiana 800shy851shy3379 K84 K85 20323 51891 9380 23950

Humana Value Plan shy LakePorterLaPorte Counties 888shy393shy6765 MW4 MW5 10247 22697 4729 10476

Humana Health Plan of Ohio shyHighshy Portions of Indiana 888shy393shy6765 A61 A62 13880 30882 6406 14253

Humana Health Plan of Ohio shyStdshy Portions of Indiana 888shy393shy6765 A64 A65 12491 27794 5765 12828

Humana Health Plan Inc shyHighshy LakePorterLaPorte Counties 888shy393shy6765 751 752 40638 90413 18756 41729

Humana Health Plan Inc shyStdshy LakePorterLaPorte Counties 888shy393shy6765 754 755 15825 35210 7304 16251

Humana Health Plan Inc shyHighshy Southern Indiana 888shy393shy6765 MH1 MH2 15825 35210 7304 16251

Humana Health Plan Inc shyStdshy Southern Indiana 888shy393shy6765 MH4 MH5 13880 30882 6406 14253

Physicians Health Plan of Northern Indiana shyHighshy Northeast Indiana 260shy432shy6690 DQ1 DQ2 30786 68557 14209 31642

Iowa

Aetna Value Planshy All of Iowa 877shy459shy6604 H44 H45 13093 29732 6043 13722

Coventry Health Care of Iowa shyHighshy CentralEasternWestern Iowa 800shy257shy4692 SV1 SV2 13351 31376 6162 14481

Coventry Health Care of Iowa shyStdshy CentralEasternWestern Iowa 800shy257shy4692 SY4 SY5 9799 23027 4522 10628

Health Alliance HMO shyHighshy Central and Eastern Iowa 800shy851shy3379 FX1 FX2 26932 67294 12430 31059

Health Alliance HMO shyStdshy Central and Eastern Iowa 800shy851shy3379 K84 K85 20323 51891 9380 23950

HealthPartners High Option shyNorthern Iowa 800shy883shy2177 V31 V32 26865 64982 12399 29992

HealthPartners Standard Option shyNorthern Iowa 800shy883shy2177 V34 V35 8897 20464 4106 9445

Sanford Health Plan shyHighshy Northwestern Iowa 800shy752shy5863 AU1 AU2 26173 63455 12080 29287

Sanford Health Plan shyStdshy Northwestern Iowa 800shy752shy5863 AU4 AU5 23647 57594 10914 26582

UnitedHealthcare Plan of the River Valley Inc shyHighshy Eastern and Central Iowa 800shy747shy1446 YH1 YH2 14091 38330 6503 17691


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



48


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Indiana


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649





4040

$25$50

$25$50

$35$55

40

$200day x 5

20

20

50+

$7

$7

$10

50+50+

$35$70

$35$70

$40$60

No

Yes

Yes

Yes

745 915 88 962 878 868 67


Humana Health Plan of OhioshyHigh

Humana Health Plan of OhioshyStandard





Physicians Health Plan of Northern IndianashyHigh

Iowa


5050

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$15

$25$40

50

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

20

20

$10+

$10

$10

$10

$10

$10

$10

$10

$10

$40+$60+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$25$50

30to$60050 to$1200

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

647

647

562

822

822

878

788

788

815

943

943

934

859

859

868

834

834

893

66

66

593


Coventry Health Care of IowashyHigh

Coventry Health Care of IowashyStandard



HealthPartners High Option

HealthPartners Standard Option

Sanford Health Plan InshyNetwork

4040

$25$50

$25$50

$25$50

$25$50

$25$45

$0 for 3 then 20

$20$30

40

20

20

$200day x 5

20

Nothing

20 in40 out

$100day x 5

50+

$3 $10

$3 $10

$7

$7

$12

$9

$15

50+50+

$45$70$100

30$5000 Max

$35$70

$35$70

$45$90

$40$70

$30$50

No

Yes

No

Yes

Yes

Yes

Yes

NA

562

562

745

647

647

535

905

905

915

893

893

903

888

888

88

875

875

89

964

964

962

951

951

977

837

837

878

92

92

902

903

903

868

911

911

912

652

652

67

725

725

558 Sanford Health Plan OutshyNetwork


4040

$25$25

40

$100day x 5

40+

$15

40+40+

$30$50

NA

NA 535 903 89 977 902 912 558 Sanford Health Plan OutshyNetwork


40+40+

$25$50

40+

20

40+

$10

40+40+

$35$50

NA

Yes 577 896 86 956 914 918 623

49



Monthly Biweekly Enrollment Code

Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family

Kansas

Aetna Value Planshy Most of Kansas 877shy459shy6604 G54 G55 12822 29119 5918 13440

Aetna Open Access shyHighshy Kansas City area 877shy459shy6604 HY1 HY2 13577 50039 6266 23095

Coventry Health Care of Kansas shyHighshy Kansas City Metro Area (KS and MO) 800shy969shy3343 HA1 HA2 13519 32270 6240 14894

Coventry Health Care of Kansas shyStdshy Kansas City Metro Area (KS and MO) 800shy969shy3343 HA4 HA5 12568 29535 5800 13631

Humana Value Plan shy Kansas City Area 888shy393shy6765 PH4 PH5 10247 22697 4729 10476

Humana Health Plan Inc shyHighshy Kansas City 888shy393shy6765 MS1 MS2 62521 139111 28856 64205

Humana Health Plan Inc shyStdshy Kansas City 888shy393shy6765 MS4 MS5 15825 35210 7304 16251

Kentucky

Aetna Value Planshy Most of Kentucky 877shy459shy6604 H44 H45 13093 29732 6043 13722

Humana Health Plan of Ohio shyHighshy Portions of Kentucky 888shy393shy6765 A61 A62 13880 30882 6406 14253

Humana Health Plan of Ohio shyStdshy Portions of Kentucky 888shy393shy6765 A64 A65 12491 27794 5765 12828

Humana Health Plan Inc shyHighshy Louisville 888shy393shy6765 MH1 MH2 15825 35210 7304 16251

Humana Health Plan Inc shyStdshy Louisville 888shy393shy6765 MH4 MH5 13880 30882 6406 14253

Humana Health Plan Inc shyHighshy Lexington 888shy393shy6765 MI1 MI2 19459 43292 8981 19981

Humana Health Plan Inc shyStdshy Lexington 888shy393shy6765 MI4 MI5 13880 30882 6406 14253

Louisiana

Aetna Value Planshy Most of Louisiana 877shy459shy6604 F54 F55 13058 29656 6027 13687

Coventry Health Care of Louisiana shyHighshy New Orleans Area 800shy341shy6613 BJ1 BJ2 19208 48754 8865 22502

Coventry Health Care of Louisiana shyStdshy New Orleans Area 800shy341shy6613 BJ4 BJ5 13035 30271 6016 13971

Humana Health Benefit Plan of Louisiana Inc shyHighshy Baton Rouge 888shy393shy6765 AE1 AE2 15825 35210 7304 16251

Humana Health Benefit Plan of Louisiana Inc shyStdshy Baton Rouge 888shy393shy6765 AE4 AE5 13149 29256 6069 13503

Humana Health Benefit Plan of Louisiana Inc shyHighshy New Orleans 888shy393shy6765 BC1 BC2 13880 30882 6406 14253

Humana Health Benefit Plan of Louisiana Inc shyStdshy New Orleans 888shy393shy6765 BC4 BC5 12491 27794 5765 12828


50


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Kansas


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649



Coventry Health Care of KansasshyHigh

Coventry Health Care of KansasshyStandard


4040

$20$35

$30$60

$30$60

$35$55

40

$250day x 4

25

30

20

50+

$10

$3 $12

$3 $12

$10

50+50+

$35$100

$50$75

$5020

$40$60

No

Yes

Yes

Yes

Yes

639

602

602

862

906

906

862

88

88

94

96

96

838

894

894

901

884

884

538

663

663




Kentucky


5050

$20$35

$25$40

$25$40

50

$250day x 3

$500day x 3

20

$10+

$10

$10

$10

$40+$60+

$40$60

$40$60

30to$60050 to$1200

No

Yes

Yes

Yes

676

676

903

903

901

901

951

951

881

881

918

918

729

729








Louisiana


4040

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$25$40

40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

20

50+

$10

$10

$10

$10

$10

$10

$10

50+50+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

30to$60050 to$1200

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes Aetna Value Plan OutshyNetwork

Coventry Health Care of LouisianashyHigh

Coventry Health Care of LouisianashyStandard

Humana Health Benefit Plan of LA shyHigh

Humana Health Benefit Plan of LA shyStandard



4040

$25$45

$30$55

$20$35

$35$40

$20$35

$35$40

40

Ded+$100

Ded+30

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+

$5

$5

$10

$10

$10

$10

50+50+

$40$100

$40$100

$40$60

$40$60

$40$60

$40$60

No

Yes

Yes

Yes

Yes

Yes

Yes

573

573

874

874

823

823

968

968

831

831

827

827

625

625

51





Maine

Aetna Value Planshy All of Maine 877shy459shy6604 EP4 EP5 12694 28827 5859 13305

Maryland

Aetna Value Planshy All of Maryland 877shy459shy6604 F54 F55 13058 29656 6027 13687

Aetna Open Access shyHighshy NorthernCentralSouthern Maryland Areas 877shy459shy6604 JN1 JN2 46867 105610 21631 48743

Aetna Open Access shyBasicshy NorthernCentralSouthern Maryland Areas 877shy459shy6604 JN4 JN5 14021 31351 6471 14470

CareFirst BlueChoice shyHighshy All of Maryland 888shy789shy9065 2G1 2G2 21177 48693 9774 22474

CareFirst BlueChoice shyStdshy All of Maryland 888shy789shy9065 2G4 2G5 15284 35429 7054 16352

Coventry Health Care shyHighshy All of Maryland 800shy833shy7423 IG1 IG2 14998 37685 6922 17393

Coventry Health Care shyStdshy All of Maryland 800shy833shy7423 IG4 IG5 13265 30509 6122 14081

Kaiser Foundation Health Plan MidshyAtlantic States shyHighshy BaltimoreWashington DC areas 877shy574shy3337 E31 E32 16926 42124 7812 19442

Kaiser Foundation Health Plan MidshyAtlantic States shyStdshy BaltimoreWashington DC areas 877shy574shy3337 E34 E35 9646 22186 4452 10240

MD IPA shyHighshy All of Maryland 877shy835shy9861 JP1 JP2 20245 50123 9344 23134

Massachusetts

Aetna Value Plan shy Most of Massachusetts 877shy459shy6604 EP4 EP5 12694 28827 5859 13305

Fallon Community Health Plan shyBasic shy CentralEastern Massachusetts 800shy868shy5200 JG1 JG2 29337 80043 13540 36943


52


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Maine


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649


Maryland


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No






4040

$15$30

$20$35

$25$35

Nothing$35

40

$150day x3

10 Plan Allow

$200

$200

50+

$5

$10

Nothing

Nothing

50+50+

$35$100

$35$100

$35$65

$35$65

No

Yes

Yes

Yes

Yes

69

69

648

648

844

844

86

86

872

872

833

833

942

942

925

925

865

865

846

846

914

914

902

902

567

567

54


Coventry Health CareshyHigh

Coventry Health CareshyStandard



MD IPAshyHigh

Massachusetts


$70$70

$20$40

$20$40

$10$20

$20$30

$25$40

$25$40

$500

$200day x 3

$200day x 3

$100

$250dayx3

$150day x 3

20

Nothing

$3$15

$3$15

$7$17 Net

$12$22Net

$7

$10

$35$65

$30$60

$30$60

$30$50$45$65

$35$55$50$70

$30$60

30to$60050 to$1200

Yes

Yes

Yes

Yes

Yes

Yes

Yes

563

563

83

83

583

864

864

867

867

846

864

864

831

831

876

969

969

927

927

937

892

892

813

813

867

871

871

836

836

841

606

606

702

702

677


Fallon Community Health PlanshyBasic

4040

$25$35

40

$150 to $750max

50+

$10

50+50+

$30$60

No

Yes 627 851 882 929 883 801 649

53





Michigan

Aetna Value Planshy All of Michigan 877shy459shy6604 G54 G55 12822 29119 5918 13440

Bluecare Network of MI shyHighshy East Region 800shy662shy6667 K51 K52 22055 52593 10179 24274

Bluecare Network of MI shyHighshy Southeast Region 800shy662shy6667 LX1 LX2 18055 50747 8333 23422

Grand Valley Health Plan shyHighshy Grand Rapids area 616shy949shy2410 RL1 RL2 24184 61492 11162 28381

Grand Valley Health Plan shyStdshy Grand Rapids area 616shy949shy2410 RL4 RL5 19656 50897 9072 23491

Health Alliance Plan shyHighshy Southeastern MichiganFlint Area 800shy556shy9765 521 522 20111 55722 9282 25718

Health Alliance Plan shyStdshy Southeastern MichiganFlint Area 800shy556shy9765 GY4 GY5 16974 48191 7834 22242

HealthPlus of MI shyHighshy East Michigan 800shy332shy9161 X51 X52 13915 49809 6422 22989

Total Health Care USA shyHighshy Michigan 800shy826shy2862 A51 A52 13670 50117 6309 23131

Minnesota

Aetna Value Planshy Most of Minnesota 877shy459shy6604 H44 H45 13093 29732 6043 13722

HealthPartners High Option shy Minnesota 800shy883shy2177 V31 V32 26865 64982 12399 29992

HealthPartners Standard Option shy Minnesota 800shy883shy2177 V34 V35 8897 20464 4106 9445

Mississippi Aetna Value Plan shy Most of Mississippi 877shy459shy6604 H44 H45 13093 29732 6043 13722


54


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Michigan


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649


Bluecare Network of MIshyHigh


Grand Valley Health PlanshyHigh

Grand Valley Health PlanshyStandard

Health Alliance PlanshyHigh

Health Alliance PlanshyStandard

HealthPlus of MIshyHigh

Total Health Care USAshyHigh

Minnesota


4040

$15$25

$15$25

$10$10

$20$20

$10$20

$15$30

$10$20

$15$15

$25$40

40

Nothing

Nothing

Nothing

$500x3

Nothing

Nothing

None

None

20

50+

$10

$10

$5

$10

$5

$15

$0$8

$10

$10

50+50+

$30$60

$30$60

$15$15

NA$40

$50$50

$50$50

$40$60

$40$40

30to$60050 to$1200

No

Yes

Yes

No

No

Yes

Yes

Yes

Yes

Yes

651

651

742

742

793

793

793

899

899

90

90

888

888

919

875

875

912

912

862

862

92

933

933

952

952

943

943

951

884

884

883

883

899

899

946

937

937

836

836

902

902

919

672

672

795

795

656

656

658




Mississippi Aetna Value Plan InshyNetwork

4040

$25$45

$0 for 3 then 20

$25$40

40

Nothing

20 in40 out

20

50+

$12

$9

$10

50+50+

$45$90

$40$70

30to$60050 to$1200

No

Yes

Yes

Yes

647

647

893

893

875

875

951

951

92

92

911

911

725

725


55


Missouri Aetna Value Planshy Most of Missouri 877shy459shy6604 G54 G55 12822 29119 5918 13440


Blue Preferred Plus POS shyHighshy StLouisCentralSW areas 888shy811shy2092 9G1 9G2 32158 67069 14842 30955






United Healthcare of the Midwest Inc shyHighshy St Louis Area 877shy835shy9861 B91 B92 33072 74273 15264 34280

Montana

Aetna Value Planshy SouthSoutheastWestern MT Areas 877shy459shy6604 H44 H45 13093 29732 6043 13722

Nebraska

Aetna Value Planshy All of Nebraska 877shy459shy6604 H44 H45 13093 29732 6043 13722

Nevada

Aetna Value Planshy Las Vegas Area 877shy459shy6604 G54 G55 12822 29119 5918 13440

Aetna Open Access shyHighshy Clark County and Las Vegas areas 877shy459shy6604 HF1 HF2 11267 36491 5200 16842

Health Plan of Nevada shyHighshy Las VegasEsmeralda and Nye counties 877shy545shy7378 NM1 NM2 9883 23303 4561 10755

New Hampshire

Aetna Value Planshy All of New Hampshire 877shy459shy6604 EP4 EP5 12694 28827 5859 13305


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



56


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Missouri Aetna Value Plan InshyNetwork $25$40 20 $10

HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649




4040

$20$35

$25$35

40

$250day x 4

$500

50+

$10

$5

50+50+

$35$100 $40$60

25$6025

No

Yes

Yes

639

647

862

891

862

861

94

961

838

84

901

864

538

685 Blue Preferred Plus POS OutshyNetwork




30 after ded

$30$60

$30$60

$35$55

30 after ded

25

30

20

NA

$3 $12

$3 $12

$10

NA

$50$75

$5020

$40$60

NA

Yes

Yes

Yes

602

602

906

906

88

88

96

96

894

894

884

884

663

663





Montana


5050

$20$35

$25$40

$25$40

$25$40

50

$250day x 3

$500day x 3

$450

20

$10+

$10

$10

$7

$10

$40+$60+

$40$60

$40$60

$30$60

30to$60050 to$1200

No

Yes

Yes

Yes

Yes

676

676

665

903

903

919

901

901

902

951

951

957

881

881

892

918

918

898

729

729

732


Nebraska


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No


Nevada


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No



Health Plan of NevadashyHigh

New Hampshire


4040

$20$35

$10$25

$25$40

40

$250day x 4

$300

20

50+

$10

$7

$10

50+50+

$35$100

$35$55$100

30to$60050 to$1200

No

Yes

Yes

Yes

602

516

838

696

861

66

923

892

849

892

918

912

636

529


57


New Jersey

Aetna Value Planshy All of New Jersey 877shy459shy6604 EP4 EP5 12694 28827 5859 13305

Aetna Open Access shyHighshy Northern New Jersey 877shy459shy6604 JR1 JR2 52355 123641 24164 57065

Aetna Open Access shyBasicshy Northern New Jersey 877shy459shy6604 JR4 JR5 34184 82457 15777 38057

Aetna Open Access shyHighshy Southern NJ 877shy459shy6604 P31 P32 64801 164359 29908 75858

Aetna Open Access shyBasicshy Southern NJ 877shy459shy6604 P34 P35 49560 118027 22874 54474

GHI Health Plan shyHighshy Northern New Jersey 212shy501shy4444 801 802 32591 93212 15042 43021

GHI Health Plan shyStdshy Northern New Jersey 212shy501shy4444 804 805 14135 33572 6524 15495

New Mexico

Aetna Value Planshy AlbuquerqueDona AnaHobbs Area 877shy459shy6604 G54 G55 12822 29119 5918 13440

Lovelace Health Plan shyHighshy All of New Mexico 800shy808shy7363 Q11 Q12 13099 30785 6046 14208

Presbyterian Health Plan shyHighshy All counties in New Mexico 800shy356shy2219 P21 P22 23940 56335 11049 26001


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code


Monthly Biweekly


58

Primary care Hospital

Prescription Drugs


Mail lan

eeded

are

ll icate

r ng rm

ation

Plan Name ndash Location Specialist

office copay per stay

deductible Level I Level II Level III

order discount

Ove

rall p

satisfaction

Gettin

g n

care

Gettin

g c

quickly

How

we

doctors

commun

Custome

service

Claim

sproce

ssi

Plan

Info

on

Costs

New Jersey


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649






GHI Health Plan InshyNetwork

$15$35

$20$20

20 Plan Allow

$150max$450

$5

$20

$35$100

$45$85

Yes

Yes

631

663

852

844

837

851

928

936

895

86

809

828

623

642 GHI Health Plan OutshyNetwork

GHI Health PlanshyStandard

New Mexico


50 of sch

$30$30

$25$40

+50 of sch

$250day x 3

20

NA

$10

$10

NA

$45$85

30to$60050 to$1200

No

Yes

Yes

663 844 851 936 86 828 642


Lovelace Health PlanshyHigh $25$35 $250 after ded $5 $35$6050 Yes 651 796 753 918 828 939 656

Presbyterian Health PlanshyHigh $25$40 $100 x 5 days $10 $40$7550 Yes 655 824 783 917 848 852 616

59


New York

Aetna Value Planshy Most of New York 877shy459shy6604 EP4 EP5 12694 28827 5859 13305

Aetna Open Access shyHighshy NYC AreaUpstate NY 877shy459shy6604 JC1 JC2 40198 109033 18553 50323

Aetna Open Access shyBasicshy NYC AreaUpstate NY 877shy459shy6604 JC4 JC5 26007 71920 12003 33194

CDPHP Universal Benefits Inc shyHighshy Upstate Hudson Valley Central NY 877shy269shy2134 SG1 SG2 22952 71235 10593 32878

CDPHP Universal Benefits Inc shyStdshy Upstate Hudson Valley Central NY 877shy269shy2134 SG4 SG5 12294 32053 5674 14794

GHI HMO Select shyHighshy BrnxBrklynManhatQueenRichmonWestche 877shy244shy4466 6V1 6V2 19548 60991 9022 28150

GHI HMO Select shyHighshy CapitalHudson Valley Regions 877shy244shy4466 X41 X42 14167 47634 6538 21985

GHI Health Plan shyHighshy All of New York 212shy501shy4444 801 802 32591 93212 15042 43021

GHI Health Plan shyStdshy All of New York 212shy501shy4444 804 805 14135 33572 6524 15495

HIP Health of Greater New York shyHighshy New York City area including Long Island 800shy447shy8255 511 512 17000 63158 7846 29150

HIP Health of Greater New York shyStdshy New York City area including Long Island 800shy447shy8255 514 515 12206 34562 5633 15952

Independent Health Association shyHighshy Western New York 800shy501shy3439 QA1 QA2 18597 58201 8583 26862

Independent Health Association shyStdshy Western New York 800shy501shy3439 C54 C55 14454 47853 6671 22086

MVP Health Care shyHighshy Eastern Region 888shy687shy6277 GA1 GA2 16586 53386 7655 24640

MVP Health Care shyStdshy Eastern Region 888shy687shy6277 GA4 GA5 13377 39674 6174 18311

MVP Health Care shyHighshy Western Region 888shy687shy6277 GV1 GV2 13042 35704 6019 16479

MVP Health Care shyStdshy Western Region 888shy687shy6277 GV4 GV5 11193 28006 5166 12926

MVP Health Care shyHighshy Central Region 888shy687shy6277 M91 M92 17110 54877 7897 25328

MVP Health Care shyStdshy Central Region 888shy687shy6277 M94 M95 13779 42651 6360 19685

MVP Health Care shyHighshy Northern Region 888shy687shy6277 MF1 MF2 25417 75411 11731 34805

MVP Health Care shyStdshy Northern Region 888shy687shy6277 MF4 MF5 22349 67734 10315 31262

MVP Health Care shyHighshy MidshyHudson Region 888shy687shy6277 MX1 MX2 18731 58664 8645 27076

MVP Health Care shyStdshy MidshyHudson Region 888shy687shy6277 MX4 MX5 13657 42345 6303 19544


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



60

North Dakota


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

New York


HHMMOO ationaPPOOSSNNationalAAveragge

30to$60050 to$1200 Yes

l vera e 679 864 849 942 877 875 649




CDPHP Universal Benefits IncshyHigh

CDPHP Universal Benefits IncshyStandard

GHI HMO SelectshyHigh



4040

$20$35

$15$35

$20$30

$25$40

$25$40

$25$40

$20$20

40

$250day x 4

20 Plan Allow

$100 x 5

$500+10

$500

$500

$150max$450

50+

$10

$5

25

30

$10

$10

$20

50+50+

$35$100

$35$100

2525

3030

$30$50

$30$50

$45$85

No

Yes

Yes

No

No

Yes

Yes

Yes

662

662

729

729

663

848

848

928

928

844

849

849

90

90

851

937

937

949

949

936

888

888

922

922

86

874

874

924

924

828

547

547

70

70



HIP Health of Greater New YorkshyHigh

HIP Health of Greater New YorkshyStandard

Independent Health Assoc InshyNetwork

50 of sch

$30$30

$20$40

$30$50

$25$25

+50 of sch

$250day x 3

None

$1000

$250

NA

$10

$15

$15$100Ded

$10

NA

$45$85

$35$75

$30$75

$35$75 $75$100Ded

No

Yes

Yes

Yes

No

663

729

729

735

844

814

814

933

851

786

786

923

936

888

888

952

86

787

787

92

828

848

848

916

642

60

60

755 Independent Health Assoc OutshyNetwork

Independent Health Association InshyNetwork

2525

$30$50

25

$750

NA

$10

NA

$5050

No

Yes Independent Health Association OutshyNetwork

MVP Health CareshyHigh

MVP Health CareshyStandard









3030

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

30

$500

$750

$500

$750

$500

$750

$500

$750

$500

$750

NA

$5

$5

$5

$5

$5

$5

$5

$5

$5

$5

NA

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

739

739

739

739

739

739

739

739

739

739

934

934

934

934

934

934

934

934

934

934

89

89

89

89

89

89

89

89

89

89

962

962

962

962

962

962

962

962

962

962

896

896

896

896

896

896

896

896

896

896

92

92

92

92

92

92

92

92

92

92

768

768

768

768

768

768

768

768

768

768

61


North Carolina

Aetna Value Planshy All of North Carolina 877shy459shy6604 F54 F55 13058 29656 6027 13687

North Dakota

Aetna Value Planshy Most of North Dakota 877shy459shy6604 H44 H45 13093 29732 6043 13722

HealthPartners High Option shy Eastern North Dakota 800shy883shy2177 V31 V32 26865 64982 12399 29992

HealthPartners Standard Option shyEastern North Dakota 800shy883shy2177 V34 V35 8897 20464 4106 9445

Sanford Heart of America Health Plan shyHighshy Northcentral North Dakota 800shy525shy5661 RU1 RU2 13803 47086 6371 21732

Sanford Health Plan shyHighshy North Dakota 800shy752shy5863 C91 C92 20976 51441 9681 23742

Sanford Health Plan shyStdshy North Dakota 800shy752shy5863 C94 C95 14143 45836 6528 21155

Ohio

Aetna Value Planshy All of Ohio 877shy459shy6604 JS4 JS5 17258 41140 7965 18988

AultCare HMO shyHighshy StarkCarrollHolmesTuscarawasWayne Co 330shy363shy6360 3A1 3A2 14204 44676 6556 20620

Humana Health Plan of Ohio shyHighshy Greater Cincinnati Area 888shy393shy6765 A61 A62 13880 30882 6406 14253

Humana Health Plan of Ohio shyStdshy Greater Cincinnati Area 888shy393shy6765 A64 A65 12491 27794 5765 12828

HealthSpan Integrated Care shyHighshy ClevelandAkron areas 800shy686shy7100 641 642 28758 69344 13273 32005

HealthSpan Integrated Care shyStdshy ClevelandAkron areas 800shy686shy7100 644 645 13114 30163 6052 13921

The Health Plan of the Upper Ohio Valley shyHighshy Eastern Ohio 800shy624shy6961 U41 U42 26271 60855 12125 28087

Oklahoma

Aetna Value Planshy All of Oklahoma 877shy459shy6604 JS4 JS5 17258 41140 7965 18988

Globalhealth Inc shyHighshy Oklahoma 877shy280shy5600 IM1 IM2 11810 28460 5451 13135


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



62


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

North Carolina


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649


North Dakota


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No




Sanford Heart of America Health Plan InshyNetwork

4040

$25$45

$0 for 3 then 20

$15$25

40

Nothing

20 in40 out

None

50+

$12

$9

50$600ded

50+50+

$45$90

$40$70

50$600 ded

No

Yes

Yes

None

647

647

893

893

875

875

951

951

92

92

911

911

725

725

Sanford Heart of America Health Plan OutshyNetwork


2020

$20$30

20

$100day x 5

NA

$15

NA

$30$50

NA



4040

$25$25

40

$100day x 5

40+

$15

40+40+

$30$50

NA


Ohio


40+40+

$25$40

40+

20

40+

$10

40+40+

30to$60050 to$1200

NA


AultCare HMOshyHigh



HealthSpan Integrated CareshyHigh

HealthSpan Integrated CareshyStandard

The Health Plan of the Upper Ohio ValleyshyHigh

Oklahoma


4040

$15$20

$20$35

$25$40

$20$20

$30$40

$10$20

$25$40

40

$150

$250day x 3

$500day x 3

$250

$500

$250

20

50+

$15

$10

$10

$10

$15

$15

$10

50+50+

$30$40$55

$40$60

$40$60

$30$30

$40$40

$30$50

30to$60050 to$1200

No

No

Yes

Yes

Yes

Yes

Yes

Yes

877

788

788

744

922

845

845

909

907

889

889

876

941

922

922

951

944

935

935

929

935

906

906

944

853

708

708

745


Globalhealth IncshyHigh

4040

$15$45

40

$250dymx1000

50+

$4$10

50+50+

$45$70

No

Yes 592 816 839 916 893 872 727

63


Oregon

Aetna Value Planshy Most of Oregon 877shy459shy6604 H44 H45 13093 29732 6043 13722

Kaiser Foundation Health Plan of Northwest shyHighshy PortlandSalem areas 800shy813shy2000 571 572 22672 52645 10464 24298

Kaiser Foundation Health Plan of Northwest shyStdshy PortlandSalem areas 800shy813shy2000 574 575 13617 31283 6285 14438

Pennsylvania

Aetna Value Planshy All of Pennsylvania 877shy459shy6604 H44 H45 13093 29732 6043 13722

Aetna Open Access shyHighshy Philadelphia 877shy459shy6604 P31 P32 64801 164359 29908 75858

Aetna Open Access shyBasicshy Philadelphia 877shy459shy6604 P34 P35 49560 118027 22874 54474

Aetna Open Access shyHighshy Pittsburgh and Western PA Areas 877shy459shy6604 YE1 YE2 19203 59806 8863 27603

Geisinger Health Plan shyStdshy NortheasternCentralSouth Central areas 800shy447shy4000 GG4 GG5 16820 41884 7763 19331

HealthAmerica Pennsylvania shyHighshy Greater Pittsburgh Area 866shy351shy5946 261 262 17814 47183 8222 21777

UPMC Health Plan shyHighshy Western Pennsylvania 888shy876shy2756 8W1 8W2 22135 54101 10216 24970

UPMC Health Plan shyStdshy Western Pennsylvania 888shy876shy2756 UW4 UW5 13345 30692 6159 14166

Puerto Rico

Humana Health Plans of Puerto Rico Inc shyHighshy Puerto Rico 800shy314shy3121 ZJ1 ZJ2 8026 18317 3704 8454

TripleshyS Salud Inc shyHighshy All of Puerto Rico 787shy774shy6060 891 892 8829 19866 4075 9169

Rhode Island

Aetna Value Planshy All of Rhode Island 877shy459shy6604 EP4 EP5 12694 28827 5859 13305

South Carolina

Aetna Value Planshy All of South Carolina 877shy459shy6604 JS4 JS5 17258 41140 7965 18988


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



64


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Information

on Costs

Oregon


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649


Kaiser Foundation HP of NorthwestshyHigh

Kaiser Foundation HP of NorthwestshyStandard

Pennsylvania


4040

$20$30

$30$40

$25$40

40

$200

$500

20

50+

$15

$20

$10

50+50+

$40$60

$40$60

30to$60050 to$1200

No

Yes

Yes

Yes

768

768

844

844

847

847

916

916

927

927

89

89

683

683





Geisinger Health PlanshyStandard

HealthAmerica PennsylvaniashyHigh

UPMC Health PlanshyHigh

UPMC Health PlanshyStandard

Puerto Rico

Humana Health Plans of PR InshyNetwork

4040

$20$35

$15$35

$20$35

$20$35

$25$50

10 after Deduct

20 after Deduct

$5$5

40

$250day x 4

20 Plan Allow

$250day x 4

20aftrDeduct

15 after ded

10 after deduct

20after Deduct

None

50+

$10

$5

$10

30 $5$15

$5

$5 after ded

$5 after ded

$250

50+50+

$35$100

$35$100

$35$100

$35$60

$35$75

$35$75$100

$10$15

40 $40$120 50 $85$250

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

579

579

579

668

699

754

754

806

861

861

861

868

873

908

908

803

835

835

835

85

885

899

899

82

935

935

935

938

957

97

97

938

887

887

887

906

86

913

913

887

899

899

899

902

921

904

904

70

631

631

631

677

671

678

678

541 Humana Health Plans of PR OutshyNetwork $10$10 $50 NA NA

Greater of $15 or Yes

TripleshyS Salud Inc InshyNetwork TripleshyS Salud Inc OutshyNetwork

Rhode Island


$750$10

$25$40

$750 amp 10 +$10 amp 10 +

None 10 +

20

$5 or $12 NA

$10

NANA

2025 up to$100$175max

30to$60050 to$1200

Yes No

Yes

691 874 844 963 872 75 586


South Carolina


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No

Yes Aetna Value Plan OutshyNetwork 4040 40 50+ 50+50+ No

65


South Dakota

Aetna Value Planshy Rapid CitySioux Falls Area 877shy459shy6604 G54 G55 12822 29119 5918 13440

HealthPartners High Option shy Eastern South Dakota 800shy883shy2177 V31 V32 26865 64982 12399 29992

HealthPartners Standard Option shyEastern South Dakota 800shy883shy2177 V34 V35 8897 20464 4106 9445

Sanford Health Plan shyHighshy EasternCentralRapid City Areas 800shy752shy5863 AU1 AU2 26173 63455 12080 29287

Sanford Health Plan shyStdshy EasternCentralRapid City Areas 800shy752shy5863 AU4 AU5 23647 57594 10914 26582

Tennessee

Aetna Value Planshy Most of Tennessee 877shy459shy6604 F54 F55 13058 29656 6027 13687

Aetna Open Access shyHighshy Memphis Area 877shy459shy6604 UB1 UB2 24581 76516 11345 35315

Humana Health Plan Inc shyHighshy Knoxville 888shy393shy6765 GJ1 GJ2 15825 35210 7304 16251

Humana Health Plan Inc shyStdshy Knoxville 888shy393shy6765 GJ4 GJ5 12491 27794 5765 12828


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



66


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

South Dakota


HMOPOS National Average

30to$60050 to$1200 Yes

679 864 849 942 877 875 649





4040

$25$45

$20$30

$0 for 3 then 20

40

Nothing

$100day x 5

20 in40 out

50+

$12

$9

$15

50+50+

$45$90

$40$70

$30$50

No

Yes

Yes

NA

647

647

535

893

893

903

875

875

89

951

951

977

92

92

902

911

911

912

725

725



4040

$25$25

40

$100day x 5

40+

$15

40+40+

$30$50

NA

NA

535

535 903 89 977 902 912 558 Sanford Health Plan OutshyNetwork

Tennessee


40+40+

$25$40

40+

20

40+

$10

40+40+

30to$60050 to$1200

NA





4040

$20$35

$20$35

$25$40

40

$250day x 4

$250day x 3

$500day x 3

50+

$10

$10

$10

50+50+

$35$100

$40$60

$40$60

No

Yes

Yes

Yes

66 875 868 959 889 914 69

67


Texas

Aetna Value Planshy All of Texas 877shy459shy6604 JS4 JS5 17258 41140 7965 18988

Aetna Whole Health shyBasicshy Houston Area 877shy459shy6604 ES1 ES2 12817 40332 5916 18615

Firstcare shyHighshy Waco area 800shy884shy4901 B71 B72 11057 37880 5103 17483

Firstcare shyHighshy West Texas 800shy884shy4901 CK1 CK2 10809 34896 4989 16106

Firstcare shyHighshy TaylorCallahanEastland 800shy884shy4901 CN1 CN2 13391 65886 6180 30409

Firstcare shyHighshy Lubbock area 800shy884shy4901 CZ1 CZ2 13031 61566 6014 28415

Firstcare shyHighshy BryanCollege Station Area 800shy884shy4901 ET1 ET2 12638 56836 5833 26232

Humana Value Plan shy Corpus Christi Area 888shy393shy6765 TP4 TP5 10247 22697 4729 10476

Humana Value Plan shy San Antonio Area 888shy393shy6765 TU4 TU5 10247 22697 4729 10476

Humana Value Plan shy Austin Area 888shy393shy6765 TV4 TV5 10247 22697 4729 10476

Humana Health Plan of Texas shyHighshy Houston 888shy393shy6765 EW1 EW2 13880 30882 6406 14253

Humana Health Plan of Texas shyStdshy Houston 888shy393shy6765 EW4 EW5 12491 27794 5765 12828

Humana Health Plan of Texas shyHighshy Corpus Christi 888shy393shy6765 UC1 UC2 17899 39821 8261 18379

Humana Health Plan of Texas shyStdshy Corpus Christi 888shy393shy6765 UC4 UC5 13880 30882 6406 14253

Humana Health Plan of Texas shyHighshy San Antonio 888shy393shy6765 UR1 UR2 55020 122416 25394 56500

Humana Health Plan of Texas shyStdshy San Antonio 888shy393shy6765 UR4 UR5 13880 30882 6406 14253

Humana Health Plan of Texas shyHighshy Austin 888shy393shy6765 UU1 UU2 26524 59015 12242 27238

Humana Health Plan of Texas shyStdshy Austin 888shy393shy6765 UU4 UU5 15825 35210 7304 16251

Scott amp White Health Plan shyStdshy Central TX amp Some SE and SW Counties 800shy321shy7947 A84 A85 14907 37260 6880 17197

UnitedHealthcare Benefits of Texas Inc shyHighshy San Antonio 866shy546shy0510 GF1 GF2 32515 78160 15007 36074


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



68


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Texas


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649


Aetna Whole Health InshyNetwork

4040

$5$25$35

40

15

50+

$5

50+50+

$35$60

No

Yes Aetna Whole Health OutshyNetwork

FirstcareshyHigh

FirstcareshyHigh

FirstcareshyHigh

FirstcareshyHigh

FirstcareshyHigh


4040

$30$55

$30$55

$30$55

$30$55

$30$55

$35$55

40

$250day x 5

$250day x 5

$250day x 5

$250day x 5

$250day x 5

20

40

$10

$10

$10

$10

$10

$10

4040

$35$70

$35$70

$35$70

$35$70

$35$70

$40$60

No

Yes

Yes

Yes

Yes

Yes



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No


Humana Health Plan of TexasshyHigh

Humana Health Plan of TexasshyStandard







Scott amp White Health PlanshyStandard

UnitedHealthcare Benefits of Texas IncshyHigh

5050

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$45

$20$40

50

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

10

$250day x 5

$10+

$10

$10

$10

$10

$10

$10

$10

$10

$5

$10

$40+$60+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$45$100

$35$60

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

63

63

702

835

835

862

764

764

863

931

931

937

864

864

875

856

856

87

673

673

569

69



Enrollment Code

Monthly Biweekly


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Aetna Value Planshy Most of Utah 877shy459shy6604 G54 G55 12822 29119 5918 13440

Altius Health Plans shyHighshy Wasatch Front 800shy377shy4161 9K1 9K2 19819 42542 9147 19635

Altius Health Plans shyStdshy Wasatch Front 800shy377shy4161 DK4 DK5 11798 25954 5445 11979

SelectHealth shyHighshy Urban and Suburban Utah 800shy538shy5038 SF1 SF2 19210 43095 8866 19890

SelectHealth shyStdshy Urban and Suburban Utah 800shy538shy5038 SF4 SF5 12435 27741 5739 12803

Aetna Value Planshy All of Vermont 877shy459shy6604 EP4 EP5 12694 28827 5859 13305

TripleshyS Salud Inc shyHighshy US Virgin Islands 800shy981shy3241 851 852 10305 23402 4756 10801

Vermont

Virgin Islands

Utah


70


Prescription Drugs


Mail lan

eeded

are

ll icate

r ng rm

ation




order discount

Ove

rall p

satisfaction

Gettin

g n

care

Gettin

g c

quickly

How

we

doctors

commun

Custome

service

Claim

sproce

ssi

Plan

Info

on

Costs

Utah


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649


Altius Health PlansshyHigh $20$30 $200 $7 $25$50 No 552 852 813 948 883 895 588

Altius Health PlansshyStandard $20$40 None $7 $35$60 None 552 852 813 948 883 895 588

SelectHealthshyHigh $15$25 $100 $5$25$50 $25$50$50 Yes 629 876 851 958 912 903 64


Vermont


$20$30

$25$40

$100 after

20

$5$25$50

$10

$25 $50$50

30to$60050 to$1200

Yes

Yes

629 876 851 958 912 903 64


Virgin Islands

4040 40 50+ 50+50+ No

Greater of $15 or TripleshyS Salud Inc InshyNetwork TripleshyS Salud Inc OutshyNetwork

$750$10 $750 amp 10 + $10 amp 10 +

None 10 +

$5 or $12 NA NANA

2025 up to$100$175max

Yes No

691 874 844 963 872 75 586

71


Virginia

Aetna Value Planshy Most of Virginia 877shy459shy6604 F54 F55 13058 29656 6027 13687

Aetna Open Access shyHighshy NorthernCentralRichmond Virginia Areas 877shy459shy6604 JN1 JN2 46867 105610 21631 48743

Aetna Open Access shyBasicshy NorthernCentralRichmond Virginia Areas 877shy459shy6604 JN4 JN5 14021 31351 6471 14470

Aetna Whole Health shyBasicshy Roanoke VA area 877shy459shy6604 D91 D92 12138 40332 5602 18615

Aetna Whole Health shyBasicshy Newport News VA area 877shy459shy6604 J91 J92 11280 29365 5206 13553

CareFirst BlueChoice shyHighshy Northern Virginia 888shy789shy9065 2G1 2G2 21177 48693 9774 22474

CareFirst BlueChoice shyStdshy Northern Virginia 888shy789shy9065 2G4 2G5 15284 35429 7054 16352

HealthKeepers Inc shyHighshy Virginia 855shy580shy1200 A91 A92 20427 47008 9428 21696

Kaiser Foundation Health Plan MidshyAtlantic States shyHighshy Northern VirginiaFredericksburg area 877shy574shy3337 E31 E32 16926 42124 7812 19442

Kaiser Foundation Health Plan MidshyAtlantic States shyStdshy Northern VirginiaFredericksburg area 877shy574shy3337 E34 E35 9646 22186 4452 10240

MD IPA shyHighshy Northern Viginia 877shy835shy9861 JP1 JP2 20245 50123 9344 23134

Optima Health Plan shyHighshy Hampton Roads and Richmond areas 800shy206shy1060 9R1 9R2 26858 69565 12396 32107

Optima Health Plan shyStdshy Hampton Roads and Richmond areas 800shy206shy1060 9R4 9R5 11269 26665 5201 12307

Piedmont Community Healthcare shyHighshy Lynchburg area 888shy674shy3368 2C1 2C2 12235 28017 5647 12931

Washington

Aetna Value Planshy Most of Washington 877shy459shy6604 G54 G55 12822 29119 5918 13440

Aetna Open Access shyHighshy Seattle and Spokane areas 877shy459shy6604 C31 C32 14933 62274 6892 28742

Group Health Cooperative shyHighshy Western WACentral WASpokanePullman 888shy901shy4636 541 542 27070 55009 12494 25389

Group Health Cooperative shyStdshy Western WACentral WASpokanePullman 888shy901shy4636 544 545 11742 26509 5419 12235

KPS Health Plans shyStdshy All of Washington 800shy552shy7114 L11 L12 12426 26823 5735 12380

KPS Health Plans shyHighshy All of Washington 800shy552shy7114 VT1 VT2 31651 67459 14608 31135

Kaiser Foundation Health Plan of Northwest shyHighshy VancouverLongview 800shy813shy2000 571 572 22672 52645 10464 24298

Kaiser Foundation Health Plan of Northwest shyStdshy VancouverLongview 800shy813shy2000 574 575 13617 31283 6285 14438


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



72


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Virginia

Aetna Value Plan InshyNetwork Aetna Value Plan OutshyNetwork



Aetna Whole Health InshyNetwork Aetna Whole Health OutshyNetwork




$25$40 4040

$15$30

$20$35

$25$35 4040

$5$25$35 4040

$25$35

Nothing$35

20 40

$150day x3

10 Plan Allow

15 40

15 40

$200

$200

$10 50+

$5

$10

$5 40

$5 40

Nothing

Nothing

HMOP

50+50+

$35$100

$35$100

$35$60 4040

$35$60 4040

$35$65

$35$65

30to$60050 to$1200

OS National

Yes No

Yes

Yes

Yes No

Yes No

Yes

Yes

Average

69

69

648

648

679

844

844

86

86

864

872

872

833

833

849

942

942

925

925

942

865

865

846

846

877

914

914

902

902

875

567

567

54

54

649

CareFirst BlueChoice OutshyNetwork

HealthKeepers IncshyHigh



MD IPAshyHigh

Optima Health PlanshyHigh

Optima Health PlanshyStandard

Piedmont Community HealthcareshyHigh

Washington





KPS Health Plans InshyNetwork KPS Health Plans OutshyNetwork




$70$70

$10$20

$20$30

$25$40

$25$30

$35$35

$25$40 4040

$20$35

$25$25

$25$35

$154 or 2020

$30$30 $30+40+diff

$20$30

$30$40

$0$3530 NonshyNetwork

$20$0childlt22$30

$154+40+diff 40+diff

$500

$200 x3 days

$100

$250dayx3

$150day x 3

$150max$750

$20020

20

20 40

$250day x 4

$350

$500

Nothing Nothing

None None

$200

$500

Nothing

$0

$7$17 Net

$12$22Net

$7

$10

$10

$15

$10 50+

$10

$20

$20

$10 Not Covered

$5 Not Covered

$15

$20

$35$65

$30$50$50

$30$50$45$65

$35$55$50$70

$30$60

$40$55

50+50+

$35$100

$40$60

$40$60

Not Covered

NA

$40$60

$40$60

$353050up to $3000

$355050 up to $3000

$35$50 30day $100 90day

$25$50 30day$100 90day

30to$60050 to$1200

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes No

Yes

Yes

Yes

Yes No

Yes No

Yes

Yes

83

83

583

692

692

659

659

798

798

768

768

867

867

846

864

864

86

86

94

94

844

844

833

831

831

876

886

886

869

869

928

928

847

847

927

927

937

969

969

941

941

957

957

916

916

813

813

867

87

87

912

912

931

931

927

927

836

836

841

916

916

881

881

897

897

89

89

702

702

677

674

674

692

692

65

65

683

683

73


West Virginia

Aetna Value Planshy Most of West Virginia 877shy459shy6604 F54 F55 13058 29656 6027 13687

The Health Plan of the Upper Ohio Valley shyHighshy NorthernCentral West Virginia 800shy624shy6961 U41 U42 26271 60855 12125 28087

Wisconsin

Aetna Value Planshy All of Wisconsin 877shy459shy6604 JS4 JS5 17258 41140 7965 18988

Aetna Whole Health shyBasicshy Milwaukee WI Area 877shy459shy6604 F71 F72 10600 29208 4892 13481

Dean Health Plan shyHighshy South Central Wisconsin 800shy279shy1301 WD1 WD2 24382 72670 11253 33540

Group Health Cooperative shyHighshy South Central Wisconsin 800shy605shy4327 WJ1 WJ2 15910 51534 7343 23785

HealthPartners High Option shy Western Wisconsin 800shy883shy2177 V31 V32 26865 64982 12399 29992

HealthPartners Standard Option shy Western Wisconsin 800shy883shy2177 V34 V35 8897 20464 4106 9445

MercyCare HMO shyHighshy South Central Wisconsin 800shy895shy2421 EY1 EY2 14597 48275 6737 22281

Physicians Plus shyHighshy All of WI 800shy545shy5015 LW1 LW2 16556 55954 7641 25825

Wyoming

Aetna Value Plan shyBasicshy All of Wyoming 877shy459shy6604 H44 H45 13093 29732 6043 13722

Altius Health Plans shyHighshy Uinta County 800shy377shy4161 9K1 9K2 19819 42542 9147 19635

Altius Health Plans shyStdshy Uinta County 800shy377shy4161 DK4 DK5 11798 25954 5445 11979


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



74


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

West Virginia


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649



Wisconsin


4040

$10$20

$25$40

40

$250

20

50+

$15

$10

50+50+

$30$50

30to$60050 to$1200

No

Yes

Yes

744 909 876 951 929 944 745



4040

$25$35

40

15

50+

$5

50+50+

$35$60

No


Dean Health PlanshyHigh

Group Health Cooperative shy High



MercyCare HMOshyHigh

Physicians PlusshyHigh

Wyoming


4040

$25$25

$10$10

$25$45

$0 for 3then 20

$10$10

$10$10

$25$40

40

None

None

Nothing

20 in40 out

Nothing

Nothing

20

40

$10

$5

$12

$9

$10

$10

$10

4040

$20$20

$45$90

$40$70

$20$50

3050

30$75max 50 wmin$50

30to$60050 to$1200

No

Yes

Yes

Yes

Yes

Yes

No

Yes

682

785

647

647

784

601

909

834

893

893

888

857

90

834

875

875

854

822

97

953

951

951

938

96

834

929

92

92

888

863

879

932

911

911

87

866

588

718

725

725

684

686




4040

$20$30

$20$40

40

$200

None

50+

$7

$7

50+50+

$25$50

$35$60

No

No

None

552

552

852

852

813

813

948

948

883

883

895

895

588

588

75


High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement


A High Deductible Health Plan (HDHP) provides comprehensive coverage for highshycost medical events and a taxshyadvantaged way to help you build savings for future medical expenses The HDHP gives you greater flexibility and discretion over how you use your health care benefits

When you enroll your health plan establishes for you either a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA) The plan automatically deposits the monthly ldquopremium pass throughrdquo into your HSA The plan credits an amount into the HRA (This is the ldquoPremium Contribution to HSAHRArdquo column in the following charts)

Preventive care is covered in full As you receive other nonshypreventive medical care you must meet the plan deductible before the health plan pays benefits You can choose to pay your deductible with funds from your HSA or you can choose instead to pay for your deductible outshyofshypocket allowing your savings to continue to grow

The HDHP features higher annual deductibles (a minimum of $1250 for Self Only and $2500 for Self and Family coverage) and annual outshyofshypocket limits (not to exceed $6350 for Self Only and $12700 for Self and Family coverage) than other insurance plans Depending on the HDHP you choose you may have the choice of using InshyNetwork and OutshyofshyNetwork providers There may be higher deductibles and outshyofshypocket limits when you use OutshyofshyNetwork providers Using InshyNetwork providers will save you money

Health Savings Account (HSA)

A Health Savings Account allows individuals to pay for current health expenses and save for future qualified medical expenses on a preshytax basis Funds deposited into an HSA are not taxed the balance in the HSA grows tax free and that amount is available on a tax free basis to pay medical costs You are eligible for an HSA if you are enrolled in an HDHP not covered by any other health plan that is not an HDHP (including a spousersquos health plan but does not include specific injury insurance and accident disability dental care vision care or longshyterm coverage) not enrolled in Medicare not received VA benefits or IHS benefits within the last three months not covered by your own or your spousersquos flexible spending account (FSA) and are not claimed as a dependent on someone elsersquos tax return If you are enrolled in a High Deductible Health Plan with an HSA you may not participate in a Health Care Flexible Spending Account (HCFSA) but you are permitted to participate in a Limited Expense (LEX) HCFSA HSAs are subject to a number of rules and limitations established by the Department of the Treasury

Visit wwwtreasurygovresourceshycenterfaqstaxespageshealthshysavingsshyaccountsaspx for more information The 2014 maximum contribution limits are $3300 for Self Only coverage and $6550 for Self and Family coverage If you are over 55 you can make an additional ldquocatch uprdquo contribution You can use funds in your account to help pay your health plan deductible

76



Features of an HSA include

bull Taxshydeductible deposits you make to the HSA Your own HSA contributions are either taxshydeductible or preshytax (if made by payroll deduction) See IRS Publication 969

bull Taxshydeferred interest earned on the account

bull Taxshyfree withdrawals for qualified medical expenses

bull Carryover of unused funds and interest from year to year

bull Portability the account is owned by you and is yours to keep ndash even when you retire leave government service or change plans

Health Reimbursement Arrangement (HRA)

Health Reimbursement Arrangements are a common feature of ConsumershyDriven Health Plans They may be referred to by the health plan under a different name such as personal care account They are also available to enrollees in High Deductible Health Plans who are not eligible for an HSA HRAs are similar to HSAs except

bull An enrollee cannot make deposits into an HRA

bull A health plan may impose a ceiling on the value of an HRA

bull Interest is not earned on an HRA and

bull The amount in an HRA is not transferable if the enrollee leaves the health plan

If you are enrolled in a High Deductible Health Plan with an HRA you may participate in a Health Care Flexible Spending Account (HCFSA)

The plan will credit the HRA different amounts depending on whether you have a Self Only or a Self and Family enrollment You can use funds in your account to help pay your health plan deductible

Features of an HRA include

bull Taxshyfree withdrawals for qualified medical expenses bull Carryover of unused credits from year to year bull Credits in an HRA do not earn interest bull Credits in the HRA are forfeited if you leave federal employment or switch health

insurance plans

77



ELIGIBILITY

FUNDING


You must enroll in a High Deductible Health Plan (HDHP) No other general medical insurance coverage is permitted You cannot be enrolled in Medicare Part A or Part B You cannot be claimed as a dependent on someone elsersquos tax returns

The plan deposits a monthly ldquopremium pass throughrdquo into your account


You must enroll in a High Deductible Health Plan (HDHP)

The plan deposits the credit amount directly into your account

CONTRIBUTIONS

DISTRIBUTIONS

The maximum allowed is a combination of the health plan ldquopremium pass throughrdquo and the member contribution up to the maximum contribution amount set by the IRS each year

May be used to pay the outshyofshypocket medical expenses for yourself your spouse or your dependents (even if they are not covered by the HDHP) or to pay the planrsquos deductible

See IRS Publication 502 for a complete list of eligible expenses

Only that portion of the premium specified by the health plan will be contributed You cannot add your own money to an HRA

May be used to pay the outshyofshypocket expenses for qualified medical expenses for individuals covered under the HDHP or to pay the planrsquos deductible


ANNUAL ROLLOVER

PORTABLE Yes you can take this account with you when you change plans separate from service or retire

Yes funds accumulate without a maximum cap

If you retire and remain in your 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 that HDHP will be eligible for reimbursement subject to timely filing requirements Unused credits are forfeited

Yes credits accumulate without a maximum cap

IMPORTANT REMINDER This is only a summary of the features of the HDHPHSA or HRA Refer to the specific Plan brochure for the complete details covering Plan design operation and administration as each Plan will have differences

78




A ConsumershyDriven plan provides you with freedom in spending health care dollars the way you want The typical plan has features such as member responsibility for certain upshyfront medical costs an employershyfunded account that you may use to pay these upshyfront costs and catastrophic coverage with a high deductible You and your family receive full coverage for InshyNetwork preventive care

79



The tables on the following pages highlight what you are expected to pay for selected features under each plan The charts are not a complete statement of your outshyofshypocket obligations in every individual circumstance Unlike many regular medical plans the covered outshyofshypocket expenses under a High Deductible Health Plan including office visit copayments and prescription drug copayments count toward the calendar year deductible and the catastrophic limit You must read the planrsquos brochure for details

Premium Contribution (pass through) to HSAHRA (or personal care account) shows the amount your health plan automatically deposits or credits into your account on a monthly basis for Self OnlySelf and Family enrollments (ConsumershyDriven Health Plans credit accounts annually) The amount credited under ldquoPremium Contributionrdquo is shown as a monthly amount for comparison purposes only

Calendar Year (CY) Deductible SelfFamily is the maximum amount of covered expenses an individual or family must pay outshyofshypocket including deductibles coinsurance and copayments before the plan pays catastrophic benefits

Catastrophic (Cat) Limit SelfFamily is the maximum amount of covered expenses an individual or family must pay outshyofshypocket including deductibles and coinsurance and copays before the Plan pays catastrophic benefits

Office Visit shows what you pay for a visit to a primary care physician after the deductible is met for other than preventive care

Inpatient Hospital shows what you pay after the deductible is met for hospital services when an inpatient The amount could be a daily copayment up to a specified amount (eg $50 a day up to three days) a coinsurance amount such as


Plan Name Telephone Number

Enrollment Code Monthly Biweekly

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

APWU Health Plan shyCDHPshy Nationwide

GEHA High Deductible Health Plan shyHDHPshy Nationwide

MHBP shy Consumer Option shyHDHPshy Nationwide

NALC shyCDHPshy Nationwide

800shy718shy1299

800shy821shy6136

800shy694shy9901

888shy636shy6252

474 475

341 342

481 482

324 325

9742

11021

13642

10454

21915

25172

30912

22700

4496 10115

5087 11618

6296 14267

4825 10477


80



20 or a flat deductible amount (eg $200 per admission) This amount does not include charges from physicians or for services that may not be charged by the hospital such as laboratory or radiology

Outpatient Surgery shows what you pay the doctor for surgery performed on an outpatient basis

Preventive Services are often covered in full usually with no or only a small deductible or copayment Preventive services may also be payable up to an annual maximum dollar amount (eg up to $300 per person per year)

Prescription Drug Payment Levels Plans use terms such as Level (L I L II) or Tier (T1 T2) to show what you pay for generic or brand name prescription drugs The payment levels that plans use follow L I or Tier 1 includes generic drugs but may include some preferred brands L II or Tier 2 includes preferred brands and may include some generics L III or Tier 3 includes nonshypreferred brands other covered drugs and with some exceptions specialty drugs L IV or Tier 4 includes mostly preferred specialty drugs L V or Tier 5 generally includes nonshypreferred specialty drugs

High Deductible Health Plans and ConsumershyDriven Health Plans are much different from the other types of plans shown in this Guide You can use inshynetwork providers to save money If you use outshyofshynetwork providers however you not only pay more of the costs but you are also usually responsible for any difference between the amount billed for a service and what the plan actually allows (For example you receive a bill from an outshyofshynetwork provider for $100 but the plan allows $85 for the service You pay the higher copayment for outshyofshynetwork care plus the $15 difference between $100 ndash the billed amount ndash and the planrsquos allowance of $85) In addition the difference you pay between the billed amount and the planrsquos allowance does not count toward satisfying the catastrophic limit

Plan Name Benefit Premium CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Type Contribution SelfFamily SelfFamily Visit Hospital Surgery Services Drugs

SelfFamily Levels I II III

APWU Health Plan InshyNetwork $1200$2400 $600$1200 $3000$4500 15 None 15 Nothing 252525 APWU Health Plan OutshyNetwork $1200$2400 $600$1200 $9000$9000 40+diff None 40+diff Nothing up to $1200 Not Covered

GEHA HDHP InshyNetwork $6250$125 $1500$3000 $5000$10000 5 5 5 Nothing 252525 GEHA HDHP OutshyNetwork $6250$125 $1500$3000 $5000$10000 25 25 25 Ded25 25+25+25+

MHBP shy Consumer Option InshyNetwork $70$141 $2000$4000 $5000$10000 $15 $75 dayshy$750 Nothing Nothing $10$25$40 MHBP shy Consumer Option OutshyNetWork $70$141 $2000$4000 $7500$15000 40 40 40 Not Covered Not Covered

NALC InshyNetwork $1200$2400 $2000$4000 $4000$8000 20 20 20 Nothing $10$40$60 NALC OutshyNetwork $1200$2400 $4000$8000 $8000$16000 50 50 50 50 505050+

81

High Deductible Health Plans and ConsumershyDriven Health Plan Member Survey Results










High Deductible Health Plans Plan Name


Plan Code


Getting needed care


How well doctors


Claims processing


HDHP National Average 614 885 866 929 860 876 585

Aetna HealthFund shy Nationwide

GEHA High Deductible Health Plan shy Nationwide

Mail Handlers Benefit Plan Consumer Option shy Nationwide

22

34

48

606

623

614

891

873

891

888

851

859

952

923

912

830

863

887

879

865

885

563

602

590

ConsumershyDriven Health Plans Plan Name

Plan Code


Getting needed care


How well doctors


Claims processing


CDHP National Average 579 881 865 939 850 847 585


APWU Health Plan shy Nationwide

Humana CoverageFirst shy TX

Humana Coverage First shy IN

22

47

TP TU TV

MW

606

664

566

478

891

909

849

875

888

907

864

801

952

925

932

948

830

871

843

856

879

845

853

812

563

680

542

555

82


83

High Deductible and ConsumershyDriven Health Plans See pages 80shy81 for an explanation of the columns on these pages


Plan Name

Telephone Number


Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Aetna HealthFund shyHDHPshy All 50 States and DC 877shy459shy6604 224 225 11856 25965 5472 11984


Alabama

Aetna HealthFund shyCDHPshy Most of Alabama

Alaska

Aetna HealthFund shyCDHPshy Most of Alaska

Arizona

Aetna HealthFund shyCDHPshy All of Arizona

Arkansas

Aetna HealthFund shyCDHPshy Most of Arkansas

California

Aetna HealthFund shyCDHPshy Most of California

Colorado

Aetna HealthFund shyCDHPshy All of Colorado

Plan Name

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

Telephone Number


F51

JS1

G51

F51

JS1

G51

Self only

F52

JS2

G52

F52

JS2

G52

Self amp family

16322

22787

21977

16322

22787

21977

Self only

39021

53701

51861

39021

53701

51861

Self amp family

7533

10517

10143

7533

10517

10143

Self only

18010

24785

23936

18010

24785

23936

Self amp family


84

Benefit Type

Premium Contribution to HSAHRA

CY Ded SelfFamily

Cat Limit SelfFamily

Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III Plan Name

Aetna HealthFund HDHP InshyNetwork $6250$125 $1500$3000 $4000$8000 10 10 10 Nothing $10$35$60 Aetna HealthFund HDHP OutshyNetwork $6250$125 $2500$5000 $5000$10000 30 30 30 Ded30 30+30+30+

Alabama

Aetna HealthFund CDHP Aetna HealthFund CDHP

Alaska


Arizona


Arkansas


California

AAetna HealthFund CDHP Aetna HealthFund CDHP

Colorado


Plan Name

InshyNetwork OutshyNetwork






Benefit Type

$8333$16666 $8333$16666

$8333$16666 $8333$16666

$8333$16666 $8333$16666

$8333$16666 $8333$16666

$8333$16666 $8333$16666

$8333$16666 $8333$16666


$1000$2000 $1000$2000

$1000$2000 $1000$2000

$1000$2000 $1000$2000

$1000$2000 $1000$2000

$1000$2000 $1000$2000

$1000$2000 $1000$2000

CY Ded SelfFamily

$4000$8000 $5000$10000

$4000$8000 $5000$10000

$4000$8000 $5000$10000

$4000$8000 $5000$10000

$4000$8000 $5000$10000

$4000$8000 $5000$10000


15 40

15 40

15 40

15 40

15 40

15 40

Office Visit

15 40

15 40

15 40

15 40

15 40

15 40

Inpatient Hospital

15 40

15 40

15 40

15 40

15 40

15 40

Outpatient Surgery

Nothing FundDed40

Nothing FundDed40

Nothing FundDed40

Nothing FundDed40

Nothing FundDed40

Nothing FundDed40

Preventive Services

$10$35$60 40+40+40+

$10$35$60 40+40+40+

$10$35$60 40+40+40+

$10$35$60 40+40+40+

$10$35$6 40+40+40+

$10$35$60 40+40+40+

Prescription Drugs

Levels I II III

85



Connecticut

Aetna HealthFund shyCDHPshy All of Connecticut

Delaware

Aetna HealthFund shyCDHPshy All of Delaware


Aetna HealthFund shyCDHPshy All of Washington DC

CareFirst BlueChoice shyHDHPshy Washington DC Metro Area

Florida

Aetna HealthFund shyCDHPshy Most of Florida

Coventry Health Plan of Florida shyHDHPshy Southern Florida

Humana CoverageFirst shyCDHPshy Tampa Area

Humana CoverageFirst shyCDHPshy South Florida Area

Georgia

Aetna HealthFund shyCDHPshy All of Georgia

Humana CoverageFirst shyCDHPshy Atlanta Area

Humana CoverageFirst shyCDHPshy Macon Area

Guam

TakeCare shyHDHPshy GuamN Mariana IslandsBelau (Palau)

Plan Name

877shy459shy6604

877shy459shy6604

877shy459shy6604

888shy789shy9065

877shy459shy6604

800shy441shy5501

888shy393shy6765

888shy393shy6765

877shy459shy6604

888shy393shy6765

888shy393shy6765

671shy647shy3526

Telephone Number


EP1

EP1

F51

B61

F51

J41

MJ1

QP1

F51

AD1

LM1

KX1

Self only

EP2

EP2

F52

B62

F52

J42

MJ2

QP2

F52

AD2

LM2

KX2

Self amp family

20174

20174

16322

14018

16322

13979

12818

10987

16322

11598

12208

6822

Self only

47770

47770

39021

31268

39021

43929

28521

24447

39021

25804

27163

17900

Self amp family

9311

9311

7533

6470

7533

6452

5916

5071

7533

5353

5634

3148

Self only

22048

22048

18010

14431

18010

20275

13163

11283

18010

11910

12537

8261

Self amp family


86

Connecticut

Aetna HealthFund CDHP InshyNetwork $8333$16666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFund CDHP OutshyNetwork $8333$16666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+

Delaware




CareFirst BlueChoice InshyNetwork $3750$7500 $1500$3000 $4000$8000 Nothing $300 Nothing Nothing Nothing$30$60 CareFirst BlueChoice OutshyNetwork $3750$7500 $3000$6000 $6000$12000 $70 $500 $70 Nothing Nothing$30$60

Florida


Coventry Health Plan of Florida $8334$16667 $2500$5000 $5000$10000 $10 Ded+20 Ded+20 Nothing $5$35$5020

Humana CoverageFirst InshyNetwork $8333 $1000$2000 $4000$8000 $25 10 10 Nothing $10$40$60 Humana CoverageFirst OutshyNetwork NA $3000$6000 $7000$14000 40 40 40 30 $10+$40+$60+


Georgia




Guam

TakeCare InshyNetwork $8666$22208 $3000$6000 $5000$10000 20 after Ded 20 after Ded 20 after Ded Nothing $20$40$150 TakeCare OutshyNetwork $8666$22208 $3000$6000 $10000$20000 30 after Ded 30 after Ded 30 after Ded 1st $300ded

Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

30 after Ded30 after Ded 30 after Ded

87



Hawaii Aetna HealthFund shyCDHPshy All of Hawaii

Idaho

Aetna HealthFund shyCDHPshy Most of Idaho

Altius Health Plans shyHDHPshy Southern Region

Illinois

Aetna HealthFund shyCDHPshy Most of Illinois

Humana CoverageFirst shyCDHPshy Central Illinois

Humana CoverageFirst shyCDHPshy Chicago Area

Indiana

Aetna HealthFund shyCDHPshy All of Indiana

Humana CoverageFirst shyCDHPshy LakePorterLaPorte Counties

Iowa

Aetna HealthFund shyCDHPshy All of Iowa

Coventry Health Care of Iowa shyHDHPshy CentralEasternWestern Iowa

Kansas

Aetna HealthFund shyCDHPshy Most of Kansas

Coventry Health Care of Kansas shy Kansas City Metro Area

Humana CoverageFirst shyCDHPshy Kansas City Area

Plan Name

877shy459shy6604

877shy459shy6604

800shy377shy4161

877shy459shy6604

888shy393shy6765

888shy393shy6765

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy257shy4692

877shy459shy6604

800shy969shy3343

888shy393shy6765

Telephone Number


JS1

H41

9K4

H41

GB1

MW1

JS1

MW1

H41

SV4

G51

9H1

PH1

Self only

JS2

H42

9K5

H42

GB2

MW2

JS2

MW2

H42

SV5

G52

9H2

PH2

Self amp family

22787

16237

8704

16237

12208

12208

22787

12208

16237

8970

21977

12747

10987

Self only

53701

38826

18033

38826

27163

27162

53701

27162

38826

21408

51861

29956

24447

Self amp family

10517

7494

4017

7494

5634

5634

10517

5634

7494

4140

10143

5883

5071

Self only

24785

17920

8323

17920

12537

12536

24785

12536

17920

9880

23936

13826

11283

Self amp family


88

Hawaii Aetna HealthFund CDHP InshyNetwork $8333$16666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFund CDHP OutshyNetwork $8333$16666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+

Idaho


Altius Health Plans $5208$10415 $1250$2500 $5000$10000 $20 10 10 Nothing $7$25$50

Illinois




Indiana



Iowa


Coventry Health Care of Iowa $8333$16666 $2100$4200 $5000$10000 25 15 45 Nothing $3 $10$45$70

Kansas


Coventry Health Care of Kansas (Kansas City)shyHDHP $6666$13333 $2500$5000 $4000$8000 20 20 20 Nothing 202020


Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

89



Kentucky

Aetna HealthFund shyCDHPshy Most of Kentucky

Humana CoverageFirst shyCDHPshy Lexington Area

Louisiana Aetna HealthFund shyCDHPshy Most of Louisiana

Maine

Aetna HealthFund shyCDHPshy All of Maine

Maryland Aetna HealthFund shyCDHPshy All of Maryland

CareFirst BlueChoice shyHDHPshy All of Maryland

Coventry Health Care HDHPshy All of Maryland

Massachusetts Aetna HealthFund shyCDHPshy Most of Massachusetts

Michigan Aetna HealthFund shyCDHPshy All of Michigan

Minnesota Aetna HealthFund shyCDHPshy Most of Minnesota

Mississippi Aetna Regional CDHPshyMost of Mississippi

Plan Name

877shy459shy6604

888shy393shy6765

877shy459shy6604

877shy459shy6604

877shy459shy6604

888shy789shy9065

800shy833shy7423

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

Telephone Number


H41

6N1

F51

EP1

F51

B61

GZ1

EP1

G51

H41

H41

Self only

H42

6N2

F52

EP2

F52

B62

GZ2

EP2

G52

H42

H42

Self amp family

16237

10987

16322

20174

16322

14018

11980

20174

21977

16237

16237

Self only

38826

24447

39021

47770

39021

31268

26835

47770

51861

38826

38826

Self amp family

7494

5071

7533

9311

7533

6470

5529

9311

10143

7494

7494

Self only

17920

11283

18010

22048

18010

14431

12385

22048

23936

17920

17920

Self amp family


90

Kentucky



Louisiana Aetna HealthFund CDHP InshyNetwork $8333$16666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFund CDHP OutshyNetwork $8333$16666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+

Maine


Maryland Aetna HealthFund CDHP InshyNetwork $8333$16666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFund CDHP OutshyNetwork $8333$16666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+


Coventry Health Care HDHP InshyNetwork $4167$8334 $2000$4000 $4000$8000 Nothing Nothing Nothing Nothing $3$15$30$60 Coventry Health Care HDHP OutshyNetwork $4167$8334 $2000$4000 $4000$8000 30 30 30 30 NANA NA

Massachusetts Aetna HealthFund CDHP InshyNetwork $8333$16666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFund CDHP OutshyNetwork $8333$16666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+

Michigan Aetna HealthFund CDHP InshyNetwork $8333$16666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFund CDHP OutshyNetwork $8333$16666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+

Minnesota Aetna HealthFund CDHP InshyNetwork $8333$16666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFund CDHP OutshyNetwork $8333$16666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+

Mississippi Aetna Regional CDHP InshyNetwork null $1000$2000 $4000$8000 15 15 15 null $10$35$60 Aetna Regional CDHP OutshyNetwork null $1000$2000 $5000$10000 40 40 40 null 4040+40+

Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

91



Missouri Aetna HealthFund shyCDHPshy Most of Missouri


Montana Aetna HealthFund CDHP shy SouthSoutheastWestern MT Areas

Nebraska

Aetna HealthFund shyCDHPshy All of Nebraska

Nevada

Aetna HealthFund shyCDHPshy Las Vegas Area

New Hampshire

Aetna HealthFund shyCDHPshy All of New Hampshire

New Jersey

Aetna HealthFund shyCDHPshy All of New Jersey

New Mexico

Aetna HealthFund shyCDHPshy AlbuquerqueDona AnaHobbs Area

New York Aetna HealthFund shyCDHPshy Most of New York

Independent Health Assoc shyHDHPshy Western New York

Plan Name

Coventry Health Care of Kansas (Kansas City)shyHDHP Kansas City Metro Area (KS and MO)

877shy459shy6604

800shy969shy3343

888shy393shy6765

77shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

800shy501shy3439

Telephone Number


G51

9H1

PH1

H41

H41

G51

EP1

EP1

G51

EP1

QA4

Self only

G52

9H2

PH2

H42

H42

G52

EP2

EP2

G52

EP2

QA5

Self amp family

21977

12747

10987

16237

16237

21977

20174

20174

21977

20174

9575

Self only

51861

29956

24447

38826

38826

51861

47770

47770

51861

47770

24919

Self amp family

10143

5883

5071

7494

7494

10143

9311

9311

10143

9311

4419

Self only

23936

13826

11283

17920

17920

23936

22048

22048

23936

22048

11501

Self amp family


92

Missouri Aetna HealthFund CDHP InshyNetwork $8333$16666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFund CDHP OutshyNetwork $8333$16666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+



Montana Aetna HealthFund CDHP InshyNetwork $8333$16666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFund CDHP OutshyNetwork $8333$16666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+

Nebraska


Nevada


New Hampshire


New Jersey


New Mexico


New York Aetna HealthFund CDHP InshyNetwork $8333$16666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFund CDHP OutshyNetwork $8333$16666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+

Independent Health Assoc InshyNetwork $6642$16667 $2000$4000 $5000$10000 $15 Nothing 20 Nothing $7$25$40 Independent Health Assoc OutshyNetwork $6642$16667 $2000$4000 $5000$10000 40 40 40 Nothing NANANA

Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

93



North Carolina

Aetna HealthFund shyCDHPshy All of North Carolina

North Dakota

Aetna HealthFund shyCDHPshy Most of North Dakota

Ohio Aetna HealthFund shyCDHPshy All of Ohio

AultCare HMO shyHDHPshy StarkCarrollHolmesTuscarawasWayne Co

Oklahoma Aetna HealthFund shyCDHPshy All of Oklahoma

Oregon Aetna HealthFund shyCDHPshy Most of Oregon

Pennsylvania

Aetna HealthFund shyCDHPshy All of Pennsylvania

HealthAmerica Pennsylvania shy HDHPshy Greater Pittsburgh Area

UPMC Health Plan shyHDHPshy Western Pennsylvania

Rhode Island

Aetna HealthFund shyCDHPshy All of Rhode Island

South Carolina

Aetna HealthFund shyCDHPshy All of South Carolina

Plan Name

877shy459shy6604

877shy459shy6604

877shy459shy6604

330shy363shy6360

877shy459shy6604

877shy459shy6604

877shy459shy6604

866shy351shy5946

888shy876shy2756

877shy459shy6604

877shy459shy6604

Telephone Number


F51

H41

JS1

3A4

JS1

H41

H41

Y61

8W4

EP1

JS1

Self only

F52

H42

JS2

3A5

JS2

H42

H42

Y62

8W5

EP2

JS2

Self amp family

16322

16237

22787

8669

22787

16237

16237

12298

12448

20174

22787

Self only

39021

38826

53701

17501

53701

38826

38826

28345

28053

47770

53701

Self amp family

7533

7494

10517

4001

10517

7494

7494

5676

5745

9311

10517

Self only

18010

17920

24785

8077

24785

17920

17920

13082

12948

22048

24785

Self amp family


94

North Carolina


North Dakota


Ohio Aetna HealthFund CDHP InshyNetwork $8333$16666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFund CDHP OutshyNetwork $8333$16666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+

AultCare HMO InshyNetwork $8333$16666 $2000$4000 $4000$8000 20 20 20 Nothing 202020 AultCare HMO OutshyNetwork $8333$16666 $4000$8000 $8000$16000 40 UCR 40 UCR 40 UCR 50 UCR

Oklahoma Aetna HealthFund CDHP InshyNetwork $8333$16666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFund CDHP OutshyNetwork $8333$16666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+

Oregon Aetna HealthFund CDHP InshyNetwork $8333$16666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFund CDHP OutshyNetwork $8333$16666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+

Pennsylvania


HealthAmerica Pennsylvania shy HDHP $6250$125 $1500$3000 $4000$8000 $15 Nothing Nothing Nothing $5$35$50

UPMC Health Plan InshyNetwork $8333$$16667 $2000$4000 $3000$6000 10 after deduct 10after deduct Nothing UPMC Health Plan OutshyNetwork $8333$16667 $2000$4000 $6000$12000 30after deduct 30 NA

Rhode Island


South Carolina


Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Benefit Type

Prescription Drugs

Levels I II III

20 Plan Allow20 Plan Allow 20 Plan Allow

$5 after deduct$35 after deduct$75

10After Deduct 30After Deduct

30 after deduct

95



South Dakota

Aetna HealthFund shyCDHPshy Rapid CitySioux Falls Area

Tennessee


Texas Aetna HealthFund shyCDHPshy All of Texas

Humana CoverageFirst shyCDHPshy Corpus Christi Area

Humana CoverageFirst shyCDHPshy San Antonio Area

Humana CoverageFirst shyCDHPshy Austin Area

Utah Aetna HealthFund shyCDHPshy Most of Utah

Altius Health Plans shyHDHPshy Wasatch Front

Vermont

Aetna HealthFund shyCDHPshy All of Vermont

Virginia Aetna HealthFund shyCDHPshy Most of Virginia

CareFirst BlueChoice shyHDHPshy Northern Virginia

Plan Name

877shy459shy6604

877shy459shy6604

877shy459shy6604

888shy393shy6765

888shy393shy6765

888shy393shy6765

877shy459shy6604

800shy377shy4161

877shy459shy6604

877shy459shy6604

888shy789shy9065

Telephone Number


G51

G51

JS1

TP1

TU1

TV1

G51

9K4

EP1

F51

B61

Self only

G52

G52

JS2

TP2

TU2

TV2

G52

9K5

EP2

F52

B62

Self amp family

21977

16322

22787

12208

12208

13429

21977

8704

20174

16322

14018

Self only

51861

39021

53701

27163

27162

29879

51861

18033

47770

39021

31268

Self amp family

10143

7533

10517

5634

5634

6198

10143

4017

9311

7533

6470

Self only

23936

18010

24785

12537

12536

13790

23936

8323

22048

18010

14431

Self amp family


96

South Dakota


Tennessee


Texas Aetna HealthFund CDHP InshyNetwork $8333$16666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFund CDHP OutshyNetwork $8333$16666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+




Utah Aetna HealthFund CDHP InshyNetwork $8333$16666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFund CDHP OutshyNetwork $8333$16666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+


Vermont


Virginia Aetna HealthFund CDHP InshyNetwork $8333$16666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFund CDHP OutshyNetwork $8333$16666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+


Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

97



Washington Aetna HealthFund shyCDHPshy Most of Washington

KPS Health Plans shyHDHPshy All of Washington

West Virginia Aetna HealthFund shyCDHPshy Most of West Virginia

Wisconsin Aetna HealthFund shyCDHPshy All of Wisconsin

Wyoming

Aetna HealthFund shyCDHPshy All of Wyoming

Altius Health Plans shyHDHPshy Uinta County

Plan Name

877shy459shy6604

800shy552shy7114

877shy459shy6604

877shy459shy6604

877shy459shy6604

800shy377shy4161

Telephone Number


G51

L14

F51

JS1

H41

9K4

Self only

G52

L15

F52

JS2

H42

9K5

Self amp family

21977

10262

16322

22787

16237

8704

Self only

51861

22425

39021

53701

38826

18033

Self amp family

10143

4736

7533

10517

7494

4017

Self only

23936

10350

18010

24785

17920

8323

Self amp family


98

Washington Aetna HealthFund CDHP InshyNetwork $8333$16666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFund CDHP OutshyNetwork $8333$16666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+

KPS Health Plans InshyNetwork $6250$125 $1300$2600 $4000$8000 20 None 20 Nothing KPS Health Plans OutshyNetwork $6250$125 $1300$2600 $4000$8000 40 None 40 Not Covered Not Covered

West Virginia Aetna HealthFund CDHP InshyNetwork $8333$16666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFund CDHP OutshyNetwork $8333$16666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+

Wisconsin Aetna HealthFund CDHP InshyNetwork $8333$16666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFund CDHP OutshyNetwork $8333$16666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+

Wyoming



Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

$10$35$50 30day $100 90day

99


100

Appendix F

FEDVIP Program Features

Waiting Periods

Dental shy limited only to orthodontic services on most plans for all other services you may use your benefits as soon as your coverage becomes effective There are very few preshyexisting condition limitations

Vision shy no waiting period you may use your benefits as soon as your coverage becomes effective There are no preshyexisting condition limitations

A Choice of Coverage

Choose between Self Only Self Plus One or Self and Family

Contributions

There are no Government contributions The enrollee pays 100 of the premium

Salary Deduction

You automatically pay your premium through a payroll deduction using preshytax dollars employees cannot elect to waive this preshytax option and annuitants are not eligible for this option When premium contributions are withheld on a preshytax basis Internal Revenue Service (IRS) guidelines affect your ability to change coverage ie you may cancel or change coverage levels only during a FEDVIP Open Season You may also make changes throughout the plan year if a qualified life event occurs

Annual Enrollment Opportunity Each year you may enroll or change your dental andor vision plan enrollment Open Season runs from the Monday of the second full work week in November through the Monday of the second full work week in December Other events allow for certain types of changes throughout the year

Continued Coverage Eligibility for you or your family member may continue following your retirement or changes in employment status

Claim Dispute Resolution The claim review process will differ among plans Upon written request from the enrollee and as a final option the carrier will submit a dispute for resolution through a binding arbitration process OPM will not review nor resolve disputes regarding FEDVIP Please see your plan brochure for details

101

Appendix G FEDVIP Definitions

Eligible Dependents ndash Your spouse and unmarried dependent children under age 22 Under certain circumstances you may also continue coverage for a disabled child 22 years of age or older who is incapable of selfshysupport Please Note The health care law does not change the age or unmarried requirement for dependents under FEDVIP

First Payer ndash Under this rule the FEHB plan is considered the primary payer and pays first while the FEDVIP plan is considered the secondary payer No more than 100 of any claim is paid by both plans

InshyNetwork Services ndash Services provided by members of the planrsquos provider network

Nationwide Plan ndash A plan which provides services throughout the United States and around the world

OutshyofshyNetwork Services ndash Services provided by health care professionals who are not a member of the planrsquos provider network

Plan ndash The insurance company which participates in the FEDVIP program Also called carrier

Precertification ndash Also called predetermination This is the procedure used by dental offices to determine what services a plan will cover and how much may be paid before the service is rendered

Provider ndash A licensed health care professional for example dentists oral surgeons optometrists and ophthalmologists

Provider Network ndash A group of health care providers who have a contract with a specific plan to provide services at an agreed upon cost

Qualifying Life Event (QLE) ndash An event that allows you to enroll or if you are already enrolled allows you to change your enrollment outside of an Open Season There is no QLE under FEDVIP which allows for cancellation except upon deployment to active military duty or transitions to certain agencies

Regional Plan ndash A plan which provides services only in specified geographic regions

Usual Customary and Reasonable ndash A widely used method which may vary from company to company for determining benefit reimbursement levels The initials simply mean

Usual The fee that an individual dentist most frequently charges for a given dental service

Customary A fee determined by the insurance company based on the range of usual fees charged by dentists in the same geographic area

Reasonable A fee which is justifiable considering special circumstances of the particular care rendered

Waiting Period ndash The length of time a person must be covered under the plan before they are eligible for certain benefits For example most plans have a 12 month waiting period for orthodontic benefits This means that you must be covered continuously by the same plan and option for 12 months before your child is eligible for orthodontic coverage

102

Appendix H FEDVIP Qualifying Life Events for Enrollment Changes

A qualifying life event (QLE) is an event that allows you to enroll or if you are already enrolled allows you to change your enrollment outside of an Open Season

The following chart lists the QLEs and the enrollment actions you may take

Qualifying Life Event


Increase Enrollment Type

Decrease Enrollment Type

Cancel Change from One Plan to Another

Acquiring an eligible family member

No Yes No No No

Losing a covered family member No No Yes No No

Losing other dentalvision

coverage (eligible or covered person)

Yes Yes No No No

Moving out of regional planrsquos service area

No No No No Yes

Going on active military duty nonshypay status (enrollee

or spouse)

No No No Yes No

Returning to pay status from active military duty

(enrollee or spouse)

Yes No No No No

Annuity compensation restored

Yes Yes Yes No No

Transferring to an eligible position

No No No Yes No

The time frame for requesting a QLE change is from 31 days before to 60 days after the event There are two exceptions

bull There is no time limit for a change based on moving from a regional plans service area and

bull You cannot request a new enrollment based on a QLE before the QLE occurs except for enrollment due to a loss of dental or vision insurance You must make the change no later than 60 days after the event

Generally enrollments and enrollment changes made based on a QLE are effective on the first day of the pay period following the one in which BENEFEDS receives and confirms the enrollment or change BENEFEDS will send you confirmation of your new coverage effective date BENEFEDS is a secure enrollment website sponsored by OPM

Cancelling an enrollment

You can cancel your enrollment only during the annual Open Season upon deployment to active military duty or transfers to certain agencies An eligible family members coverage also ends upon the effective date of the cancellation

103

Appendix I FEDVIP Plan Comparison Charts

This is a brief summary of the features of the dental and vision plans Before making a final decision please read the plan brochures and provider directories thoroughly All plans are not the same All benefits are subject to the definitions limitations copayments annual maximums and exclusions set forth in the individual plan brochures Go to our website at wwwopmgovhealthcareshyinsurancedentalshyvisionplanshyinformationpremiumsdentalpremiumpdf to find the rating region assigned to the area where you live and the related premium cost you will pay for dental coverage Go to wwwopmgovhealthcareshyinsurancedentalshyvisionplanshyinformationpremiumsvisionpremiumpdf to see the premium cost for vision coverage

Reading the Chart

The table on the following pages highlights the selected featuresclasses of dental andor vision services Always consult plan brochures before making a decision The chart does not show all of your possible outshyofshypocket costs

Dental Insurance

The deductibles shown for the dental plans are the amount of covered expenses that you pay before the plan begins to pay Service Class refers to the level of benefits for each plan The Service Classes are listed below Calendar year maximum refers to the annual amount of benefits that you can receive per person

Please Note Most plans require that you are continuously enrolled in the same dental plan andor option for the full waiting period before accessing orthodontia services There are no other waiting periods for services

Dental plans provide a comprehensive range of services including but not limited to the following

bull Class A (Basic) services which include oral examinations prophylaxis diagnostic evaluations sealants and xshyrays

bull Class B (Intermediate) services which include restorative procedures such as fillings prefabricated stainless steel crowns periodontal scaling tooth extractions and denture adjustments

bull Class C (Major) services which include endodontic services such as root canals periodontal services such as gingivectomy major restorative services such as crowns oral surgery bridges and prosthodontic services such as complete dentures

bull Class D (Orthodontic) services with up to a 12shymonth waiting period

Please review the dental plansrsquo benefits material for detailed information on the benefits covered costshysharing requirements and provider directories

Vision Insurance

Vision plans provide comprehensive eye examinations and coverage for lenses frames and contact lenses (in lieu of eye glasses) Other benefits such as discounts on lasik surgery may also be available

Please review the vision plansrsquo benefits material for detailed information on the benefits covered costshysharing requirements and provider directories

104

Appendix I Federal Employees Dental and Vision Insurance Program (FEDVIP)

Nationwide and International Dental Plans Open to All

Plan Name

Telephone amp

Website

You pay Calendar Year Maximum

Class A

Class B

Class C

Class D

Deductible

Aetna High (InshyNetwork Benefits)

1shy877shy459shy6604 aetnafedscomdental

0 40 60 50 $0 $4000 per year per person shy inshynetwork $2000 per year per person shy outshyofshynetwork $2000 lifetime max per person (orthodontic services only) 12shymonth waiting period for orthodontia services

Aetna High (OutshyofshyNetwork Benefits)

0 40 60 50 $0

Delta Dental Standard (InshyNetwork Benefits)

1shy855shy410shy3255 deltadentalfedsorg

0 45 65 50 $0 $1500 standard option inshynetwork annual nonshyorthodontic maximum per person $600 standard option outshyofshynetwork annual nonshyorthodontic maximum per person

Delta Dental Standard (OutshyofshyNetwork Benefits)

40 60 80 50 $75 $4000 high option inshynetwork annual nonshyorthodontic maximum per person $3000 high option outshyofshynetwork annual nonshyorthodontic maximum per person

Delta Dental High (InshyNetwork Benefits)

0 30 50 50 $0 $2000 standard option inshynetwork lifetime max per person (orthodontic services only) $1000 standard option outshyofshynetwork lifetime max per person (orthodontic services only)

Delta Dental High (OutshyofshyNetwork Benefits)

10 40 60 50 $50 $2000 high option lifetime max per person (orthodontic services only) inshynetwork and outshyofshynetwork 12 month waiting period for orthodontia services

FEP BlueDental Standard (InshyNetwork Benefits)

1shy855shy504shy2583 fepblueorg


FEP BlueDental Standard (OutshyofshyNetwork Benefits)


FEP BlueDental High (InshyNetwork Benefits)


FEP BlueDental High (OutshyofshyNetwork Benefits)


Please Note OutshyofshyNetwork Benefits ndash members are responsible for paying the difference between the planrsquos payment and the nonshynetwork providerrsquos billed charges

105



Plan Name

Telephone amp

Website


Class A

Class B

Class C

Class D

Deductible

GEHA Standard (InshyNetwork Benefits)

GEHA Standard

1shy877shy434shy2336 gehadentalcom

0 45 65 30 $0 $15000 per year per person (high option) or $2500 per year per person (standard option) $2500 lifetime max per person (high option orthodontic services only) $2500 lifetime max per person (standard option orthodontic

(OutshyofshyNetwork Benefits)

0 45 65 30 $0 services only) 12 month waiting period for orthodontia services

GEHA High (InshyNetwork Benefits)

0 20 50 30 $0

GEHA High (OutshyofshyNetwork Benefits)

0 20 50 30 $0

MetLife Standard (InshyNetwork Benefits)

1shy888shy865shy6854 federaldentalmetlifecom

0 45 65 50 $0 $1500 standard option inshynetwork annual nonshyorthodontic maximum per person $2000 standard option inshynetwork lifetime max per person for orthodontics shy child

MetLife Standard (OutshyofshyNetwork Benefits)

40 60 80 50 $100person $800 standard option outshyofshynetwork annual nonshyorthodontic maximum per person $1500 standard option outshyofshynetwork lifetime max per person for orthodontics shy child

MetLife High (InshyNetwork Benefits)

0 30 50 50 $0 $10000 high option inshynetwork annual nonshyorthodontic maximum per person $3500 high option inshynetwork lifetime max per person for orthodontics shy child

MetLife High (OutshyofshyNetwork Benefits)

10 40 60 50 $50person $10000 high option outshyofshynetwork annual nonshyorthodontic maximum per person $3500 high option outshyofshynetwork lifetime max per person for orthodontics shy child There is no calendar year deductible for Class D services No waiting period for orthodontia services $1500 high option lifetime max per person for orthodontics shy Adult

United Concordia High (InshyNetwork Benefits)

1shy877shy438shy8224 (Open Season) 1shy877shy394shy8224 (General)

uccifedvipcom

0 20 50 50 $0 $10000 per year per person $3000 lifetime max per person (orthodontic services only) 12shymonth waiting period for orthodontic services

United Concordia High (OutshyofshyNetwork Benefits)

20 40 60 50 $0


106


Regional Dental Plans Only Open to Persons Living in Specific Geographic Areas

Plan Name

You pay

Telephone amp

Website

Class A

Class B

Class C

Class D Deductible

Calendar Year Maximum

Humana High (Open to residents of the Southeastern Midwestern and MidshyAtlantic states)

EmblemHealth (formerly GHI) High (inshynetwork benefits)

(Open to NY and Northern NJ residents and parts of CT and PA)

EmblemHealth (formerly GHI) High (outshyofshynetwork benefits)

TripleshyS Salud High (Open to Puerto Rico residents)

Dominion Dental High

Dominion Dental Standard

(Open to residents of DC DE MD PA and parts of VA and NJ)

1shy877shy692shy2468 fedshumanacom

212shy501shy4444 ghicom

787shy774shy6060 787shy749shy4777 1shy800shy981shy3241 TTY 787shy792shy1370 TTY 1shy866shy215shy1999

sssprcom

1shy855shy836shy6337 FederalDentalPlanscom

0

0

0

0

0

flat rate

Flat Rate

Approx 30

0

0

30

flat rate

flat rate

Flat Rate

Approx 50

0

0

60 30

flat rate

flat rate

Flat Rate

Approx 60

0

0

50

flat rate

flat rate

$0

$0

$50 self$150 self amp familyself plus one Class B and Class C

$0

$0

$0

$15000 per year per person Unlimited lifetime orthodontic coverage Outshyofshynetwork benefits NOT provided No waiting period for orthodontia services

$5000 per year per person $2000 lifetime max per person (orthodontic services only) Outshyofshynetwork benefits available ndash paid at the same inshynetwork rate 12shymonth waiting period for orthodontia services

No maximum $2000 lifetime max per person (orthodontic services only) Outshyofshynetwork benefits NOT provided 12 month waiting period for orthodontia services

No annual maximum benefit No lifetime maximum Outshyofshynetwork benefits NOT provided except emergency services No waiting period for orthodontia services $10 office visit copay


107


Nationwide and International Vision Plans Open to All

The table below highlights the selected features of available vision plans Always consult plan brochures before making a decision The chart does not show all of your possible outshyofshypocket costs

Vision plans provide comprehensive eye examinations and coverage for lenses frames and contact lenses (in lieu of eye glasses) There are no deductibles or waiting periods Other benefits such as discounts on lasik surgery may also be available

Additional Features

Aetna Vision Standard

Aetna Vision High

FEP BlueVision Standard

FEP BlueVision High

UnitedHealthcare Vision Plan Standard

Plan Name Frames Lenses Exams Coshypayments

Covered Lens Options

$120 frame allowance plus 20 off remaining cost $120 contact lens allowance varying reimbursement amounts for out of network care discounts on Laser vision correction additional lens options retinal imaging and 2nd pairs of eyeglasses Additional lens options covered with a coshypay


Breakage warranty Laser vision correction discount low vision coverage $130 plus 20 of remaining cost frame allowance Additional lens options covered with a coshypay $130 allowance for contact lens Outshyofshynetwork benefits NOT provided Flat rate reimbursement in limited access areas and internationally FSAFEDS paperless reimbursement available

Breakage warranty Laser vision correction discount low vision coverage $150 plus 20 of remaining cost frame allowance $150 allowance to purchase contact lenses (materials) Additional lens options covered with a coshypay Outshyofshynetwork benefits available at a lower rate Flat rate reimbursement in limited access areas and internationally FSAFEDS paperless reimbursement available

Low vision coverage prosthetic eye vision therapy Laser vision correction discount $150 frame allowance Additional lens option discounts Outshyofshynetwork benefits availablendash paid at a lower rate Flat rate reimbursement for international outshyofshynetwork and limited access services

Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshy resistant coating

Single Lined Bifocal Lined Trifocal Lenticular UV Coating Polycarbonate Scratchshyresistant coating

Single Lined Bifocal Lined Trifocal Lenticular UV Coating Scratchshyresistant coating

Single Lined Bifocal Lined Trifocal Lenticular Standard Progressives UV Coating Scratchshyresistant coating Transitionsreg

Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant coating Lenses that transition to light

$0 exam $10 lenses $0 materials


$0

$0

$10 exam $25 material

Every24 months

Every 12 months

Every 24 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

108





Additional Features

UnitedHealthcare Vision Plan High

VSP (Vision Service Plan) Standard

VSP (Vision Service Plan) High




Laser vision correction discount $120 frame allowance $120 allowance for contacts and contact lens exam Additional lenses options covered at a discount Outshyofshynetwork benefits available ndash paid at a lower rate Additional lens option and contact lens exam discounts Additional prescription glasses and sunglasses discounts FSAFEDS paperless reimbursement available Retinal screening low vision coverage

Laser vision correction discount $150 frame allowance $150 allowance for contacts and contact lens exam Outshyofshynetwork benefits available ndash paid at a lower rate Additional lens option and contact lens exam discounts Additional prescription glasses and sunglasses discounts FSAFEDS paperless reimbursement available Retinal screening low vision coverage

Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant coating Tinted lenses UV coating Lenses that transition to light

Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant coating

Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant coating Antishyreflective coating Lenses that transition to light UV coating Select tints



$10 (including exam and glasses)

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

109

Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)

Dental Rating Regional Chart Please note that regional plans may not cover the entirety of the StateZip shown in Appendix J Rating Areas For further detail regarding service area see plan specific brochures at wwwopmgovhealthcareshyinsurancedentalshyvision

110

AK entire state 5 5 5 5 5 5 5 5 5 5 NA NA NA NA NA

AL 356shy358 1 1 1 1 1 1 1 1 1 1 NA NA 3 NA NA

AL rest of state 2 1 1 1 1 1 1 1 1 1 NA NA 2 NA NA

AR entire state 2 2 2 1 1 1 1 1 1 1 NA NA 3 NA NA

AZ 850shy853 3 5 5 2 2 2 2 1 1 1 NA NA 4 NA NA

AZ rest of state 3 5 5 3 3 2 2 1 1 1 NA NA 3 NA NA

CA 900shy908 910shy918 922shy931 3 5 5 4 4 4 4 5 5 3 NA NA 5 NA NA

CA 919shy921 3 5 5 5 5 4 4 4 4 4 NA NA 5 NA NA

CA 939shy941 943shy952 954 4 5 5 5 5 5 5 5 5 5 NA NA 5 NA NA

CA 942 956shy958 4 5 5 5 5 4 4 4 4 4 NA NA 5 NA NA

CA rest of state 4 5 5 3 3 4 4 5 5 4 NA NA 4 NA NA

CO 800shy806 3 4 4 3 3 4 4 4 4 3 NA NA 5 NA NA

CO rest of state 3 4 4 3 3 4 4 4 4 3 NA NA 5 NA NA

CT 060shy063 5 5 5 5 5 4 4 5 5 5 NA NA NA NA NA

CT 064shy069 3 5 5 5 5 5 5 5 5 5 NA NA NA 1 NA

DC entire area 2 5 5 3 3 4 4 4 4 4 4 4 3 NA NA

DE entire state 2 4 4 3 3 3 3 3 3 2 5 5 NA NA NA

FL 330shy334 2 4 4 3 3 3 3 3 3 3 NA NA 2 NA NA

FL rest of state 3 4 4 1 1 2 2 1 1 1 NA NA 2 NA NA

GA 300shy303 305 311 399 3 2 2 2 2 3 3 2 2 1 NA NA 2 NA NA

GA rest of state 4 2 2 1 1 2 2 1 1 1 NA NA 2 NA NA

GU entire area 5 5 5 5 5 1 1 1 1 5 NA NA NA NA NA

HI entire state 4 5 5 5 5 3 3 4 4 4 NA NA NA NA NA

IA entire state 3 4 4 2 2 1 1 1 1 1 NA NA NA NA NA

ID entire state 4 5 5 3 3 2 2 1 1 2 NA NA NA NA NA

IL 600shy608 2 2 2 3 3 3 3 4 4 3 NA NA 2 NA NA

IL rest of state 3 2 2 1 1 1 1 1 1 1 NA NA 1 NA NA

IN 460shy462 472 2 1 1 1 1 2 2 1 1 1 NA NA 3 NA NA

IN 463shy464 2 2 2 3 3 3 3 4 4 3 NA NA 2 NA NA

IN 470 2 1 1 1 1 2 2 1 1 1 NA NA 1 NA NA

IN rest of state 3 1 1 1 1 1 1 1 1 1 NA NA 2 NA NA

KS entire state 3 4 4 1 1 2 2 1 1 2 NA NA 1 NA NA

KY 410 452 459 2 1 1 1 1 2 2 1 1 1 NA NA 1 NA NA

KY rest of state 1 1 1 1 1 1 1 1 1 1 NA NA 1 NA NA

LA entire state 2 1 1 1 1 2 2 1 1 1 NA NA 3 NA NA

FEP FEP Delta Delta BlueDental BlueDental GEHA GEHA MetLife MetLife United Dominion Dominion TripleshyS

State StateZip (First 3) Aetna Std High Std FEP Std High Std High Concordia Std High Humana Emblem Salud



111

MA 010shy011 013 5 5 5 5 5 4 4 5 5 5 NA NA NA NA NA


MA rest of state 5 5 5 3 3 4 4 5 5 5 NA NA NA NA NA

MD 200202shy212 214 217 2 5 5 3 3 4 4 4 4 4 4 4 3 NA NA

MD 219 2 4 4 3 3 3 3 3 3 2 5 5 NA NA NA

MD rest of state 2 5 5 2 2 2 2 4 4 4 2 2 3 NA NA

ME 038 5 5 5 5 5 4 4 5 5 5 NA NA NA NA NA

ME rest of state 5 5 5 3 3 3 3 2 2 3 NA NA NA NA NA

MI 480shy485 3 4 4 3 3 3 3 3 3 2 NA NA NA NA NA

MI rest of state 3 4 4 2 2 2 2 2 2 2 NA NA NA NA NA

MN 550shy555 563 2 4 4 4 4 3 3 4 4 3 NA NA NA NA NA

MN rest of state 3 4 4 2 2 2 2 2 2 2 NA NA NA NA NA

MO entire state 3 4 4 1 1 2 2 1 1 1 NA NA 2 NA NA

MS entire state 2 1 1 1 1 1 1 1 1 1 NA NA 3 NA NA

MT entire state 4 1 1 1 1 2 2 1 1 1 NA NA NA NA NA

NC 275shy277 283 4 2 2 2 2 2 2 1 1 2 NA NA 5 NA NA

NC rest of state 4 2 2 1 1 2 2 1 1 2 NA NA 4 NA NA

ND entire state 3 1 1 4 4 1 1 1 1 1 NA NA NA NA NA

NE entire state 1 1 1 1 1 1 1 1 1 1 NA NA NA NA NA

NH 030shy033 038 5 5 5 5 5 4 4 5 5 5 NA NA NA NA NA

NH rest of state 5 5 5 4 4 4 4 5 5 5 NA NA NA NA NA

NJ 3 5 5 5 5 5 5 5 5 5 NA NA NA 1 NA

NJ 080shy084 2 4 4 3 3 3 3 3 3 2 5 5 NA NA NA

NJ rest of state 3 5 5 4 4 5 5 5 5 5 NA NA NA 1 NA

NM entire state 3 4 4 1 1 3 3 1 1 2 NA NA NA NA NA

NV entire state 2 5 5 1 1 3 3 2 2 4 NA NA NA NA NA

NY 005 100shy119 124shy126 3 5 5 5 5 5 5 5 5 5 NA NA NA 1 NA

NY 063 5 5 5 5 5 4 4 5 5 5 NA NA NA 1 NA

NY 140shy143 4 5 5 3 3 2 2 2 2 3 NA NA NA 1 NA

NY rest of state 4 5 5 3 3 2 2 2 2 3 NA NA NA 1 NA

OH 430shy432 2 1 1 1 1 2 2 1 1 2 NA NA 2 NA NA

OH 440shy443 2 1 1 1 1 2 2 1 1 3 NA NA 2 NA NA

OH 450shy452 2 1 1 1 1 2 2 1 1 1 NA NA 1 NA NA

OH 453shy455 2 1 1 1 1 2 2 1 1 2 NA NA 1 NA NA

OH rest of state 3 1 1 1 1 1 1 1 1 1 NA NA 1 NA NA



070072shy075077shy079085shy089


Dental Rating Regional Chart Please note that regional plans may not cover the entirety of the StateZip shown in Appendix JRating Areas For further detail regarding service area see plan specific brochures at wwwopmgovhealthcareshyinsurancedentalshyvision

112

OK entire state 2 3 3 1 1 2 2 1 1 1 NA NA 3 NA NA

OR 970shy973 4 5 5 3 3 3 3 4 4 5 NA NA NA NA NA

OR rest of state 5 5 5 2 2 3 3 3 3 4 NA NA NA NA NA

PA 153shy154 156 160shy162 1 2 2 1 1 1 1 1 1 1 1 1 NA NA NA

PA 173shy174 2 5 5 3 3 4 4 4 4 4 4 4 NA NA NA

PA 183 3 5 5 5 5 5 5 5 5 5 1 1 NA 1 NA

PA 189shy196 2 4 4 3 3 3 3 3 3 2 5 5 NA NA NA

PA rest of state 3 2 2 1 1 1 1 1 1 1 1 1 NA NA NA

PR entire area 3 1 1 1 1 1 1 1 1 1 NA NA NA NA 1

RI entire state 5 5 5 5 5 4 4 5 5 5 NA NA NA NA NA

SC entire state 4 5 5 1 1 2 2 1 1 1 NA NA 4 NA NA

SD entire state 3 5 5 1 1 1 1 1 1 1 NA NA NA NA NA

TN 422 1 1 1 1 1 1 1 1 1 1 NA NA 1 NA NA

TN rest of state 1 1 1 1 1 2 2 1 1 1 NA NA 1 NA NA

TX 739 2 3 3 1 1 2 2 1 1 1 NA NA 3 NA NA

TX 750shy754 760shy762 2 2 2 1 1 2 2 1 1 1 NA NA 1 NA NA

TX 770 772shy775 2 2 2 1 1 2 2 1 1 1 NA NA 1 NA NA

TX rest of state 2 2 2 1 1 2 2 1 1 1 NA NA 1 NA NA

UT entire state 2 5 5 1 1 1 1 1 1 3 NA NA 3 NA NA

VA 200shy205 220shy227 2 5 5 3 3 4 4 4 4 4 4 4 3 NA NA

VA 231shy232 238 3 3 3 2 2 2 2 1 1 2 3 3 3 NA NA

VA rest of state 3 3 3 1 1 2 2 1 1 1 4 4 4 NA NA

VI entire area 2 5 5 5 5 1 1 1 1 5 NA NA NA NA NA

VT entire state 5 5 5 4 4 2 2 2 2 3 NA NA NA NA NA

WA 980shy985 5 5 5 5 5 5 5 5 5 5 NA NA NA NA NA

WA 986 4 5 5 3 3 3 3 4 4 5 NA NA NA NA NA

WA rest of state 5 5 5 4 4 4 4 4 4 4 NA NA NA NA NA

WI 530shy532 534 3 5 5 3 3 2 2 2 2 3 NA NA NA NA NA

WI 540 2 4 4 4 4 3 3 4 4 3 NA NA NA NA NA

WI rest of state 3 5 5 3 3 2 2 2 2 2 NA NA NA NA NA

WV 254 2 5 5 3 3 4 4 4 4 4 NA NA 3 NA NA

WV rest of state 4 2 2 1 1 2 2 1 1 1 NA NA 2 NA NA

WY 834 4 5 5 3 3 2 2 1 1 2 NA NA NA NA NA

WY rest of state 4 5 5 1 1 1 1 1 1 2 NA NA NA NA NA

INTER 2 5 5 5 5 1 1 5 5 5 NA NA NA NA NA



Intershynational

Appendix K Federal Employees Dental and Vision Insurance Program (FEDVIP)

Premium Rate Charts Nationwide Dental Rates Please note Rating areas for each carrier are not the same for all plans Please refer to Appendix J to determine your specific region

113113

Aetna PPO

Delta Dental PPO

Delta Dental PPO

FEP BlueDental PPO

FEP BlueDental PPO

GEHA PPO

GEHA PPO

MetLife PPO

MetLife PPO

United Concordia PPO

High (In and OutshyofshyNetwork Benefits)

Standard (In and OutshyofshyNetwork Benefits)









1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

$1288 $1418 $1510 $1666 $1809

$871 $949 $1024 $1080 $1234

$1669 $1831 $2008 $2136 $2485

$939 $1069 $1184 $1249 $1381

$1634 $1860 $2061 $2177 $2408

$900 $989 $1124 $1213 $1347

$1525 $1677 $1904 $2056 $2284

$868 $940 $1044 $1159 $1273

$1606 $1797 $1959 $2121 $2374

$1372 $1541 $1710 $1880 $2049

$2578 $2840 $3022 $3334 $3621

$1744 $1901 $2049 $2160 $2470

$3340 $3663 $4018 $4275 $4973

$1881 $2139 $2370 $2500 $2765

$3270 $3721 $4124 $4357 $4818

$1803 $1981 $2249 $2428 $2697

$3053 $3357 $3812 $4115 $4572

$1738 $1883 $2089 $2320 $2548

$3214 $3597 $3920 $4244 $4750

$2747 $3085 $3422 $3761 $4099

$3867 $4258 $4532 $5001 $5430

$2615 $2850 $3074 $3240 $3704

$5009 $5494 $6026 $6412 $7458

$2820 $3208 $3554 $3749 $4146

$4904 $5581 $6185 $6534 $7226

$2705 $2970 $3372 $3641 $4043

$4579 $5038 $5716 $6174 $6859

$2606 $2823 $3133 $3479 $3821

$4820 $5394 $5879 $6366 $7124

$4118 $4625 $5134 $5641 $6148

$2791 $3073 $3272 $3610 $3919

$1887 $2056 $2219 $2340 $2674

$3616 $3967 $4351 $4628 $5384

$2035 $2316 $2565 $2706 $2992

$3540 $4030 $4466 $4717 $5217

$1950 $2143 $2435 $2628 $2919

$3304 $3634 $4125 $4455 $4949

$1881 $2037 $2262 $2511 $2758

$3480 $3894 $4245 $4596 $5144

$2973 $3339 $3705 $4073 $4440

$5587 $6153 $6549 $7224 $7846

$3779 $4119 $4440 $4680 $5352

$7237 $7937 $8706 $9263 $10775

$4076 $4635 $5135 $5417 $5991

$7085 $8062 $8935 $9440 $10439

$3907 $4292 $4873 $5261 $5844

$6615 $7274 $8259 $8916 $9906

$3766 $4080 $4526 $5027 $5521

$6964 $7794 $8493 $9195 $10292

$5952 $6684 $7414 $8149 $8881

$8378 $9226 $9819 $10835 $11765

$5666 $6175 $6660 $7020 $8025

$10853 $11904 $13056 $13893 $16159

$6110 $6951 $7700 $8123 $8983

$10625 $12092 $13401 $14157 $15656

$5861 $6435 $7306 $7889 $8760

$9921 $10916 $12385 $13377 $14861

$5646 $6117 $6788 $7538 $8279

$10443 $11687 $12738 $13793 $15435

$8922 $10021 $11124 $12222 $13321

Biweekly Premium Monthly Premium

Plan Name Option Rating Region

Self Only Self Plus One

Self amp Family Self Only Self Plus One

Self amp Family


Premium Rate Charts Regional Dental Rates

Please note Rating areas for each carrier are not the same for all plans Please refer to Appendix J to determine your specific region

Dominion Dental HMO

Dominion Dental HMO

EmblemHealth PPO

Humana

Triple S Salud PPO

Standard (InshyNetwork Benefits Only except

for emergency services)

High (InshyNetwork Benefits Only except






for services rendered by orthodontists)

1 2 3 4 5

1 2 3 4 5

1

1 2 3 4 5

1

$596 $622 $694 $829 $884

$1018 $1055 $1109 $1291 $1517

$1826

$990 $1048 $1136 $1378 $1475

$454

$1194 $1246 $1391 $1660 $1771

$2038 $2113 $2221 $2585 $3037

$3652

$1982 $2098 $2273 $2759 $2952

$910

$1790 $1868 $2085 $2489 $2655

$3056 $3168 $3330 $3876 $4554

$5478

$2971 $3146 $3409 $4136 $4428

$1191

$1291 $1348 $1504 $1796 $1915

$2206 $2286 $2403 $2797 $3287

$3956

$2145 $2271 $2461 $2986 $3196

$984

$2587 $2700 $3014 $3597 $3837

$4416 $4578 $4812 $5601 $6580

$7913

$4294 $4546 $4925 $5978 $6396

$1972

$3878 $4047 $4518 $5393 $5753

$6621 $6864 $7215 $8398 $9867

$11869

$6437 $6816 $7386 $8961 $9594

$2581





Self amp Family

International Dental Rates Please note International premium rates are not regionally based

114

Aetna

Delta Dental Standard

Delta Dental High

FEP BlueDental Standard

FEP BlueDental High

GEHA Standard

GEHA High

MetLife Standard

MetLife High

United Concordia

$1418

$1234

$2485

$1381

$2408

$900

$1525

$1273

$2374

$2049

$2840

$2470

$4973

$2765

$4818

$1803

$3053

$2548

$4750

$4099

$4258

$3704

$7458

$4146

$7226

$2705

$4579

$3821

$7124

$6148

$3073

$2674

$5384

$2992

$5217

$1950

$3304

$2758

$5144

$4440

$9226

$8025

$16159

$8983

$15656

$5861

$9921

$8279

$15435

$13321


Plan Name Self Only Self Plus One


Self amp Family

$6153

$5352

$10775

$5991

$10439

$3907

$6615

$5521

$10292

$8881


Premium Rate Charts

Nationwide Vision Rates

Aetna Vision

FEP BlueVision

UnitedHealthcare Vision Plan

VSP (Vision Service Plan)

1shy877shy459shy6604 aetnafedscomvision


1shy866shy249shy1999 TTY 1shy800shy524shy3157

myuhcvisioncomfedvip

1shy800shy807shy0764 choosevspcom

$680 $1328

$800 $1012

$622 $884

$771 $1339

$1304 $2533

$1601 $2028

$1220 $1729

$1547 $2685

$1913 $3716

$2401 $3042

$1814 $2572

$2321 $4026

$314 $613

$369 $467

$287 $408

$356 $618

Standard High

Standard High

Standard High

Standard High

$602 $1169

$739 $936

$563 $798

$714 $1239

$883 $1715

$1108 $1404

$837 $1187

$1071 $1858


Plan Name Telephone amp Website



Self amp Family Plan Option

International Vision Rates

Aetna Vision

FEP BlueVision








$680 $1328

$800 $1012

$622 $884

$771 $1339

$1304 $2533

$1601 $2028

$1220 $1729

$1547 $2685

$1913 $3716

$2401 $3042

$1814 $2572

$2321 $4026

$314 $613

$369 $467

$287 $408

$356 $618

Standard High

Standard High

Standard High

Standard High

$602 $1169

$739 $936

$563 $798

$714 $1239

$883 $1715

$1108 $1404

$837 $1187

$1071 $1858






115

______________________________________________________________________________________________________________

Medicaid and the Childrenrsquos Health Insurance Program (CHIP) Offer Free or LowshyCost Health Coverage to Children and Families

If you or your children are eligible for Medicaid or CHIP and you are eligible for health coverage from your employer your State may have a premium assistance program that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for these programs but also have access to health insurance through their employer If you or your children are not eligible for Medicaid or CHIP you will not be eligible for these premium assistance programs

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below you can contact your State Medicaid or CHIP office to find out if premium assistance is available

If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1shy877shyKIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can ask the State if it has a program that might help you pay the premiums for an employershysponsored plan

Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP as well as eligible under your employer plan your employer must permit you to enroll in your employer plan if you are not already enrolled This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance If you have questions about enrolling in your employer plan you can contact the Department of Labor electronically at wwwaskebsadolgov or by calling tollshyfree 1shy866shy444shyEBSA (3272)

If you live in one of the following States you may be eligible for assistance paying your employer health plan premiums The following list of States is current as of January 31 2013 You should contact your State for further information on eligibility ndash

ALABAMA ndash Medicaid KANSAS ndash Medicaid Website httpwwwmedicaidalabamagov Phone 1shy855shy692shy5447

Website httpwwwkdheksgovhcf Phone 1shy800shy792shy4884

ALASKA ndash Medicaid KENTUCKY ndash Medicaid Website httphealthhssstateakusdpaprogramsmedicaid Phone (Outside of Anchorage) 1shy888shy318shy8890 Phone (Anchorage) 907shy269shy6529

Website httpchfskygovdmsdefaulthtm Phone 1shy800shy635shy2570

ARIZONA ndash CHIP LOUISIANA ndash Medicaid Website httpwwwazahcccsgovapplicants Phone (Outside of Maricopa County) 1shy877shy764shy5437 Phone (Maricopa County) 602shy417shy5437

Website httpwwwlahippdhhlouisianagov Phone 1shy888shy695shy2447

COLORADO ndash Medicaid MAINE ndash Medicaid Medicaid Website httpwwwcoloradogov Medicaid Phone (In state) 1shy800shy866shy3513 Medicaid Phone (Out of state) 1shy800shy221shy3943

Website httpwwwmainegovdhhsofipublicshyassistanceindexhtml Phone 1shy800shy977shy6740 TTY 1shy800shy977shy6741

FLORIDA ndash Medicaid MASSACHUSETTS ndash Medicaid and CHIP Website httpswwwflmedicaidtplrecoverycom Phone 1shy877shy357shy3268

Website httpwwwmassgovMassHealth Phone 1shy800shy462shy1120

GEORGIA ndash Medicaid MINNESOTA ndash Medicaid Website httpdchgeorgiagov Click on Programs then Medicaid then Health Insurance Premium Payent (HIPP) Phone 1shy800shy869shy1150

Website httpwwwdhsstatemnus Click on Health Care then Medical Assistance Phone 1shy800shy657shy3629

IDAHO ndash Medicaid and CHIP MISSOURI ndash Medicaid Medicaid Website wwwaccesstohealthinsuranceidahogov Medicaid Phone 1shy800shy926shy2588 CHIP Website wwwmedicaididahogov CHIP Phone 1shy800shy926shy2588

Website httpwwwdssmogovmhdparticipantspageshipphtm Phone 573shy751shy2005

INDIANA ndash Medicaid MONTANA ndash Medicaid Website httpwwwingovfssa Phone 1shy800shy889shy9949

Website httpmedicaidproviderhhsmtgovclientpages clientindexshtml Phone 1shy800shy694shy3084

IOWA ndash Medicaid NEBRASKA ndash Medicaid Website wwwdhsstateiaushipp Phone 1shy888shy346shy9562

Website wwwACCESSNebraskanegov Phone 1shy877shy383shy4278

116


NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid Medicaid Website httpdwssnvgov Medicaid Phone 1shy800shy992shy0900

Website httpwwwscdhhsgov Phone 1shy888shy549shy0820

NEW HAMPSHIRE ndash Medicaid SOUTH DAKOTA ndash Medicaid Website httpwwwdhhsnhgovoiidocumentshippapppdf Phone 603shy271shy5218

Website httpdsssdgov Phone 1shy888shy828shy0059

NEW JERSEY ndash Medicaid and CHIP TEXAS ndash Medicaid Medicaid Website httpwwwstatenjushumanservices dmahsclientsmedicaid Medicaid Phone 609shy631shy2392 CHIP Website httpwwwnjfamilycareorgindexhtml CHIP Phone 1shy800shy701shy0710

Website httpswwwgethipptexascom Phone 1shy800shy440shy0493

NEW YORK ndash Medicaid UTAH ndash Medicaid and CHIP Website httpwwwnyhealthgovhealth_caremedicaid Phone 1shy800shy541shy2831

Website httphealthutahgovupp Phone 1shy866shy435shy7414

NORTH CAROLINA ndash Medicaid VERMONTndash Medicaid Website httpwwwncdhhsgovdma Phone 919shy855shy4100

Website httpwwwgreenmountaincareorg Phone 1shy800shy250shy8427

NORTH DAKOTA ndash Medicaid VIRGINIA ndash Medicaid and CHIP Website httpwwwndgovdhsservicesmedicalservmedicaid Phone 1shy800shy755shy2604

Medicaid Website httpwwwdmasvirginiagovrcpshyHIPPhtm Medicaid Phone 1shy800shy432shy5924 CHIP Website httpwwwfamisorg CHIP Phone 1shy866shy873shy2647

OKLAHOMA ndash Medicaid and CHIP WASHINGTON ndash Medicaid Website httpwwwinsureoklahomaorg Phone 1shy888shy365shy3742

Website httphrsadshswagovpremiumpymtApplyshtm Phone 1shy800shy562shy3022 ext 15473

OREGON ndash Medicaid and CHIP WEST VIRGINIA ndash Medicaid Website httpwwworegonhealthykidsgov httpwwwhijossaludablesoregongov Phone 1shy877shy314shy5678

Website wwwdhhrwvgovbms Phone 1shy877shy598shy5820 HMS Third Party Liability

PENNSYLVANIA ndash Medicaid WISCONSIN ndash Medicaid Website httpwwwdpwstatepaushipp Phone 1shy800shy692shy7462

Website httpwwwbadgercareplusorgpubspshy10095htm Phone 1shy800shy362shy3002

RHODE ISLAND ndash Medicaid WYOMING ndash Medicaid Website wwwohhsrigov Phone 401shy462shy5300

Website httphealthwyogovhealthcarefinequalitycare Phone 307shy777shy7531

To see if any more States have added a premium assistance program since January 31 2013 or for more information on special enrollment rights you can contact either

US Department of Labor US Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare amp Medicaid Services wwwdolgovebsa wwwcmshhsgov 1shy866shy444shyEBSA (3272) 1shy877shy267shy2323 Ext 61565

117

Summary Information

























19121-c1-30 (70-10)_0

19121-pg31-36 (70-10)_0

19121-pg37-100 (70-10)_0

19121-pg101-118 (70-10)_0

Summary Information

























Table of Contents

Page





























1











2
















3


Current Employees




























4

















5







FSAFEDS




6



FEGLI












7






Key FEHB facts













8














9










10















11






Key FEDVIP facts













12

















13














14

















15





Key FSAFEDS facts










16













17















18


How do I enroll










19




Key FEGLI facts



















20











How do I enroll








21




Key FLTCIP facts












22





How do I apply








23


24


















25







donrsquot



















26












27


Definitions













28















Yes

Yes

Yes

Not Applicable

Yes

No

Yes

Not Applicable

Yes

Yes

Yes

No

Yes

Not Applicable

Yes

Yes

Yes

No

Yes1

Not Applicable

Yes

Not Applicable

Yes

Yes2



29













30










31













Telephone Number

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family






MHBP shystd

MHBP shyValue Plan

NALC shyhigh

NALC Value Option

SAMBA shyhigh

SAMBA shystd






800shy222shy2798

Local phone

Local phone

800shy821shy6136

800shy821shy6136

800shy410shy7778

800shy410shy7778

888shy636shy6252

888shy636shy6252

800shy638shy6589

800shy638shy6589

888shy438shy9135

202shy833shy4910

800shy424shy8196

800shy638shy8432

471

104

111

311

314

454

414

321

KM1

441

444

421

401

431

381

472

105

112

312

315

455

415

322

KM2

442

445

422

402

432

382

13670

19028

13209

20317

10418

20913

11302

16122

9001

27523

13171

15613

12535

11170

18913

30910

44412

30930

48310

23691

50565

26946

32727

19546

70356

30081

39039

30885

23316

30210

6309

8782

6096

9377

4808

9652

5216

7441

4154

12703

6079

7206

5785

5155

8729

14266

20498

14275

22297

10934

23338

12436

15105

9021

32472

13884

18018

14255

10761

13943


32




APWU shyhigh

BCBS shystd

BCBS shybasic

GEHA shyhigh

GEHA shystd

MHBP shystd

MHBP shyValue

NALC shyhigh

NALC Value

SAMBA shyhigh

SAMBA shystd

CRHP

FS

PCABP

Rural

Plan

PPO NonshyPPO

PPO NonshyPPO

PPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

NonshyPPO PPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

Benefit Type


$350 None $250 $350 None $350 + 35+


$350 None $100 $350 None $300


$400 None $200 $600 None $500


$300 None $200 $300 None $350

$4000 None 50 $2000 None 20

$300 None $200 $300 None $300


$350 None $200 $400 None $400



$350 $200 $100 $400 $200 $300

Deductible

Calendar Year

Prescription Drug

Hospital Inpatient

Per Person

$18 10 10 $8 2525 Yes 30+diff 30+diff 30 50 5050 Yes







$20 15 Nothing 20 3045 Yes 30 30 30 45+ 45+45+ Yes

50 50 50 50 5050+ No 20 20 20 $10 $40$60 No






$20 10 Nothing 30 3030 Yes 25 25 25 30 3030 Yes



RampB

Prescription Drugs



Office Visits


T2 $45 T3 50($55Min) T4 $50to$140 T5 $70to$195


33













Plan Code


Getting needed care


How well doctors


Claims processing





47

10 835 946 917 955 926 956 703



10

11

31

757

838

896

934

891

922

95

961

921

912

936

929

643

699


31

31 725 907 895 949 875 926 688

MHBP shystd

31

45 84 938 916 935 906 954 696

MHBP shyValue Plan

45

41 63 908 857 929 866 887 636

NALC shyhigh

41

32 856 936 922 959 934 965 771


32

KM

SAMBA shyhigh

KM

44 897 947 943 96 946 953 789

SAMBA shystd

44

44 816 93 905 956 911 946 757



44

42

roups

verage

837

805

941

927

945

917

962

951

94

911

927

934

747

716


42

40 798 898 909 935 892 889 721


40

43


43

38 865 946 947 967 928 966 773 38

34



Plan Name Location


Plan Code


Getting needed care


How well doctors


Claims processing




Arizona 10 11

851 747

905 898

919 884

933 923

938 914

969 928

724 680


California 10 11

809 705

915 873

897 840

954 943

881 910

937 912

677 616



768 691

935 893

930 874

951 940

882 881

898 922

657 622


Florida 10 11

864 806

942 916

922 894

952 947

934 916

954 937

733 660


Illinois 10 11

861 796

933 912

934 881

955 950

901 936

972 938

712 653


Maryland 10 11

857 770

931 897

917 898

954 940

897 921

956 967

713 666


Texas 10 11

887 825

934 898

931 883

950 955

936 910

957 967

721 617


Virginia 10 11

871 782

924 901

929 894

966 962

914 917

959 960

708 681

35


36















37



Enrollment Code

Monthly Biweekly


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Alabama


Alaska


Arizona









Arkansas





38


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Alabama




Alaska

4040 40 50+ 50+50+ No



Arizona

4040 40 50+ 50+50+ No










Arkansas

$25$40 $500day x 3 $10 $40$60 Yes





39



Enrollment Code

Monthly Biweekly


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

California
















Colorado




Connecticut


Delaware





40


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

California

HMOPOS National 679 864 849 942 877 875 649


to$1200 Yes

Average
















Colorado

$25$40 30 $10 $25$50 Yes 701 80 804 923 825 889 57





Connecticut

$20$40 10 $15 $40$80 Yes 722 884 873 936 876 879 622



Delaware

4040 40 50+ 50+50+ No





41











Florida


















Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



42


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs



HMOPOS Nationa

30to$60050 to$1200 Yes

l Average 679 864 849 942 877 875 649






4040

$15$30

$20$35

$25$35

Nothing$35

40

$150day x3

10 Plan Allow

$200

$200

50+

$5

$10

Nothing

Nothing

50+50+

$35$100

$35$100

$35$65

$35$65

No

Yes

Yes

Yes

Yes

69

69

648

648

844

844

86

86

872

872

833

833

942

942

925

925

865

865

846

846

914

914

902

902

567

567

54




MD IPAshyHigh

Florida


$70$70

$10$20

$20$30

$25$40

$25$40

$500

$100

$250dayx3

$150day x 3

20

Nothing

$7$17 Net

$12$22Net

$7

$10

$35$65

$30$50$45$65

$35$55$50$70

$30$60

30to$60050 to$1200

Yes

Yes

Yes

Yes

Yes

83

83

583

867

867

846

831

831

876

927

927

937

813

813

867

836

836

841

702

702

677








4040

$15$40

$25$45

$15$25

$15$30

$20$50

$35$55

40

$250dayx3

$300dayx3

$250

Ded + $150x3

Ded + $150x5

20

50+

$5

$10

$15 Tier 1

$3$20

$3$10

$10

50+50+

$30$5030

$40$6030


$40$6020

$50$7020

$40$60

No

No

No

No

No

No

Yes

746

746

855

514

514

877

877

905

808

808

847

847

905

764

764

957

957

953

921

921

919

919

938

827

827

87

87

946

783

783

68

68

755

535

535



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No










5050

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

50

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$10+

$10

$10

$10

$10

$10

$10

$10

$10

$40+$60+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

529

529

86

86

824

824

937

937

846

846

843

843

687

687

43


Georgia













Guam









Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



44


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Georgia


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649




4040

$20$35

$35$55

40

$250day x 4

20

50+

$10

$10

50+50+

$35$100

$40$60

No

Yes

Yes

59 90 878 941 86 857 62



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No










Guam


5050

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$30

$20$35

$15$40

50

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250dayx3

$250dayx3

$200

$10+

$10

$10

$10

$10

$10

$10

$10$20 Comm

$15$25 Comm

$10

$40+$60+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$50 Comm

$40$50 Comm

$2550 of AWP

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

514

794

794

883

845

845

837

85

85

941

935

935

859

884

884

849

839

839

556

625

625


TakeCareshyHigh

TakeCareshyStandard


3030

$5 at FHP$40

$5 at FHP$40

$25$40

30

$100day for 5

$150day for 5

20

NA

$10

$15

$10

NA

$25$50

$40$80

30to$60050 to$1200

NA

Yes

Yes

Yes

687

687

669

669

686

686

904

904

792

792

786

786

571

571


HMSA InshyNetwork

4040

$15$15

40

$100

50+

$7

50+50+

$30$65

No




3030

$20$20

$30$30

30

$100

10

$7 + 20

$10

$15

$45$45

$50$50

$30 + 20$65 + 20 No

Yes

Yes

754

754

826

826

815

815

94

94

875

875

811

811

613

613

45


Idaho








Illinois
















Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



46


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

6

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Idaho


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649






SelectHealthshyHigh


Illinois


4040

$20$30

$20$40

$25$25

$25$35

$15$25

$20$30

$25$40

40

$200

None

$350

$500

$100

$100 after

20

50+

$7

$7

$20

$20

$5 $25$50

$5

$10

50+50+

$25$50

$35$60

$40$60

$40$60

$25$50$50

$25$50

30to$60050 to$1200

No

No

None

Yes

Yes

Yes

Yes

Yes

552

552

659

659

629

629

852

852

86

86

876

876

813

813

869

869

851

851

948

948

941

941

958

958

883

883

912

912

912

912

895

895

881

881

903

903

588

588

692

692

64

64




4040

$20$35

$25$35

40

Nothing

$500

50+

$10 copay

$5

50+50+

$40$60

$40$6025 $6025

No

Yes







30 after ded

$25$50

$25$50

$20$35

$25$40

$35$55

30 after ded

$200day x 5

20

$250day x 3

$500day x 3

20

NA

$7

$7

$10

$10

$10

NA

$35$70

$35$70

$40$60

$40$60

$40$60

NA

Yes

Yes

Yes

Yes

Yes

745 915 88 962 878 868 67



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No







5050

$20$35

$25$40

$15$15

$25$40

$25$50

50

$250day x 3

$500day x 3

None

$450

20

$10+

$10

$10

$10

$7

$10

$40+$60+

$40$60

$40$60

$35$60

$30$60

$35$50

No

Yes

Yes

Yes

Yes

Yes

647

647

665

577

822

822

919

896

788

788

902

86

943

943

957

956

859

859

892

914

834

834

898

918

66

66

732

623

47


Indiana












Iowa












Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



48


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Indiana


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649





4040

$25$50

$25$50

$35$55

40

$200day x 5

20

20

50+

$7

$7

$10

50+50+

$35$70

$35$70

$40$60

No

Yes

Yes

Yes

745 915 88 962 878 868 67









Iowa


5050

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$15

$25$40

50

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

20

20

$10+

$10

$10

$10

$10

$10

$10

$10

$10

$40+$60+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$25$50

30to$60050 to$1200

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

647

647

562

822

822

878

788

788

815

943

943

934

859

859

868

834

834

893

66

66

593









4040

$25$50

$25$50

$25$50

$25$50

$25$45

$0 for 3 then 20

$20$30

40

20

20

$200day x 5

20

Nothing

20 in40 out

$100day x 5

50+

$3 $10

$3 $10

$7

$7

$12

$9

$15

50+50+

$45$70$100

30$5000 Max

$35$70

$35$70

$45$90

$40$70

$30$50

No

Yes

No

Yes

Yes

Yes

Yes

NA

562

562

745

647

647

535

905

905

915

893

893

903

888

888

88

875

875

89

964

964

962

951

951

977

837

837

878

92

92

902

903

903

868

911

911

912

652

652

67

725

725



4040

$25$25

40

$100day x 5

40+

$15

40+40+

$30$50

NA



40+40+

$25$50

40+

20

40+

$10

40+40+

$35$50

NA

Yes 577 896 86 956 914 918 623

49





Kansas








Kentucky








Louisiana









50


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Kansas


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649






4040

$20$35

$30$60

$30$60

$35$55

40

$250day x 4

25

30

20

50+

$10

$3 $12

$3 $12

$10

50+50+

$35$100

$50$75

$5020

$40$60

No

Yes

Yes

Yes

Yes

639

602

602

862

906

906

862

88

88

94

96

96

838

894

894

901

884

884

538

663

663




Kentucky


5050

$20$35

$25$40

$25$40

50

$250day x 3

$500day x 3

20

$10+

$10

$10

$10

$40+$60+

$40$60

$40$60

30to$60050 to$1200

No

Yes

Yes

Yes

676

676

903

903

901

901

951

951

881

881

918

918

729

729








Louisiana


4040

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$25$40

40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

20

50+

$10

$10

$10

$10

$10

$10

$10

50+50+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

30to$60050 to$1200

No

Yes

Yes

Yes

Yes

Yes

Yes








4040

$25$45

$30$55

$20$35

$35$40

$20$35

$35$40

40

Ded+$100

Ded+30

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+

$5

$5

$10

$10

$10

$10

50+50+

$40$100

$40$100

$40$60

$40$60

$40$60

$40$60

No

Yes

Yes

Yes

Yes

Yes

Yes

573

573

874

874

823

823

968

968

831

831

827

827

625

625

51





Maine


Maryland











Massachusetts




52


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Maine


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649


Maryland


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No






4040

$15$30

$20$35

$25$35

Nothing$35

40

$150day x3

10 Plan Allow

$200

$200

50+

$5

$10

Nothing

Nothing

50+50+

$35$100

$35$100

$35$65

$35$65

No

Yes

Yes

Yes

Yes

69

69

648

648

844

844

86

86

872

872

833

833

942

942

925

925

865

865

846

846

914

914

902

902

567

567

54






MD IPAshyHigh

Massachusetts


$70$70

$20$40

$20$40

$10$20

$20$30

$25$40

$25$40

$500

$200day x 3

$200day x 3

$100

$250dayx3

$150day x 3

20

Nothing

$3$15

$3$15

$7$17 Net

$12$22Net

$7

$10

$35$65

$30$60

$30$60

$30$50$45$65

$35$55$50$70

$30$60

30to$60050 to$1200

Yes

Yes

Yes

Yes

Yes

Yes

Yes

563

563

83

83

583

864

864

867

867

846

864

864

831

831

876

969

969

927

927

937

892

892

813

813

867

871

871

836

836

841

606

606

702

702

677



4040

$25$35

40

$150 to $750max

50+

$10

50+50+

$30$60

No

Yes 627 851 882 929 883 801 649

53





Michigan










Minnesota






54


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Michigan


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649










Minnesota


4040

$15$25

$15$25

$10$10

$20$20

$10$20

$15$30

$10$20

$15$15

$25$40

40

Nothing

Nothing

Nothing

$500x3

Nothing

Nothing

None

None

20

50+

$10

$10

$5

$10

$5

$15

$0$8

$10

$10

50+50+

$30$60

$30$60

$15$15

NA$40

$50$50

$50$50

$40$60

$40$40

30to$60050 to$1200

No

Yes

Yes

No

No

Yes

Yes

Yes

Yes

Yes

651

651

742

742

793

793

793

899

899

90

90

888

888

919

875

875

912

912

862

862

92

933

933

952

952

943

943

951

884

884

883

883

899

899

946

937

937

836

836

902

902

919

672

672

795

795

656

656

658





4040

$25$45

$0 for 3 then 20

$25$40

40

Nothing

20 in40 out

20

50+

$12

$9

$10

50+50+

$45$90

$40$70

30to$60050 to$1200

No

Yes

Yes

Yes

647

647

893

893

875

875

951

951

92

92

911

911

725

725


55











Montana


Nebraska


Nevada




New Hampshire



Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



56


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649




4040

$20$35

$25$35

40

$250day x 4

$500

50+

$10

$5

50+50+

$35$100 $40$60

25$6025

No

Yes

Yes

639

647

862

891

862

861

94

961

838

84

901

864

538





30 after ded

$30$60

$30$60

$35$55

30 after ded

25

30

20

NA

$3 $12

$3 $12

$10

NA

$50$75

$5020

$40$60

NA

Yes

Yes

Yes

602

602

906

906

88

88

96

96

894

894

884

884

663

663





Montana


5050

$20$35

$25$40

$25$40

$25$40

50

$250day x 3

$500day x 3

$450

20

$10+

$10

$10

$7

$10

$40+$60+

$40$60

$40$60

$30$60

30to$60050 to$1200

No

Yes

Yes

Yes

Yes

676

676

665

903

903

919

901

901

902

951

951

957

881

881

892

918

918

898

729

729

732


Nebraska


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No


Nevada


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No




New Hampshire


4040

$20$35

$10$25

$25$40

40

$250day x 4

$300

20

50+

$10

$7

$10

50+50+

$35$100

$35$55$100

30to$60050 to$1200

No

Yes

Yes

Yes

602

516

838

696

861

66

923

892

849

892

918

912

636

529


57


New Jersey








New Mexico





Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code


Monthly Biweekly


58


Prescription Drugs


Mail lan

eeded

are

ll icate

r ng rm

ation




order discount

Ove

rall p

satisfaction

Gettin

g n

care

Gettin

g c

quickly

How

we

doctors

commun

Custome

service

Claim

sproce

ssi

Plan

Info

on

Costs

New Jersey


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649







$15$35

$20$20

20 Plan Allow

$150max$450

$5

$20

$35$100

$45$85

Yes

Yes

631

663

852

844

837

851

928

936

895

86

809

828

623



New Mexico


50 of sch

$30$30

$25$40

+50 of sch

$250day x 3

20

NA

$10

$10

NA

$45$85

30to$60050 to$1200

No

Yes

Yes

663 844 851 936 86 828 642




59


New York

























Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



60

North Dakota


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

New York



30to$60050 to$1200 Yes

l vera e 679 864 849 942 877 875 649









4040

$20$35

$15$35

$20$30

$25$40

$25$40

$25$40

$20$20

40

$250day x 4

20 Plan Allow

$100 x 5

$500+10

$500

$500

$150max$450

50+

$10

$5

25

30

$10

$10

$20

50+50+

$35$100

$35$100

2525

3030

$30$50

$30$50

$45$85

No

Yes

Yes

No

No

Yes

Yes

Yes

662

662

729

729

663

848

848

928

928

844

849

849

90

90

851

937

937

949

949

936

888

888

922

922

86

874

874

924

924

828

547

547

70

70






50 of sch

$30$30

$20$40

$30$50

$25$25

+50 of sch

$250day x 3

None

$1000

$250

NA

$10

$15

$15$100Ded

$10

NA

$45$85

$35$75

$30$75

$35$75 $75$100Ded

No

Yes

Yes

Yes

No

663

729

729

735

844

814

814

933

851

786

786

923

936

888

888

952

86

787

787

92

828

848

848

916

642

60

60



2525

$30$50

25

$750

NA

$10

NA

$5050

No












3030

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

30

$500

$750

$500

$750

$500

$750

$500

$750

$500

$750

NA

$5

$5

$5

$5

$5

$5

$5

$5

$5

$5

NA

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

739

739

739

739

739

739

739

739

739

739

934

934

934

934

934

934

934

934

934

934

89

89

89

89

89

89

89

89

89

89

962

962

962

962

962

962

962

962

962

962

896

896

896

896

896

896

896

896

896

896

92

92

92

92

92

92

92

92

92

92

768

768

768

768

768

768

768

768

768

768

61


North Carolina


North Dakota







Ohio








Oklahoma




Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



62


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

North Carolina


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649


North Dakota


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No





4040

$25$45

$0 for 3 then 20

$15$25

40

Nothing

20 in40 out

None

50+

$12

$9

50$600ded

50+50+

$45$90

$40$70

50$600 ded

No

Yes

Yes

None

647

647

893

893

875

875

951

951

92

92

911

911

725

725



2020

$20$30

20

$100day x 5

NA

$15

NA

$30$50

NA



4040

$25$25

40

$100day x 5

40+

$15

40+40+

$30$50

NA


Ohio


40+40+

$25$40

40+

20

40+

$10

40+40+

30to$60050 to$1200

NA


AultCare HMOshyHigh






Oklahoma


4040

$15$20

$20$35

$25$40

$20$20

$30$40

$10$20

$25$40

40

$150

$250day x 3

$500day x 3

$250

$500

$250

20

50+

$15

$10

$10

$10

$15

$15

$10

50+50+

$30$40$55

$40$60

$40$60

$30$30

$40$40

$30$50

30to$60050 to$1200

No

No

Yes

Yes

Yes

Yes

Yes

Yes

877

788

788

744

922

845

845

909

907

889

889

876

941

922

922

951

944

935

935

929

935

906

906

944

853

708

708

745



4040

$15$45

40

$250dymx1000

50+

$4$10

50+50+

$45$70

No

Yes 592 816 839 916 893 872 727

63


Oregon




Pennsylvania









Puerto Rico



Rhode Island


South Carolina



Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



64


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Information

on Costs

Oregon


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649




Pennsylvania


4040

$20$30

$30$40

$25$40

40

$200

$500

20

50+

$15

$20

$10

50+50+

$40$60

$40$60

30to$60050 to$1200

No

Yes

Yes

Yes

768

768

844

844

847

847

916

916

927

927

89

89

683

683









Puerto Rico


4040

$20$35

$15$35

$20$35

$20$35

$25$50

10 after Deduct

20 after Deduct

$5$5

40

$250day x 4

20 Plan Allow

$250day x 4

20aftrDeduct

15 after ded

10 after deduct

20after Deduct

None

50+

$10

$5

$10

30 $5$15

$5

$5 after ded

$5 after ded

$250

50+50+

$35$100

$35$100

$35$100

$35$60

$35$75

$35$75$100

$10$15

40 $40$120 50 $85$250

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

579

579

579

668

699

754

754

806

861

861

861

868

873

908

908

803

835

835

835

85

885

899

899

82

935

935

935

938

957

97

97

938

887

887

887

906

86

913

913

887

899

899

899

902

921

904

904

70

631

631

631

677

671

678

678




Rhode Island


$750$10

$25$40

$750 amp 10 +$10 amp 10 +

None 10 +

20

$5 or $12 NA

$10

NANA

2025 up to$100$175max

30to$60050 to$1200

Yes No

Yes

691 874 844 963 872 75 586


South Carolina


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No


65


South Dakota






Tennessee






Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



66


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

South Dakota



30to$60050 to$1200 Yes

679 864 849 942 877 875 649





4040

$25$45

$20$30

$0 for 3 then 20

40

Nothing

$100day x 5

20 in40 out

50+

$12

$9

$15

50+50+

$45$90

$40$70

$30$50

No

Yes

Yes

NA

647

647

535

893

893

903

875

875

89

951

951

977

92

92

902

911

911

912

725

725



4040

$25$25

40

$100day x 5

40+

$15

40+40+

$30$50

NA

NA

535


Tennessee


40+40+

$25$40

40+

20

40+

$10

40+40+

30to$60050 to$1200

NA





4040

$20$35

$20$35

$25$40

40

$250day x 4

$250day x 3

$500day x 3

50+

$10

$10

$10

50+50+

$35$100

$40$60

$40$60

No

Yes

Yes

Yes

66 875 868 959 889 914 69

67


Texas






















Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



68


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Texas


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649



4040

$5$25$35

40

15

50+

$5

50+50+

$35$60

No


FirstcareshyHigh

FirstcareshyHigh

FirstcareshyHigh

FirstcareshyHigh

FirstcareshyHigh


4040

$30$55

$30$55

$30$55

$30$55

$30$55

$35$55

40

$250day x 5

$250day x 5

$250day x 5

$250day x 5

$250day x 5

20

40

$10

$10

$10

$10

$10

$10

4040

$35$70

$35$70

$35$70

$35$70

$35$70

$40$60

No

Yes

Yes

Yes

Yes

Yes



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No












5050

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$45

$20$40

50

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

10

$250day x 5

$10+

$10

$10

$10

$10

$10

$10

$10

$10

$5

$10

$40+$60+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$45$100

$35$60

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

63

63

702

835

835

862

764

764

863

931

931

937

864

864

875

856

856

87

673

673

569

69



Enrollment Code

Monthly Biweekly


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family








Vermont

Virgin Islands

Utah


70


Prescription Drugs


Mail lan

eeded

are

ll icate

r ng rm

ation




order discount

Ove

rall p

satisfaction

Gettin

g n

care

Gettin

g c

quickly

How

we

doctors

commun

Custome

service

Claim

sproce

ssi

Plan

Info

on

Costs

Utah


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649






Vermont


$20$30

$25$40

$100 after

20

$5$25$50

$10

$25 $50$50

30to$60050 to$1200

Yes

Yes

629 876 851 958 912 903 64


Virgin Islands

4040 40 50+ 50+50+ No


$750$10 $750 amp 10 + $10 amp 10 +

None 10 +

$5 or $12 NA NANA

2025 up to$100$175max

Yes No

691 874 844 963 872 75 586

71


Virginia















Washington










Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



72


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Virginia








$25$40 4040

$15$30

$20$35

$25$35 4040

$5$25$35 4040

$25$35

Nothing$35

20 40

$150day x3

10 Plan Allow

15 40

15 40

$200

$200

$10 50+

$5

$10

$5 40

$5 40

Nothing

Nothing

HMOP

50+50+

$35$100

$35$100

$35$60 4040

$35$60 4040

$35$65

$35$65

30to$60050 to$1200

OS National

Yes No

Yes

Yes

Yes No

Yes No

Yes

Yes

Average

69

69

648

648

679

844

844

86

86

864

872

872

833

833

849

942

942

925

925

942

865

865

846

846

877

914

914

902

902

875

567

567

54

54

649





MD IPAshyHigh




Washington









$70$70

$10$20

$20$30

$25$40

$25$30

$35$35

$25$40 4040

$20$35

$25$25

$25$35

$154 or 2020

$30$30 $30+40+diff

$20$30

$30$40


$20$0childlt22$30


$500

$200 x3 days

$100

$250dayx3

$150day x 3

$150max$750

$20020

20

20 40

$250day x 4

$350

$500

Nothing Nothing

None None

$200

$500

Nothing

$0

$7$17 Net

$12$22Net

$7

$10

$10

$15

$10 50+

$10

$20

$20

$10 Not Covered

$5 Not Covered

$15

$20

$35$65

$30$50$50

$30$50$45$65

$35$55$50$70

$30$60

$40$55

50+50+

$35$100

$40$60

$40$60

Not Covered

NA

$40$60

$40$60

$353050up to $3000

$355050 up to $3000

$35$50 30day $100 90day

$25$50 30day$100 90day

30to$60050 to$1200

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes No

Yes

Yes

Yes

Yes No

Yes No

Yes

Yes

83

83

583

692

692

659

659

798

798

768

768

867

867

846

864

864

86

86

94

94

844

844

833

831

831

876

886

886

869

869

928

928

847

847

927

927

937

969

969

941

941

957

957

916

916

813

813

867

87

87

912

912

931

931

927

927

836

836

841

916

916

881

881

897

897

89

89

702

702

677

674

674

692

692

65

65

683

683

73


West Virginia



Wisconsin









Wyoming





Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



74


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

West Virginia


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649



Wisconsin


4040

$10$20

$25$40

40

$250

20

50+

$15

$10

50+50+

$30$50

30to$60050 to$1200

No

Yes

Yes

744 909 876 951 929 944 745



4040

$25$35

40

15

50+

$5

50+50+

$35$60

No








Wyoming


4040

$25$25

$10$10

$25$45

$0 for 3then 20

$10$10

$10$10

$25$40

40

None

None

Nothing

20 in40 out

Nothing

Nothing

20

40

$10

$5

$12

$9

$10

$10

$10

4040

$20$20

$45$90

$40$70

$20$50

3050

30$75max 50 wmin$50

30to$60050 to$1200

No

Yes

Yes

Yes

Yes

Yes

No

Yes

682

785

647

647

784

601

909

834

893

893

888

857

90

834

875

875

854

822

97

953

951

951

938

96

834

929

92

92

888

863

879

932

911

911

87

866

588

718

725

725

684

686




4040

$20$30

$20$40

40

$200

None

50+

$7

$7

50+50+

$25$50

$35$60

No

No

None

552

552

852

852

813

813

948

948

883

883

895

895

588

588

75











76



















insurance plans

77



ELIGIBILITY

FUNDING







CONTRIBUTIONS

DISTRIBUTIONS







ANNUAL ROLLOVER







78





79












Self only

Self amp family

Self only

Self amp family

Self only

Self amp family





800shy718shy1299

800shy821shy6136

800shy694shy9901

888shy636shy6252

474 475

341 342

481 482

324 325

9742

11021

13642

10454

21915

25172

30912

22700

4496 10115

5087 11618

6296 14267

4825 10477


80














81













Plan Code


Getting needed care


How well doctors


Claims processing






22

34

48

606

623

614

891

873

891

888

851

859

952

923

912

830

863

887

879

865

885

563

602

590


Plan Code


Getting needed care


How well doctors


Claims processing







22

47

TP TU TV

MW

606

664

566

478

891

909

849

875

888

907

864

801

952

925

932

948

830

871

843

856

879

845

853

812

563

680

542

555

82


83



Plan Name

Telephone Number


Self only

Self amp family

Self only

Self amp family

Self only

Self amp family



Alabama


Alaska


Arizona


Arkansas


California


Colorado


Plan Name

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

Telephone Number


F51

JS1

G51

F51

JS1

G51

Self only

F52

JS2

G52

F52

JS2

G52

Self amp family

16322

22787

21977

16322

22787

21977

Self only

39021

53701

51861

39021

53701

51861

Self amp family

7533

10517

10143

7533

10517

10143

Self only

18010

24785

23936

18010

24785

23936

Self amp family


84

Benefit Type


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs



Alabama


Alaska


Arizona


Arkansas


California


Colorado


Plan Name







Benefit Type

$8333$16666 $8333$16666

$8333$16666 $8333$16666

$8333$16666 $8333$16666

$8333$16666 $8333$16666

$8333$16666 $8333$16666

$8333$16666 $8333$16666


$1000$2000 $1000$2000

$1000$2000 $1000$2000

$1000$2000 $1000$2000

$1000$2000 $1000$2000

$1000$2000 $1000$2000

$1000$2000 $1000$2000

CY Ded SelfFamily

$4000$8000 $5000$10000

$4000$8000 $5000$10000

$4000$8000 $5000$10000

$4000$8000 $5000$10000

$4000$8000 $5000$10000

$4000$8000 $5000$10000


15 40

15 40

15 40

15 40

15 40

15 40

Office Visit

15 40

15 40

15 40

15 40

15 40

15 40

Inpatient Hospital

15 40

15 40

15 40

15 40

15 40

15 40

Outpatient Surgery

Nothing FundDed40

Nothing FundDed40

Nothing FundDed40

Nothing FundDed40

Nothing FundDed40

Nothing FundDed40

Preventive Services

$10$35$60 40+40+40+

$10$35$60 40+40+40+

$10$35$60 40+40+40+

$10$35$60 40+40+40+

$10$35$6 40+40+40+

$10$35$60 40+40+40+

Prescription Drugs

Levels I II III

85



Connecticut


Delaware





Florida





Georgia




Guam


Plan Name

877shy459shy6604

877shy459shy6604

877shy459shy6604

888shy789shy9065

877shy459shy6604

800shy441shy5501

888shy393shy6765

888shy393shy6765

877shy459shy6604

888shy393shy6765

888shy393shy6765

671shy647shy3526

Telephone Number


EP1

EP1

F51

B61

F51

J41

MJ1

QP1

F51

AD1

LM1

KX1

Self only

EP2

EP2

F52

B62

F52

J42

MJ2

QP2

F52

AD2

LM2

KX2

Self amp family

20174

20174

16322

14018

16322

13979

12818

10987

16322

11598

12208

6822

Self only

47770

47770

39021

31268

39021

43929

28521

24447

39021

25804

27163

17900

Self amp family

9311

9311

7533

6470

7533

6452

5916

5071

7533

5353

5634

3148

Self only

22048

22048

18010

14431

18010

20275

13163

11283

18010

11910

12537

8261

Self amp family


86

Connecticut


Delaware





Florida





Georgia




Guam


Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type


87




Idaho



Illinois




Indiana



Iowa



Kansas




Plan Name

877shy459shy6604

877shy459shy6604

800shy377shy4161

877shy459shy6604

888shy393shy6765

888shy393shy6765

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy257shy4692

877shy459shy6604

800shy969shy3343

888shy393shy6765

Telephone Number


JS1

H41

9K4

H41

GB1

MW1

JS1

MW1

H41

SV4

G51

9H1

PH1

Self only

JS2

H42

9K5

H42

GB2

MW2

JS2

MW2

H42

SV5

G52

9H2

PH2

Self amp family

22787

16237

8704

16237

12208

12208

22787

12208

16237

8970

21977

12747

10987

Self only

53701

38826

18033

38826

27163

27162

53701

27162

38826

21408

51861

29956

24447

Self amp family

10517

7494

4017

7494

5634

5634

10517

5634

7494

4140

10143

5883

5071

Self only

24785

17920

8323

17920

12537

12536

24785

12536

17920

9880

23936

13826

11283

Self amp family


88


Idaho



Illinois




Indiana



Iowa



Kansas




Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

89



Kentucky




Maine









Plan Name

877shy459shy6604

888shy393shy6765

877shy459shy6604

877shy459shy6604

877shy459shy6604

888shy789shy9065

800shy833shy7423

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

Telephone Number


H41

6N1

F51

EP1

F51

B61

GZ1

EP1

G51

H41

H41

Self only

H42

6N2

F52

EP2

F52

B62

GZ2

EP2

G52

H42

H42

Self amp family

16237

10987

16322

20174

16322

14018

11980

20174

21977

16237

16237

Self only

38826

24447

39021

47770

39021

31268

26835

47770

51861

38826

38826

Self amp family

7494

5071

7533

9311

7533

6470

5529

9311

10143

7494

7494

Self only

17920

11283

18010

22048

18010

14431

12385

22048

23936

17920

17920

Self amp family


90

Kentucky




Maine









Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

91






Nebraska


Nevada


New Hampshire


New Jersey


New Mexico




Plan Name


877shy459shy6604

800shy969shy3343

888shy393shy6765

77shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

800shy501shy3439

Telephone Number


G51

9H1

PH1

H41

H41

G51

EP1

EP1

G51

EP1

QA4

Self only

G52

9H2

PH2

H42

H42

G52

EP2

EP2

G52

EP2

QA5

Self amp family

21977

12747

10987

16237

16237

21977

20174

20174

21977

20174

9575

Self only

51861

29956

24447

38826

38826

51861

47770

47770

51861

47770

24919

Self amp family

10143

5883

5071

7494

7494

10143

9311

9311

10143

9311

4419

Self only

23936

13826

11283

17920

17920

23936

22048

22048

23936

22048

11501

Self amp family


92





Nebraska


Nevada


New Hampshire


New Jersey


New Mexico




Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

93



North Carolina


North Dakota






Pennsylvania




Rhode Island


South Carolina


Plan Name

877shy459shy6604

877shy459shy6604

877shy459shy6604

330shy363shy6360

877shy459shy6604

877shy459shy6604

877shy459shy6604

866shy351shy5946

888shy876shy2756

877shy459shy6604

877shy459shy6604

Telephone Number


F51

H41

JS1

3A4

JS1

H41

H41

Y61

8W4

EP1

JS1

Self only

F52

H42

JS2

3A5

JS2

H42

H42

Y62

8W5

EP2

JS2

Self amp family

16322

16237

22787

8669

22787

16237

16237

12298

12448

20174

22787

Self only

39021

38826

53701

17501

53701

38826

38826

28345

28053

47770

53701

Self amp family

7533

7494

10517

4001

10517

7494

7494

5676

5745

9311

10517

Self only

18010

17920

24785

8077

24785

17920

17920

13082

12948

22048

24785

Self amp family


94

North Carolina


North Dakota






Pennsylvania




Rhode Island


South Carolina


Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Benefit Type

Prescription Drugs

Levels I II III




30 after deduct

95



South Dakota


Tennessee








Vermont




Plan Name

877shy459shy6604

877shy459shy6604

877shy459shy6604

888shy393shy6765

888shy393shy6765

888shy393shy6765

877shy459shy6604

800shy377shy4161

877shy459shy6604

877shy459shy6604

888shy789shy9065

Telephone Number


G51

G51

JS1

TP1

TU1

TV1

G51

9K4

EP1

F51

B61

Self only

G52

G52

JS2

TP2

TU2

TV2

G52

9K5

EP2

F52

B62

Self amp family

21977

16322

22787

12208

12208

13429

21977

8704

20174

16322

14018

Self only

51861

39021

53701

27163

27162

29879

51861

18033

47770

39021

31268

Self amp family

10143

7533

10517

5634

5634

6198

10143

4017

9311

7533

6470

Self only

23936

18010

24785

12537

12536

13790

23936

8323

22048

18010

14431

Self amp family


96

South Dakota


Tennessee








Vermont




Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

97







Wyoming



Plan Name

877shy459shy6604

800shy552shy7114

877shy459shy6604

877shy459shy6604

877shy459shy6604

800shy377shy4161

Telephone Number


G51

L14

F51

JS1

H41

9K4

Self only

G52

L15

F52

JS2

H42

9K5

Self amp family

21977

10262

16322

22787

16237

8704

Self only

51861

22425

39021

53701

38826

18033

Self amp family

10143

4736

7533

10517

7494

4017

Self only

23936

10350

18010

24785

17920

8323

Self amp family


98





Wyoming



Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

$10$35$50 30day $100 90day

99


100

Appendix F


Waiting Periods





Contributions


Salary Deduction





101


















102










No Yes No No No




Yes Yes No No No


No No No No Yes


or spouse)

No No No Yes No



Yes No No No No


Yes Yes Yes No No


No No No Yes No







103



Reading the Chart


Dental Insurance









Vision Insurance



104



Plan Name

Telephone amp

Website


Class A

Class B

Class C

Class D

Deductible





0 40 60 50 $0




















105



Plan Name

Telephone amp

Website


Class A

Class B

Class C

Class D

Deductible


GEHA Standard






0 20 50 30 $0


0 20 50 30 $0












uccifedvipcom



20 40 60 50 $0


106



Plan Name

You pay

Telephone amp

Website

Class A

Class B

Class C

Class D Deductible













sssprcom


0

0

0

0

0

flat rate

Flat Rate

Approx 30

0

0

30

flat rate

flat rate

Flat Rate

Approx 50

0

0

60 30

flat rate

flat rate

Flat Rate

Approx 60

0

0

50

flat rate

flat rate

$0

$0


$0

$0

$0






107





Additional Features


Aetna Vision High


FEP BlueVision High
















$0

$0


Every24 months

Every 12 months

Every 24 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

108





Additional Features















Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

109



110


AL 356shy358 1 1 1 1 1 1 1 1 1 1 NA NA 3 NA NA



AZ 850shy853 3 5 5 2 2 2 2 1 1 1 NA NA 4 NA NA



CA 919shy921 3 5 5 5 5 4 4 4 4 4 NA NA 5 NA NA


CA 942 956shy958 4 5 5 5 5 4 4 4 4 4 NA NA 5 NA NA


CO 800shy806 3 4 4 3 3 4 4 4 4 3 NA NA 5 NA NA



CT 064shy069 3 5 5 5 5 5 5 5 5 5 NA NA NA 1 NA



FL 330shy334 2 4 4 3 3 3 3 3 3 3 NA NA 2 NA NA


GA 300shy303 305 311 399 3 2 2 2 2 3 3 2 2 1 NA NA 2 NA NA






IL 600shy608 2 2 2 3 3 3 3 4 4 3 NA NA 2 NA NA


IN 460shy462 472 2 1 1 1 1 2 2 1 1 1 NA NA 3 NA NA

IN 463shy464 2 2 2 3 3 3 3 4 4 3 NA NA 2 NA NA

IN 470 2 1 1 1 1 2 2 1 1 1 NA NA 1 NA NA



KY 410 452 459 2 1 1 1 1 2 2 1 1 1 NA NA 1 NA NA







111




MD 200202shy212 214 217 2 5 5 3 3 4 4 4 4 4 4 4 3 NA NA

MD 219 2 4 4 3 3 3 3 3 3 2 5 5 NA NA NA


ME 038 5 5 5 5 5 4 4 5 5 5 NA NA NA NA NA









NC 275shy277 283 4 2 2 2 2 2 2 1 1 2 NA NA 5 NA NA






NJ 3 5 5 5 5 5 5 5 5 5 NA NA NA 1 NA

NJ 080shy084 2 4 4 3 3 3 3 3 3 2 5 5 NA NA NA





NY 063 5 5 5 5 5 4 4 5 5 5 NA NA NA 1 NA

NY 140shy143 4 5 5 3 3 2 2 2 2 3 NA NA NA 1 NA


OH 430shy432 2 1 1 1 1 2 2 1 1 2 NA NA 2 NA NA

OH 440shy443 2 1 1 1 1 2 2 1 1 3 NA NA 2 NA NA

OH 450shy452 2 1 1 1 1 2 2 1 1 1 NA NA 1 NA NA

OH 453shy455 2 1 1 1 1 2 2 1 1 2 NA NA 1 NA NA




070072shy075077shy079085shy089



112




PA 153shy154 156 160shy162 1 2 2 1 1 1 1 1 1 1 1 1 NA NA NA

PA 173shy174 2 5 5 3 3 4 4 4 4 4 4 4 NA NA NA

PA 183 3 5 5 5 5 5 5 5 5 5 1 1 NA 1 NA

PA 189shy196 2 4 4 3 3 3 3 3 3 2 5 5 NA NA NA






TN 422 1 1 1 1 1 1 1 1 1 1 NA NA 1 NA NA


TX 739 2 3 3 1 1 2 2 1 1 1 NA NA 3 NA NA


TX 770 772shy775 2 2 2 1 1 2 2 1 1 1 NA NA 1 NA NA



VA 200shy205 220shy227 2 5 5 3 3 4 4 4 4 4 4 4 3 NA NA

VA 231shy232 238 3 3 3 2 2 2 2 1 1 2 3 3 3 NA NA





WA 986 4 5 5 3 3 3 3 4 4 5 NA NA NA NA NA



WI 540 2 4 4 4 4 3 3 4 4 3 NA NA NA NA NA


WV 254 2 5 5 3 3 4 4 4 4 4 NA NA 3 NA NA


WY 834 4 5 5 3 3 2 2 1 1 2 NA NA NA NA NA





Intershynational



113113

Aetna PPO

Delta Dental PPO

Delta Dental PPO

FEP BlueDental PPO

FEP BlueDental PPO

GEHA PPO

GEHA PPO

MetLife PPO

MetLife PPO












1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

$1288 $1418 $1510 $1666 $1809

$871 $949 $1024 $1080 $1234

$1669 $1831 $2008 $2136 $2485

$939 $1069 $1184 $1249 $1381

$1634 $1860 $2061 $2177 $2408

$900 $989 $1124 $1213 $1347

$1525 $1677 $1904 $2056 $2284

$868 $940 $1044 $1159 $1273

$1606 $1797 $1959 $2121 $2374

$1372 $1541 $1710 $1880 $2049

$2578 $2840 $3022 $3334 $3621

$1744 $1901 $2049 $2160 $2470

$3340 $3663 $4018 $4275 $4973

$1881 $2139 $2370 $2500 $2765

$3270 $3721 $4124 $4357 $4818

$1803 $1981 $2249 $2428 $2697

$3053 $3357 $3812 $4115 $4572

$1738 $1883 $2089 $2320 $2548

$3214 $3597 $3920 $4244 $4750

$2747 $3085 $3422 $3761 $4099

$3867 $4258 $4532 $5001 $5430

$2615 $2850 $3074 $3240 $3704

$5009 $5494 $6026 $6412 $7458

$2820 $3208 $3554 $3749 $4146

$4904 $5581 $6185 $6534 $7226

$2705 $2970 $3372 $3641 $4043

$4579 $5038 $5716 $6174 $6859

$2606 $2823 $3133 $3479 $3821

$4820 $5394 $5879 $6366 $7124

$4118 $4625 $5134 $5641 $6148

$2791 $3073 $3272 $3610 $3919

$1887 $2056 $2219 $2340 $2674

$3616 $3967 $4351 $4628 $5384

$2035 $2316 $2565 $2706 $2992

$3540 $4030 $4466 $4717 $5217

$1950 $2143 $2435 $2628 $2919

$3304 $3634 $4125 $4455 $4949

$1881 $2037 $2262 $2511 $2758

$3480 $3894 $4245 $4596 $5144

$2973 $3339 $3705 $4073 $4440

$5587 $6153 $6549 $7224 $7846

$3779 $4119 $4440 $4680 $5352

$7237 $7937 $8706 $9263 $10775

$4076 $4635 $5135 $5417 $5991

$7085 $8062 $8935 $9440 $10439

$3907 $4292 $4873 $5261 $5844

$6615 $7274 $8259 $8916 $9906

$3766 $4080 $4526 $5027 $5521

$6964 $7794 $8493 $9195 $10292

$5952 $6684 $7414 $8149 $8881

$8378 $9226 $9819 $10835 $11765

$5666 $6175 $6660 $7020 $8025

$10853 $11904 $13056 $13893 $16159

$6110 $6951 $7700 $8123 $8983

$10625 $12092 $13401 $14157 $15656

$5861 $6435 $7306 $7889 $8760

$9921 $10916 $12385 $13377 $14861

$5646 $6117 $6788 $7538 $8279

$10443 $11687 $12738 $13793 $15435

$8922 $10021 $11124 $12222 $13321





Self amp Family




Dominion Dental HMO

Dominion Dental HMO

EmblemHealth PPO

Humana

Triple S Salud PPO










1 2 3 4 5

1 2 3 4 5

1

1 2 3 4 5

1

$596 $622 $694 $829 $884

$1018 $1055 $1109 $1291 $1517

$1826

$990 $1048 $1136 $1378 $1475

$454

$1194 $1246 $1391 $1660 $1771

$2038 $2113 $2221 $2585 $3037

$3652

$1982 $2098 $2273 $2759 $2952

$910

$1790 $1868 $2085 $2489 $2655

$3056 $3168 $3330 $3876 $4554

$5478

$2971 $3146 $3409 $4136 $4428

$1191

$1291 $1348 $1504 $1796 $1915

$2206 $2286 $2403 $2797 $3287

$3956

$2145 $2271 $2461 $2986 $3196

$984

$2587 $2700 $3014 $3597 $3837

$4416 $4578 $4812 $5601 $6580

$7913

$4294 $4546 $4925 $5978 $6396

$1972

$3878 $4047 $4518 $5393 $5753

$6621 $6864 $7215 $8398 $9867

$11869

$6437 $6816 $7386 $8961 $9594

$2581





Self amp Family


114

Aetna


Delta Dental High


FEP BlueDental High

GEHA Standard

GEHA High

MetLife Standard

MetLife High

United Concordia

$1418

$1234

$2485

$1381

$2408

$900

$1525

$1273

$2374

$2049

$2840

$2470

$4973

$2765

$4818

$1803

$3053

$2548

$4750

$4099

$4258

$3704

$7458

$4146

$7226

$2705

$4579

$3821

$7124

$6148

$3073

$2674

$5384

$2992

$5217

$1950

$3304

$2758

$5144

$4440

$9226

$8025

$16159

$8983

$15656

$5861

$9921

$8279

$15435

$13321




Self amp Family

$6153

$5352

$10775

$5991

$10439

$3907

$6615

$5521

$10292

$8881


Premium Rate Charts


Aetna Vision

FEP BlueVision








$680 $1328

$800 $1012

$622 $884

$771 $1339

$1304 $2533

$1601 $2028

$1220 $1729

$1547 $2685

$1913 $3716

$2401 $3042

$1814 $2572

$2321 $4026

$314 $613

$369 $467

$287 $408

$356 $618

Standard High

Standard High

Standard High

Standard High

$602 $1169

$739 $936

$563 $798

$714 $1239

$883 $1715

$1108 $1404

$837 $1187

$1071 $1858







Aetna Vision

FEP BlueVision








$680 $1328

$800 $1012

$622 $884

$771 $1339

$1304 $2533

$1601 $2028

$1220 $1729

$1547 $2685

$1913 $3716

$2401 $3042

$1814 $2572

$2321 $4026

$314 $613

$369 $467

$287 $408

$356 $618

Standard High

Standard High

Standard High

Standard High

$602 $1169

$739 $936

$563 $798

$714 $1239

$883 $1715

$1108 $1404

$837 $1187

$1071 $1858






115

______________________________________________________________________________________________________________

























116
























117

Summary Information

























19121-c1-30 (70-10)_0

19121-pg31-36 (70-10)_0

19121-pg37-100 (70-10)_0

19121-pg101-118 (70-10)_0

Table of Contents

Page





























1











2
















3


Current Employees




























4

















5







FSAFEDS




6



FEGLI












7






Key FEHB facts













8














9










10















11






Key FEDVIP facts













12

















13














14

















15





Key FSAFEDS facts










16













17















18


How do I enroll










19




Key FEGLI facts



















20











How do I enroll








21




Key FLTCIP facts












22





How do I apply








23


24


















25







donrsquot



















26












27


Definitions













28















Yes

Yes

Yes

Not Applicable

Yes

No

Yes

Not Applicable

Yes

Yes

Yes

No

Yes

Not Applicable

Yes

Yes

Yes

No

Yes1

Not Applicable

Yes

Not Applicable

Yes

Yes2



29













30










31













Telephone Number

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family






MHBP shystd

MHBP shyValue Plan

NALC shyhigh

NALC Value Option

SAMBA shyhigh

SAMBA shystd






800shy222shy2798

Local phone

Local phone

800shy821shy6136

800shy821shy6136

800shy410shy7778

800shy410shy7778

888shy636shy6252

888shy636shy6252

800shy638shy6589

800shy638shy6589

888shy438shy9135

202shy833shy4910

800shy424shy8196

800shy638shy8432

471

104

111

311

314

454

414

321

KM1

441

444

421

401

431

381

472

105

112

312

315

455

415

322

KM2

442

445

422

402

432

382

13670

19028

13209

20317

10418

20913

11302

16122

9001

27523

13171

15613

12535

11170

18913

30910

44412

30930

48310

23691

50565

26946

32727

19546

70356

30081

39039

30885

23316

30210

6309

8782

6096

9377

4808

9652

5216

7441

4154

12703

6079

7206

5785

5155

8729

14266

20498

14275

22297

10934

23338

12436

15105

9021

32472

13884

18018

14255

10761

13943


32




APWU shyhigh

BCBS shystd

BCBS shybasic

GEHA shyhigh

GEHA shystd

MHBP shystd

MHBP shyValue

NALC shyhigh

NALC Value

SAMBA shyhigh

SAMBA shystd

CRHP

FS

PCABP

Rural

Plan

PPO NonshyPPO

PPO NonshyPPO

PPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

NonshyPPO PPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

Benefit Type


$350 None $250 $350 None $350 + 35+


$350 None $100 $350 None $300


$400 None $200 $600 None $500


$300 None $200 $300 None $350

$4000 None 50 $2000 None 20

$300 None $200 $300 None $300


$350 None $200 $400 None $400



$350 $200 $100 $400 $200 $300

Deductible

Calendar Year

Prescription Drug

Hospital Inpatient

Per Person

$18 10 10 $8 2525 Yes 30+diff 30+diff 30 50 5050 Yes







$20 15 Nothing 20 3045 Yes 30 30 30 45+ 45+45+ Yes

50 50 50 50 5050+ No 20 20 20 $10 $40$60 No






$20 10 Nothing 30 3030 Yes 25 25 25 30 3030 Yes



RampB

Prescription Drugs



Office Visits


T2 $45 T3 50($55Min) T4 $50to$140 T5 $70to$195


33













Plan Code


Getting needed care


How well doctors


Claims processing





47

10 835 946 917 955 926 956 703



10

11

31

757

838

896

934

891

922

95

961

921

912

936

929

643

699


31

31 725 907 895 949 875 926 688

MHBP shystd

31

45 84 938 916 935 906 954 696

MHBP shyValue Plan

45

41 63 908 857 929 866 887 636

NALC shyhigh

41

32 856 936 922 959 934 965 771


32

KM

SAMBA shyhigh

KM

44 897 947 943 96 946 953 789

SAMBA shystd

44

44 816 93 905 956 911 946 757



44

42

roups

verage

837

805

941

927

945

917

962

951

94

911

927

934

747

716


42

40 798 898 909 935 892 889 721


40

43


43

38 865 946 947 967 928 966 773 38

34



Plan Name Location


Plan Code


Getting needed care


How well doctors


Claims processing




Arizona 10 11

851 747

905 898

919 884

933 923

938 914

969 928

724 680


California 10 11

809 705

915 873

897 840

954 943

881 910

937 912

677 616



768 691

935 893

930 874

951 940

882 881

898 922

657 622


Florida 10 11

864 806

942 916

922 894

952 947

934 916

954 937

733 660


Illinois 10 11

861 796

933 912

934 881

955 950

901 936

972 938

712 653


Maryland 10 11

857 770

931 897

917 898

954 940

897 921

956 967

713 666


Texas 10 11

887 825

934 898

931 883

950 955

936 910

957 967

721 617


Virginia 10 11

871 782

924 901

929 894

966 962

914 917

959 960

708 681

35


36















37



Enrollment Code

Monthly Biweekly


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Alabama


Alaska


Arizona









Arkansas





38


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Alabama




Alaska

4040 40 50+ 50+50+ No



Arizona

4040 40 50+ 50+50+ No










Arkansas

$25$40 $500day x 3 $10 $40$60 Yes





39



Enrollment Code

Monthly Biweekly


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

California
















Colorado




Connecticut


Delaware





40


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

California

HMOPOS National 679 864 849 942 877 875 649


to$1200 Yes

Average
















Colorado

$25$40 30 $10 $25$50 Yes 701 80 804 923 825 889 57





Connecticut

$20$40 10 $15 $40$80 Yes 722 884 873 936 876 879 622



Delaware

4040 40 50+ 50+50+ No





41











Florida


















Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



42


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs



HMOPOS Nationa

30to$60050 to$1200 Yes

l Average 679 864 849 942 877 875 649






4040

$15$30

$20$35

$25$35

Nothing$35

40

$150day x3

10 Plan Allow

$200

$200

50+

$5

$10

Nothing

Nothing

50+50+

$35$100

$35$100

$35$65

$35$65

No

Yes

Yes

Yes

Yes

69

69

648

648

844

844

86

86

872

872

833

833

942

942

925

925

865

865

846

846

914

914

902

902

567

567

54




MD IPAshyHigh

Florida


$70$70

$10$20

$20$30

$25$40

$25$40

$500

$100

$250dayx3

$150day x 3

20

Nothing

$7$17 Net

$12$22Net

$7

$10

$35$65

$30$50$45$65

$35$55$50$70

$30$60

30to$60050 to$1200

Yes

Yes

Yes

Yes

Yes

83

83

583

867

867

846

831

831

876

927

927

937

813

813

867

836

836

841

702

702

677








4040

$15$40

$25$45

$15$25

$15$30

$20$50

$35$55

40

$250dayx3

$300dayx3

$250

Ded + $150x3

Ded + $150x5

20

50+

$5

$10

$15 Tier 1

$3$20

$3$10

$10

50+50+

$30$5030

$40$6030


$40$6020

$50$7020

$40$60

No

No

No

No

No

No

Yes

746

746

855

514

514

877

877

905

808

808

847

847

905

764

764

957

957

953

921

921

919

919

938

827

827

87

87

946

783

783

68

68

755

535

535



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No










5050

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

50

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$10+

$10

$10

$10

$10

$10

$10

$10

$10

$40+$60+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

529

529

86

86

824

824

937

937

846

846

843

843

687

687

43


Georgia













Guam









Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



44


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Georgia


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649




4040

$20$35

$35$55

40

$250day x 4

20

50+

$10

$10

50+50+

$35$100

$40$60

No

Yes

Yes

59 90 878 941 86 857 62



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No










Guam


5050

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$30

$20$35

$15$40

50

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250dayx3

$250dayx3

$200

$10+

$10

$10

$10

$10

$10

$10

$10$20 Comm

$15$25 Comm

$10

$40+$60+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$50 Comm

$40$50 Comm

$2550 of AWP

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

514

794

794

883

845

845

837

85

85

941

935

935

859

884

884

849

839

839

556

625

625


TakeCareshyHigh

TakeCareshyStandard


3030

$5 at FHP$40

$5 at FHP$40

$25$40

30

$100day for 5

$150day for 5

20

NA

$10

$15

$10

NA

$25$50

$40$80

30to$60050 to$1200

NA

Yes

Yes

Yes

687

687

669

669

686

686

904

904

792

792

786

786

571

571


HMSA InshyNetwork

4040

$15$15

40

$100

50+

$7

50+50+

$30$65

No




3030

$20$20

$30$30

30

$100

10

$7 + 20

$10

$15

$45$45

$50$50

$30 + 20$65 + 20 No

Yes

Yes

754

754

826

826

815

815

94

94

875

875

811

811

613

613

45


Idaho








Illinois
















Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



46


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

6

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Idaho


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649






SelectHealthshyHigh


Illinois


4040

$20$30

$20$40

$25$25

$25$35

$15$25

$20$30

$25$40

40

$200

None

$350

$500

$100

$100 after

20

50+

$7

$7

$20

$20

$5 $25$50

$5

$10

50+50+

$25$50

$35$60

$40$60

$40$60

$25$50$50

$25$50

30to$60050 to$1200

No

No

None

Yes

Yes

Yes

Yes

Yes

552

552

659

659

629

629

852

852

86

86

876

876

813

813

869

869

851

851

948

948

941

941

958

958

883

883

912

912

912

912

895

895

881

881

903

903

588

588

692

692

64

64




4040

$20$35

$25$35

40

Nothing

$500

50+

$10 copay

$5

50+50+

$40$60

$40$6025 $6025

No

Yes







30 after ded

$25$50

$25$50

$20$35

$25$40

$35$55

30 after ded

$200day x 5

20

$250day x 3

$500day x 3

20

NA

$7

$7

$10

$10

$10

NA

$35$70

$35$70

$40$60

$40$60

$40$60

NA

Yes

Yes

Yes

Yes

Yes

745 915 88 962 878 868 67



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No







5050

$20$35

$25$40

$15$15

$25$40

$25$50

50

$250day x 3

$500day x 3

None

$450

20

$10+

$10

$10

$10

$7

$10

$40+$60+

$40$60

$40$60

$35$60

$30$60

$35$50

No

Yes

Yes

Yes

Yes

Yes

647

647

665

577

822

822

919

896

788

788

902

86

943

943

957

956

859

859

892

914

834

834

898

918

66

66

732

623

47


Indiana












Iowa












Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



48


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Indiana


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649





4040

$25$50

$25$50

$35$55

40

$200day x 5

20

20

50+

$7

$7

$10

50+50+

$35$70

$35$70

$40$60

No

Yes

Yes

Yes

745 915 88 962 878 868 67









Iowa


5050

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$15

$25$40

50

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

20

20

$10+

$10

$10

$10

$10

$10

$10

$10

$10

$40+$60+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$25$50

30to$60050 to$1200

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

647

647

562

822

822

878

788

788

815

943

943

934

859

859

868

834

834

893

66

66

593









4040

$25$50

$25$50

$25$50

$25$50

$25$45

$0 for 3 then 20

$20$30

40

20

20

$200day x 5

20

Nothing

20 in40 out

$100day x 5

50+

$3 $10

$3 $10

$7

$7

$12

$9

$15

50+50+

$45$70$100

30$5000 Max

$35$70

$35$70

$45$90

$40$70

$30$50

No

Yes

No

Yes

Yes

Yes

Yes

NA

562

562

745

647

647

535

905

905

915

893

893

903

888

888

88

875

875

89

964

964

962

951

951

977

837

837

878

92

92

902

903

903

868

911

911

912

652

652

67

725

725



4040

$25$25

40

$100day x 5

40+

$15

40+40+

$30$50

NA



40+40+

$25$50

40+

20

40+

$10

40+40+

$35$50

NA

Yes 577 896 86 956 914 918 623

49





Kansas








Kentucky








Louisiana









50


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Kansas


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649






4040

$20$35

$30$60

$30$60

$35$55

40

$250day x 4

25

30

20

50+

$10

$3 $12

$3 $12

$10

50+50+

$35$100

$50$75

$5020

$40$60

No

Yes

Yes

Yes

Yes

639

602

602

862

906

906

862

88

88

94

96

96

838

894

894

901

884

884

538

663

663




Kentucky


5050

$20$35

$25$40

$25$40

50

$250day x 3

$500day x 3

20

$10+

$10

$10

$10

$40+$60+

$40$60

$40$60

30to$60050 to$1200

No

Yes

Yes

Yes

676

676

903

903

901

901

951

951

881

881

918

918

729

729








Louisiana


4040

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$25$40

40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

20

50+

$10

$10

$10

$10

$10

$10

$10

50+50+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

30to$60050 to$1200

No

Yes

Yes

Yes

Yes

Yes

Yes








4040

$25$45

$30$55

$20$35

$35$40

$20$35

$35$40

40

Ded+$100

Ded+30

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+

$5

$5

$10

$10

$10

$10

50+50+

$40$100

$40$100

$40$60

$40$60

$40$60

$40$60

No

Yes

Yes

Yes

Yes

Yes

Yes

573

573

874

874

823

823

968

968

831

831

827

827

625

625

51





Maine


Maryland











Massachusetts




52


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Maine


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649


Maryland


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No






4040

$15$30

$20$35

$25$35

Nothing$35

40

$150day x3

10 Plan Allow

$200

$200

50+

$5

$10

Nothing

Nothing

50+50+

$35$100

$35$100

$35$65

$35$65

No

Yes

Yes

Yes

Yes

69

69

648

648

844

844

86

86

872

872

833

833

942

942

925

925

865

865

846

846

914

914

902

902

567

567

54






MD IPAshyHigh

Massachusetts


$70$70

$20$40

$20$40

$10$20

$20$30

$25$40

$25$40

$500

$200day x 3

$200day x 3

$100

$250dayx3

$150day x 3

20

Nothing

$3$15

$3$15

$7$17 Net

$12$22Net

$7

$10

$35$65

$30$60

$30$60

$30$50$45$65

$35$55$50$70

$30$60

30to$60050 to$1200

Yes

Yes

Yes

Yes

Yes

Yes

Yes

563

563

83

83

583

864

864

867

867

846

864

864

831

831

876

969

969

927

927

937

892

892

813

813

867

871

871

836

836

841

606

606

702

702

677



4040

$25$35

40

$150 to $750max

50+

$10

50+50+

$30$60

No

Yes 627 851 882 929 883 801 649

53





Michigan










Minnesota






54


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Michigan


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649










Minnesota


4040

$15$25

$15$25

$10$10

$20$20

$10$20

$15$30

$10$20

$15$15

$25$40

40

Nothing

Nothing

Nothing

$500x3

Nothing

Nothing

None

None

20

50+

$10

$10

$5

$10

$5

$15

$0$8

$10

$10

50+50+

$30$60

$30$60

$15$15

NA$40

$50$50

$50$50

$40$60

$40$40

30to$60050 to$1200

No

Yes

Yes

No

No

Yes

Yes

Yes

Yes

Yes

651

651

742

742

793

793

793

899

899

90

90

888

888

919

875

875

912

912

862

862

92

933

933

952

952

943

943

951

884

884

883

883

899

899

946

937

937

836

836

902

902

919

672

672

795

795

656

656

658





4040

$25$45

$0 for 3 then 20

$25$40

40

Nothing

20 in40 out

20

50+

$12

$9

$10

50+50+

$45$90

$40$70

30to$60050 to$1200

No

Yes

Yes

Yes

647

647

893

893

875

875

951

951

92

92

911

911

725

725


55











Montana


Nebraska


Nevada




New Hampshire



Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



56


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649




4040

$20$35

$25$35

40

$250day x 4

$500

50+

$10

$5

50+50+

$35$100 $40$60

25$6025

No

Yes

Yes

639

647

862

891

862

861

94

961

838

84

901

864

538





30 after ded

$30$60

$30$60

$35$55

30 after ded

25

30

20

NA

$3 $12

$3 $12

$10

NA

$50$75

$5020

$40$60

NA

Yes

Yes

Yes

602

602

906

906

88

88

96

96

894

894

884

884

663

663





Montana


5050

$20$35

$25$40

$25$40

$25$40

50

$250day x 3

$500day x 3

$450

20

$10+

$10

$10

$7

$10

$40+$60+

$40$60

$40$60

$30$60

30to$60050 to$1200

No

Yes

Yes

Yes

Yes

676

676

665

903

903

919

901

901

902

951

951

957

881

881

892

918

918

898

729

729

732


Nebraska


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No


Nevada


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No




New Hampshire


4040

$20$35

$10$25

$25$40

40

$250day x 4

$300

20

50+

$10

$7

$10

50+50+

$35$100

$35$55$100

30to$60050 to$1200

No

Yes

Yes

Yes

602

516

838

696

861

66

923

892

849

892

918

912

636

529


57


New Jersey








New Mexico





Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code


Monthly Biweekly


58


Prescription Drugs


Mail lan

eeded

are

ll icate

r ng rm

ation




order discount

Ove

rall p

satisfaction

Gettin

g n

care

Gettin

g c

quickly

How

we

doctors

commun

Custome

service

Claim

sproce

ssi

Plan

Info

on

Costs

New Jersey


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649







$15$35

$20$20

20 Plan Allow

$150max$450

$5

$20

$35$100

$45$85

Yes

Yes

631

663

852

844

837

851

928

936

895

86

809

828

623



New Mexico


50 of sch

$30$30

$25$40

+50 of sch

$250day x 3

20

NA

$10

$10

NA

$45$85

30to$60050 to$1200

No

Yes

Yes

663 844 851 936 86 828 642




59


New York

























Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



60

North Dakota


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

New York



30to$60050 to$1200 Yes

l vera e 679 864 849 942 877 875 649









4040

$20$35

$15$35

$20$30

$25$40

$25$40

$25$40

$20$20

40

$250day x 4

20 Plan Allow

$100 x 5

$500+10

$500

$500

$150max$450

50+

$10

$5

25

30

$10

$10

$20

50+50+

$35$100

$35$100

2525

3030

$30$50

$30$50

$45$85

No

Yes

Yes

No

No

Yes

Yes

Yes

662

662

729

729

663

848

848

928

928

844

849

849

90

90

851

937

937

949

949

936

888

888

922

922

86

874

874

924

924

828

547

547

70

70






50 of sch

$30$30

$20$40

$30$50

$25$25

+50 of sch

$250day x 3

None

$1000

$250

NA

$10

$15

$15$100Ded

$10

NA

$45$85

$35$75

$30$75

$35$75 $75$100Ded

No

Yes

Yes

Yes

No

663

729

729

735

844

814

814

933

851

786

786

923

936

888

888

952

86

787

787

92

828

848

848

916

642

60

60



2525

$30$50

25

$750

NA

$10

NA

$5050

No












3030

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

30

$500

$750

$500

$750

$500

$750

$500

$750

$500

$750

NA

$5

$5

$5

$5

$5

$5

$5

$5

$5

$5

NA

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

739

739

739

739

739

739

739

739

739

739

934

934

934

934

934

934

934

934

934

934

89

89

89

89

89

89

89

89

89

89

962

962

962

962

962

962

962

962

962

962

896

896

896

896

896

896

896

896

896

896

92

92

92

92

92

92

92

92

92

92

768

768

768

768

768

768

768

768

768

768

61


North Carolina


North Dakota







Ohio








Oklahoma




Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



62


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

North Carolina


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649


North Dakota


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No





4040

$25$45

$0 for 3 then 20

$15$25

40

Nothing

20 in40 out

None

50+

$12

$9

50$600ded

50+50+

$45$90

$40$70

50$600 ded

No

Yes

Yes

None

647

647

893

893

875

875

951

951

92

92

911

911

725

725



2020

$20$30

20

$100day x 5

NA

$15

NA

$30$50

NA



4040

$25$25

40

$100day x 5

40+

$15

40+40+

$30$50

NA


Ohio


40+40+

$25$40

40+

20

40+

$10

40+40+

30to$60050 to$1200

NA


AultCare HMOshyHigh






Oklahoma


4040

$15$20

$20$35

$25$40

$20$20

$30$40

$10$20

$25$40

40

$150

$250day x 3

$500day x 3

$250

$500

$250

20

50+

$15

$10

$10

$10

$15

$15

$10

50+50+

$30$40$55

$40$60

$40$60

$30$30

$40$40

$30$50

30to$60050 to$1200

No

No

Yes

Yes

Yes

Yes

Yes

Yes

877

788

788

744

922

845

845

909

907

889

889

876

941

922

922

951

944

935

935

929

935

906

906

944

853

708

708

745



4040

$15$45

40

$250dymx1000

50+

$4$10

50+50+

$45$70

No

Yes 592 816 839 916 893 872 727

63


Oregon




Pennsylvania









Puerto Rico



Rhode Island


South Carolina



Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



64


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Information

on Costs

Oregon


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649




Pennsylvania


4040

$20$30

$30$40

$25$40

40

$200

$500

20

50+

$15

$20

$10

50+50+

$40$60

$40$60

30to$60050 to$1200

No

Yes

Yes

Yes

768

768

844

844

847

847

916

916

927

927

89

89

683

683









Puerto Rico


4040

$20$35

$15$35

$20$35

$20$35

$25$50

10 after Deduct

20 after Deduct

$5$5

40

$250day x 4

20 Plan Allow

$250day x 4

20aftrDeduct

15 after ded

10 after deduct

20after Deduct

None

50+

$10

$5

$10

30 $5$15

$5

$5 after ded

$5 after ded

$250

50+50+

$35$100

$35$100

$35$100

$35$60

$35$75

$35$75$100

$10$15

40 $40$120 50 $85$250

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

579

579

579

668

699

754

754

806

861

861

861

868

873

908

908

803

835

835

835

85

885

899

899

82

935

935

935

938

957

97

97

938

887

887

887

906

86

913

913

887

899

899

899

902

921

904

904

70

631

631

631

677

671

678

678




Rhode Island


$750$10

$25$40

$750 amp 10 +$10 amp 10 +

None 10 +

20

$5 or $12 NA

$10

NANA

2025 up to$100$175max

30to$60050 to$1200

Yes No

Yes

691 874 844 963 872 75 586


South Carolina


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No


65


South Dakota






Tennessee






Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



66


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

South Dakota



30to$60050 to$1200 Yes

679 864 849 942 877 875 649





4040

$25$45

$20$30

$0 for 3 then 20

40

Nothing

$100day x 5

20 in40 out

50+

$12

$9

$15

50+50+

$45$90

$40$70

$30$50

No

Yes

Yes

NA

647

647

535

893

893

903

875

875

89

951

951

977

92

92

902

911

911

912

725

725



4040

$25$25

40

$100day x 5

40+

$15

40+40+

$30$50

NA

NA

535


Tennessee


40+40+

$25$40

40+

20

40+

$10

40+40+

30to$60050 to$1200

NA





4040

$20$35

$20$35

$25$40

40

$250day x 4

$250day x 3

$500day x 3

50+

$10

$10

$10

50+50+

$35$100

$40$60

$40$60

No

Yes

Yes

Yes

66 875 868 959 889 914 69

67


Texas






















Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



68


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Texas


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649



4040

$5$25$35

40

15

50+

$5

50+50+

$35$60

No


FirstcareshyHigh

FirstcareshyHigh

FirstcareshyHigh

FirstcareshyHigh

FirstcareshyHigh


4040

$30$55

$30$55

$30$55

$30$55

$30$55

$35$55

40

$250day x 5

$250day x 5

$250day x 5

$250day x 5

$250day x 5

20

40

$10

$10

$10

$10

$10

$10

4040

$35$70

$35$70

$35$70

$35$70

$35$70

$40$60

No

Yes

Yes

Yes

Yes

Yes



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No












5050

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$45

$20$40

50

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

10

$250day x 5

$10+

$10

$10

$10

$10

$10

$10

$10

$10

$5

$10

$40+$60+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$45$100

$35$60

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

63

63

702

835

835

862

764

764

863

931

931

937

864

864

875

856

856

87

673

673

569

69



Enrollment Code

Monthly Biweekly


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family








Vermont

Virgin Islands

Utah


70


Prescription Drugs


Mail lan

eeded

are

ll icate

r ng rm

ation




order discount

Ove

rall p

satisfaction

Gettin

g n

care

Gettin

g c

quickly

How

we

doctors

commun

Custome

service

Claim

sproce

ssi

Plan

Info

on

Costs

Utah


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649






Vermont


$20$30

$25$40

$100 after

20

$5$25$50

$10

$25 $50$50

30to$60050 to$1200

Yes

Yes

629 876 851 958 912 903 64


Virgin Islands

4040 40 50+ 50+50+ No


$750$10 $750 amp 10 + $10 amp 10 +

None 10 +

$5 or $12 NA NANA

2025 up to$100$175max

Yes No

691 874 844 963 872 75 586

71


Virginia















Washington










Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



72


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Virginia








$25$40 4040

$15$30

$20$35

$25$35 4040

$5$25$35 4040

$25$35

Nothing$35

20 40

$150day x3

10 Plan Allow

15 40

15 40

$200

$200

$10 50+

$5

$10

$5 40

$5 40

Nothing

Nothing

HMOP

50+50+

$35$100

$35$100

$35$60 4040

$35$60 4040

$35$65

$35$65

30to$60050 to$1200

OS National

Yes No

Yes

Yes

Yes No

Yes No

Yes

Yes

Average

69

69

648

648

679

844

844

86

86

864

872

872

833

833

849

942

942

925

925

942

865

865

846

846

877

914

914

902

902

875

567

567

54

54

649





MD IPAshyHigh




Washington









$70$70

$10$20

$20$30

$25$40

$25$30

$35$35

$25$40 4040

$20$35

$25$25

$25$35

$154 or 2020

$30$30 $30+40+diff

$20$30

$30$40


$20$0childlt22$30


$500

$200 x3 days

$100

$250dayx3

$150day x 3

$150max$750

$20020

20

20 40

$250day x 4

$350

$500

Nothing Nothing

None None

$200

$500

Nothing

$0

$7$17 Net

$12$22Net

$7

$10

$10

$15

$10 50+

$10

$20

$20

$10 Not Covered

$5 Not Covered

$15

$20

$35$65

$30$50$50

$30$50$45$65

$35$55$50$70

$30$60

$40$55

50+50+

$35$100

$40$60

$40$60

Not Covered

NA

$40$60

$40$60

$353050up to $3000

$355050 up to $3000

$35$50 30day $100 90day

$25$50 30day$100 90day

30to$60050 to$1200

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes No

Yes

Yes

Yes

Yes No

Yes No

Yes

Yes

83

83

583

692

692

659

659

798

798

768

768

867

867

846

864

864

86

86

94

94

844

844

833

831

831

876

886

886

869

869

928

928

847

847

927

927

937

969

969

941

941

957

957

916

916

813

813

867

87

87

912

912

931

931

927

927

836

836

841

916

916

881

881

897

897

89

89

702

702

677

674

674

692

692

65

65

683

683

73


West Virginia



Wisconsin









Wyoming





Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



74


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

West Virginia


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649



Wisconsin


4040

$10$20

$25$40

40

$250

20

50+

$15

$10

50+50+

$30$50

30to$60050 to$1200

No

Yes

Yes

744 909 876 951 929 944 745



4040

$25$35

40

15

50+

$5

50+50+

$35$60

No








Wyoming


4040

$25$25

$10$10

$25$45

$0 for 3then 20

$10$10

$10$10

$25$40

40

None

None

Nothing

20 in40 out

Nothing

Nothing

20

40

$10

$5

$12

$9

$10

$10

$10

4040

$20$20

$45$90

$40$70

$20$50

3050

30$75max 50 wmin$50

30to$60050 to$1200

No

Yes

Yes

Yes

Yes

Yes

No

Yes

682

785

647

647

784

601

909

834

893

893

888

857

90

834

875

875

854

822

97

953

951

951

938

96

834

929

92

92

888

863

879

932

911

911

87

866

588

718

725

725

684

686




4040

$20$30

$20$40

40

$200

None

50+

$7

$7

50+50+

$25$50

$35$60

No

No

None

552

552

852

852

813

813

948

948

883

883

895

895

588

588

75











76



















insurance plans

77



ELIGIBILITY

FUNDING







CONTRIBUTIONS

DISTRIBUTIONS







ANNUAL ROLLOVER







78





79












Self only

Self amp family

Self only

Self amp family

Self only

Self amp family





800shy718shy1299

800shy821shy6136

800shy694shy9901

888shy636shy6252

474 475

341 342

481 482

324 325

9742

11021

13642

10454

21915

25172

30912

22700

4496 10115

5087 11618

6296 14267

4825 10477


80














81













Plan Code


Getting needed care


How well doctors


Claims processing






22

34

48

606

623

614

891

873

891

888

851

859

952

923

912

830

863

887

879

865

885

563

602

590


Plan Code


Getting needed care


How well doctors


Claims processing







22

47

TP TU TV

MW

606

664

566

478

891

909

849

875

888

907

864

801

952

925

932

948

830

871

843

856

879

845

853

812

563

680

542

555

82


83



Plan Name

Telephone Number


Self only

Self amp family

Self only

Self amp family

Self only

Self amp family



Alabama


Alaska


Arizona


Arkansas


California


Colorado


Plan Name

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

Telephone Number


F51

JS1

G51

F51

JS1

G51

Self only

F52

JS2

G52

F52

JS2

G52

Self amp family

16322

22787

21977

16322

22787

21977

Self only

39021

53701

51861

39021

53701

51861

Self amp family

7533

10517

10143

7533

10517

10143

Self only

18010

24785

23936

18010

24785

23936

Self amp family


84

Benefit Type


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs



Alabama


Alaska


Arizona


Arkansas


California


Colorado


Plan Name







Benefit Type

$8333$16666 $8333$16666

$8333$16666 $8333$16666

$8333$16666 $8333$16666

$8333$16666 $8333$16666

$8333$16666 $8333$16666

$8333$16666 $8333$16666


$1000$2000 $1000$2000

$1000$2000 $1000$2000

$1000$2000 $1000$2000

$1000$2000 $1000$2000

$1000$2000 $1000$2000

$1000$2000 $1000$2000

CY Ded SelfFamily

$4000$8000 $5000$10000

$4000$8000 $5000$10000

$4000$8000 $5000$10000

$4000$8000 $5000$10000

$4000$8000 $5000$10000

$4000$8000 $5000$10000


15 40

15 40

15 40

15 40

15 40

15 40

Office Visit

15 40

15 40

15 40

15 40

15 40

15 40

Inpatient Hospital

15 40

15 40

15 40

15 40

15 40

15 40

Outpatient Surgery

Nothing FundDed40

Nothing FundDed40

Nothing FundDed40

Nothing FundDed40

Nothing FundDed40

Nothing FundDed40

Preventive Services

$10$35$60 40+40+40+

$10$35$60 40+40+40+

$10$35$60 40+40+40+

$10$35$60 40+40+40+

$10$35$6 40+40+40+

$10$35$60 40+40+40+

Prescription Drugs

Levels I II III

85



Connecticut


Delaware





Florida





Georgia




Guam


Plan Name

877shy459shy6604

877shy459shy6604

877shy459shy6604

888shy789shy9065

877shy459shy6604

800shy441shy5501

888shy393shy6765

888shy393shy6765

877shy459shy6604

888shy393shy6765

888shy393shy6765

671shy647shy3526

Telephone Number


EP1

EP1

F51

B61

F51

J41

MJ1

QP1

F51

AD1

LM1

KX1

Self only

EP2

EP2

F52

B62

F52

J42

MJ2

QP2

F52

AD2

LM2

KX2

Self amp family

20174

20174

16322

14018

16322

13979

12818

10987

16322

11598

12208

6822

Self only

47770

47770

39021

31268

39021

43929

28521

24447

39021

25804

27163

17900

Self amp family

9311

9311

7533

6470

7533

6452

5916

5071

7533

5353

5634

3148

Self only

22048

22048

18010

14431

18010

20275

13163

11283

18010

11910

12537

8261

Self amp family


86

Connecticut


Delaware





Florida





Georgia




Guam


Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type


87




Idaho



Illinois




Indiana



Iowa



Kansas




Plan Name

877shy459shy6604

877shy459shy6604

800shy377shy4161

877shy459shy6604

888shy393shy6765

888shy393shy6765

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy257shy4692

877shy459shy6604

800shy969shy3343

888shy393shy6765

Telephone Number


JS1

H41

9K4

H41

GB1

MW1

JS1

MW1

H41

SV4

G51

9H1

PH1

Self only

JS2

H42

9K5

H42

GB2

MW2

JS2

MW2

H42

SV5

G52

9H2

PH2

Self amp family

22787

16237

8704

16237

12208

12208

22787

12208

16237

8970

21977

12747

10987

Self only

53701

38826

18033

38826

27163

27162

53701

27162

38826

21408

51861

29956

24447

Self amp family

10517

7494

4017

7494

5634

5634

10517

5634

7494

4140

10143

5883

5071

Self only

24785

17920

8323

17920

12537

12536

24785

12536

17920

9880

23936

13826

11283

Self amp family


88


Idaho



Illinois




Indiana



Iowa



Kansas




Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

89



Kentucky




Maine









Plan Name

877shy459shy6604

888shy393shy6765

877shy459shy6604

877shy459shy6604

877shy459shy6604

888shy789shy9065

800shy833shy7423

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

Telephone Number


H41

6N1

F51

EP1

F51

B61

GZ1

EP1

G51

H41

H41

Self only

H42

6N2

F52

EP2

F52

B62

GZ2

EP2

G52

H42

H42

Self amp family

16237

10987

16322

20174

16322

14018

11980

20174

21977

16237

16237

Self only

38826

24447

39021

47770

39021

31268

26835

47770

51861

38826

38826

Self amp family

7494

5071

7533

9311

7533

6470

5529

9311

10143

7494

7494

Self only

17920

11283

18010

22048

18010

14431

12385

22048

23936

17920

17920

Self amp family


90

Kentucky




Maine









Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

91






Nebraska


Nevada


New Hampshire


New Jersey


New Mexico




Plan Name


877shy459shy6604

800shy969shy3343

888shy393shy6765

77shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

800shy501shy3439

Telephone Number


G51

9H1

PH1

H41

H41

G51

EP1

EP1

G51

EP1

QA4

Self only

G52

9H2

PH2

H42

H42

G52

EP2

EP2

G52

EP2

QA5

Self amp family

21977

12747

10987

16237

16237

21977

20174

20174

21977

20174

9575

Self only

51861

29956

24447

38826

38826

51861

47770

47770

51861

47770

24919

Self amp family

10143

5883

5071

7494

7494

10143

9311

9311

10143

9311

4419

Self only

23936

13826

11283

17920

17920

23936

22048

22048

23936

22048

11501

Self amp family


92





Nebraska


Nevada


New Hampshire


New Jersey


New Mexico




Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

93



North Carolina


North Dakota






Pennsylvania




Rhode Island


South Carolina


Plan Name

877shy459shy6604

877shy459shy6604

877shy459shy6604

330shy363shy6360

877shy459shy6604

877shy459shy6604

877shy459shy6604

866shy351shy5946

888shy876shy2756

877shy459shy6604

877shy459shy6604

Telephone Number


F51

H41

JS1

3A4

JS1

H41

H41

Y61

8W4

EP1

JS1

Self only

F52

H42

JS2

3A5

JS2

H42

H42

Y62

8W5

EP2

JS2

Self amp family

16322

16237

22787

8669

22787

16237

16237

12298

12448

20174

22787

Self only

39021

38826

53701

17501

53701

38826

38826

28345

28053

47770

53701

Self amp family

7533

7494

10517

4001

10517

7494

7494

5676

5745

9311

10517

Self only

18010

17920

24785

8077

24785

17920

17920

13082

12948

22048

24785

Self amp family


94

North Carolina


North Dakota






Pennsylvania




Rhode Island


South Carolina


Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Benefit Type

Prescription Drugs

Levels I II III




30 after deduct

95



South Dakota


Tennessee








Vermont




Plan Name

877shy459shy6604

877shy459shy6604

877shy459shy6604

888shy393shy6765

888shy393shy6765

888shy393shy6765

877shy459shy6604

800shy377shy4161

877shy459shy6604

877shy459shy6604

888shy789shy9065

Telephone Number


G51

G51

JS1

TP1

TU1

TV1

G51

9K4

EP1

F51

B61

Self only

G52

G52

JS2

TP2

TU2

TV2

G52

9K5

EP2

F52

B62

Self amp family

21977

16322

22787

12208

12208

13429

21977

8704

20174

16322

14018

Self only

51861

39021

53701

27163

27162

29879

51861

18033

47770

39021

31268

Self amp family

10143

7533

10517

5634

5634

6198

10143

4017

9311

7533

6470

Self only

23936

18010

24785

12537

12536

13790

23936

8323

22048

18010

14431

Self amp family


96

South Dakota


Tennessee








Vermont




Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

97







Wyoming



Plan Name

877shy459shy6604

800shy552shy7114

877shy459shy6604

877shy459shy6604

877shy459shy6604

800shy377shy4161

Telephone Number


G51

L14

F51

JS1

H41

9K4

Self only

G52

L15

F52

JS2

H42

9K5

Self amp family

21977

10262

16322

22787

16237

8704

Self only

51861

22425

39021

53701

38826

18033

Self amp family

10143

4736

7533

10517

7494

4017

Self only

23936

10350

18010

24785

17920

8323

Self amp family


98





Wyoming



Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

$10$35$50 30day $100 90day

99


100

Appendix F


Waiting Periods





Contributions


Salary Deduction





101


















102










No Yes No No No




Yes Yes No No No


No No No No Yes


or spouse)

No No No Yes No



Yes No No No No


Yes Yes Yes No No


No No No Yes No







103



Reading the Chart


Dental Insurance









Vision Insurance



104



Plan Name

Telephone amp

Website


Class A

Class B

Class C

Class D

Deductible





0 40 60 50 $0




















105



Plan Name

Telephone amp

Website


Class A

Class B

Class C

Class D

Deductible


GEHA Standard






0 20 50 30 $0


0 20 50 30 $0












uccifedvipcom



20 40 60 50 $0


106



Plan Name

You pay

Telephone amp

Website

Class A

Class B

Class C

Class D Deductible













sssprcom


0

0

0

0

0

flat rate

Flat Rate

Approx 30

0

0

30

flat rate

flat rate

Flat Rate

Approx 50

0

0

60 30

flat rate

flat rate

Flat Rate

Approx 60

0

0

50

flat rate

flat rate

$0

$0


$0

$0

$0






107





Additional Features


Aetna Vision High


FEP BlueVision High
















$0

$0


Every24 months

Every 12 months

Every 24 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

108





Additional Features















Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

109



110


AL 356shy358 1 1 1 1 1 1 1 1 1 1 NA NA 3 NA NA



AZ 850shy853 3 5 5 2 2 2 2 1 1 1 NA NA 4 NA NA



CA 919shy921 3 5 5 5 5 4 4 4 4 4 NA NA 5 NA NA


CA 942 956shy958 4 5 5 5 5 4 4 4 4 4 NA NA 5 NA NA


CO 800shy806 3 4 4 3 3 4 4 4 4 3 NA NA 5 NA NA



CT 064shy069 3 5 5 5 5 5 5 5 5 5 NA NA NA 1 NA



FL 330shy334 2 4 4 3 3 3 3 3 3 3 NA NA 2 NA NA


GA 300shy303 305 311 399 3 2 2 2 2 3 3 2 2 1 NA NA 2 NA NA






IL 600shy608 2 2 2 3 3 3 3 4 4 3 NA NA 2 NA NA


IN 460shy462 472 2 1 1 1 1 2 2 1 1 1 NA NA 3 NA NA

IN 463shy464 2 2 2 3 3 3 3 4 4 3 NA NA 2 NA NA

IN 470 2 1 1 1 1 2 2 1 1 1 NA NA 1 NA NA



KY 410 452 459 2 1 1 1 1 2 2 1 1 1 NA NA 1 NA NA







111




MD 200202shy212 214 217 2 5 5 3 3 4 4 4 4 4 4 4 3 NA NA

MD 219 2 4 4 3 3 3 3 3 3 2 5 5 NA NA NA


ME 038 5 5 5 5 5 4 4 5 5 5 NA NA NA NA NA









NC 275shy277 283 4 2 2 2 2 2 2 1 1 2 NA NA 5 NA NA






NJ 3 5 5 5 5 5 5 5 5 5 NA NA NA 1 NA

NJ 080shy084 2 4 4 3 3 3 3 3 3 2 5 5 NA NA NA





NY 063 5 5 5 5 5 4 4 5 5 5 NA NA NA 1 NA

NY 140shy143 4 5 5 3 3 2 2 2 2 3 NA NA NA 1 NA


OH 430shy432 2 1 1 1 1 2 2 1 1 2 NA NA 2 NA NA

OH 440shy443 2 1 1 1 1 2 2 1 1 3 NA NA 2 NA NA

OH 450shy452 2 1 1 1 1 2 2 1 1 1 NA NA 1 NA NA

OH 453shy455 2 1 1 1 1 2 2 1 1 2 NA NA 1 NA NA




070072shy075077shy079085shy089



112




PA 153shy154 156 160shy162 1 2 2 1 1 1 1 1 1 1 1 1 NA NA NA

PA 173shy174 2 5 5 3 3 4 4 4 4 4 4 4 NA NA NA

PA 183 3 5 5 5 5 5 5 5 5 5 1 1 NA 1 NA

PA 189shy196 2 4 4 3 3 3 3 3 3 2 5 5 NA NA NA






TN 422 1 1 1 1 1 1 1 1 1 1 NA NA 1 NA NA


TX 739 2 3 3 1 1 2 2 1 1 1 NA NA 3 NA NA


TX 770 772shy775 2 2 2 1 1 2 2 1 1 1 NA NA 1 NA NA



VA 200shy205 220shy227 2 5 5 3 3 4 4 4 4 4 4 4 3 NA NA

VA 231shy232 238 3 3 3 2 2 2 2 1 1 2 3 3 3 NA NA





WA 986 4 5 5 3 3 3 3 4 4 5 NA NA NA NA NA



WI 540 2 4 4 4 4 3 3 4 4 3 NA NA NA NA NA


WV 254 2 5 5 3 3 4 4 4 4 4 NA NA 3 NA NA


WY 834 4 5 5 3 3 2 2 1 1 2 NA NA NA NA NA





Intershynational



113113

Aetna PPO

Delta Dental PPO

Delta Dental PPO

FEP BlueDental PPO

FEP BlueDental PPO

GEHA PPO

GEHA PPO

MetLife PPO

MetLife PPO












1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

$1288 $1418 $1510 $1666 $1809

$871 $949 $1024 $1080 $1234

$1669 $1831 $2008 $2136 $2485

$939 $1069 $1184 $1249 $1381

$1634 $1860 $2061 $2177 $2408

$900 $989 $1124 $1213 $1347

$1525 $1677 $1904 $2056 $2284

$868 $940 $1044 $1159 $1273

$1606 $1797 $1959 $2121 $2374

$1372 $1541 $1710 $1880 $2049

$2578 $2840 $3022 $3334 $3621

$1744 $1901 $2049 $2160 $2470

$3340 $3663 $4018 $4275 $4973

$1881 $2139 $2370 $2500 $2765

$3270 $3721 $4124 $4357 $4818

$1803 $1981 $2249 $2428 $2697

$3053 $3357 $3812 $4115 $4572

$1738 $1883 $2089 $2320 $2548

$3214 $3597 $3920 $4244 $4750

$2747 $3085 $3422 $3761 $4099

$3867 $4258 $4532 $5001 $5430

$2615 $2850 $3074 $3240 $3704

$5009 $5494 $6026 $6412 $7458

$2820 $3208 $3554 $3749 $4146

$4904 $5581 $6185 $6534 $7226

$2705 $2970 $3372 $3641 $4043

$4579 $5038 $5716 $6174 $6859

$2606 $2823 $3133 $3479 $3821

$4820 $5394 $5879 $6366 $7124

$4118 $4625 $5134 $5641 $6148

$2791 $3073 $3272 $3610 $3919

$1887 $2056 $2219 $2340 $2674

$3616 $3967 $4351 $4628 $5384

$2035 $2316 $2565 $2706 $2992

$3540 $4030 $4466 $4717 $5217

$1950 $2143 $2435 $2628 $2919

$3304 $3634 $4125 $4455 $4949

$1881 $2037 $2262 $2511 $2758

$3480 $3894 $4245 $4596 $5144

$2973 $3339 $3705 $4073 $4440

$5587 $6153 $6549 $7224 $7846

$3779 $4119 $4440 $4680 $5352

$7237 $7937 $8706 $9263 $10775

$4076 $4635 $5135 $5417 $5991

$7085 $8062 $8935 $9440 $10439

$3907 $4292 $4873 $5261 $5844

$6615 $7274 $8259 $8916 $9906

$3766 $4080 $4526 $5027 $5521

$6964 $7794 $8493 $9195 $10292

$5952 $6684 $7414 $8149 $8881

$8378 $9226 $9819 $10835 $11765

$5666 $6175 $6660 $7020 $8025

$10853 $11904 $13056 $13893 $16159

$6110 $6951 $7700 $8123 $8983

$10625 $12092 $13401 $14157 $15656

$5861 $6435 $7306 $7889 $8760

$9921 $10916 $12385 $13377 $14861

$5646 $6117 $6788 $7538 $8279

$10443 $11687 $12738 $13793 $15435

$8922 $10021 $11124 $12222 $13321





Self amp Family




Dominion Dental HMO

Dominion Dental HMO

EmblemHealth PPO

Humana

Triple S Salud PPO










1 2 3 4 5

1 2 3 4 5

1

1 2 3 4 5

1

$596 $622 $694 $829 $884

$1018 $1055 $1109 $1291 $1517

$1826

$990 $1048 $1136 $1378 $1475

$454

$1194 $1246 $1391 $1660 $1771

$2038 $2113 $2221 $2585 $3037

$3652

$1982 $2098 $2273 $2759 $2952

$910

$1790 $1868 $2085 $2489 $2655

$3056 $3168 $3330 $3876 $4554

$5478

$2971 $3146 $3409 $4136 $4428

$1191

$1291 $1348 $1504 $1796 $1915

$2206 $2286 $2403 $2797 $3287

$3956

$2145 $2271 $2461 $2986 $3196

$984

$2587 $2700 $3014 $3597 $3837

$4416 $4578 $4812 $5601 $6580

$7913

$4294 $4546 $4925 $5978 $6396

$1972

$3878 $4047 $4518 $5393 $5753

$6621 $6864 $7215 $8398 $9867

$11869

$6437 $6816 $7386 $8961 $9594

$2581





Self amp Family


114

Aetna


Delta Dental High


FEP BlueDental High

GEHA Standard

GEHA High

MetLife Standard

MetLife High

United Concordia

$1418

$1234

$2485

$1381

$2408

$900

$1525

$1273

$2374

$2049

$2840

$2470

$4973

$2765

$4818

$1803

$3053

$2548

$4750

$4099

$4258

$3704

$7458

$4146

$7226

$2705

$4579

$3821

$7124

$6148

$3073

$2674

$5384

$2992

$5217

$1950

$3304

$2758

$5144

$4440

$9226

$8025

$16159

$8983

$15656

$5861

$9921

$8279

$15435

$13321




Self amp Family

$6153

$5352

$10775

$5991

$10439

$3907

$6615

$5521

$10292

$8881


Premium Rate Charts


Aetna Vision

FEP BlueVision








$680 $1328

$800 $1012

$622 $884

$771 $1339

$1304 $2533

$1601 $2028

$1220 $1729

$1547 $2685

$1913 $3716

$2401 $3042

$1814 $2572

$2321 $4026

$314 $613

$369 $467

$287 $408

$356 $618

Standard High

Standard High

Standard High

Standard High

$602 $1169

$739 $936

$563 $798

$714 $1239

$883 $1715

$1108 $1404

$837 $1187

$1071 $1858







Aetna Vision

FEP BlueVision








$680 $1328

$800 $1012

$622 $884

$771 $1339

$1304 $2533

$1601 $2028

$1220 $1729

$1547 $2685

$1913 $3716

$2401 $3042

$1814 $2572

$2321 $4026

$314 $613

$369 $467

$287 $408

$356 $618

Standard High

Standard High

Standard High

Standard High

$602 $1169

$739 $936

$563 $798

$714 $1239

$883 $1715

$1108 $1404

$837 $1187

$1071 $1858






115

______________________________________________________________________________________________________________

























116
























117

Summary Information

























19121-c1-30 (70-10)_0

19121-pg31-36 (70-10)_0

19121-pg37-100 (70-10)_0

19121-pg101-118 (70-10)_0











2
















3


Current Employees




























4

















5







FSAFEDS




6



FEGLI












7






Key FEHB facts













8














9










10















11






Key FEDVIP facts













12

















13














14

















15





Key FSAFEDS facts










16













17















18


How do I enroll










19




Key FEGLI facts



















20











How do I enroll








21




Key FLTCIP facts












22





How do I apply








23


24


















25







donrsquot



















26












27


Definitions













28















Yes

Yes

Yes

Not Applicable

Yes

No

Yes

Not Applicable

Yes

Yes

Yes

No

Yes

Not Applicable

Yes

Yes

Yes

No

Yes1

Not Applicable

Yes

Not Applicable

Yes

Yes2



29













30










31













Telephone Number

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family






MHBP shystd

MHBP shyValue Plan

NALC shyhigh

NALC Value Option

SAMBA shyhigh

SAMBA shystd






800shy222shy2798

Local phone

Local phone

800shy821shy6136

800shy821shy6136

800shy410shy7778

800shy410shy7778

888shy636shy6252

888shy636shy6252

800shy638shy6589

800shy638shy6589

888shy438shy9135

202shy833shy4910

800shy424shy8196

800shy638shy8432

471

104

111

311

314

454

414

321

KM1

441

444

421

401

431

381

472

105

112

312

315

455

415

322

KM2

442

445

422

402

432

382

13670

19028

13209

20317

10418

20913

11302

16122

9001

27523

13171

15613

12535

11170

18913

30910

44412

30930

48310

23691

50565

26946

32727

19546

70356

30081

39039

30885

23316

30210

6309

8782

6096

9377

4808

9652

5216

7441

4154

12703

6079

7206

5785

5155

8729

14266

20498

14275

22297

10934

23338

12436

15105

9021

32472

13884

18018

14255

10761

13943


32




APWU shyhigh

BCBS shystd

BCBS shybasic

GEHA shyhigh

GEHA shystd

MHBP shystd

MHBP shyValue

NALC shyhigh

NALC Value

SAMBA shyhigh

SAMBA shystd

CRHP

FS

PCABP

Rural

Plan

PPO NonshyPPO

PPO NonshyPPO

PPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

NonshyPPO PPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

Benefit Type


$350 None $250 $350 None $350 + 35+


$350 None $100 $350 None $300


$400 None $200 $600 None $500


$300 None $200 $300 None $350

$4000 None 50 $2000 None 20

$300 None $200 $300 None $300


$350 None $200 $400 None $400



$350 $200 $100 $400 $200 $300

Deductible

Calendar Year

Prescription Drug

Hospital Inpatient

Per Person

$18 10 10 $8 2525 Yes 30+diff 30+diff 30 50 5050 Yes







$20 15 Nothing 20 3045 Yes 30 30 30 45+ 45+45+ Yes

50 50 50 50 5050+ No 20 20 20 $10 $40$60 No






$20 10 Nothing 30 3030 Yes 25 25 25 30 3030 Yes



RampB

Prescription Drugs



Office Visits


T2 $45 T3 50($55Min) T4 $50to$140 T5 $70to$195


33













Plan Code


Getting needed care


How well doctors


Claims processing





47

10 835 946 917 955 926 956 703



10

11

31

757

838

896

934

891

922

95

961

921

912

936

929

643

699


31

31 725 907 895 949 875 926 688

MHBP shystd

31

45 84 938 916 935 906 954 696

MHBP shyValue Plan

45

41 63 908 857 929 866 887 636

NALC shyhigh

41

32 856 936 922 959 934 965 771


32

KM

SAMBA shyhigh

KM

44 897 947 943 96 946 953 789

SAMBA shystd

44

44 816 93 905 956 911 946 757



44

42

roups

verage

837

805

941

927

945

917

962

951

94

911

927

934

747

716


42

40 798 898 909 935 892 889 721


40

43


43

38 865 946 947 967 928 966 773 38

34



Plan Name Location


Plan Code


Getting needed care


How well doctors


Claims processing




Arizona 10 11

851 747

905 898

919 884

933 923

938 914

969 928

724 680


California 10 11

809 705

915 873

897 840

954 943

881 910

937 912

677 616



768 691

935 893

930 874

951 940

882 881

898 922

657 622


Florida 10 11

864 806

942 916

922 894

952 947

934 916

954 937

733 660


Illinois 10 11

861 796

933 912

934 881

955 950

901 936

972 938

712 653


Maryland 10 11

857 770

931 897

917 898

954 940

897 921

956 967

713 666


Texas 10 11

887 825

934 898

931 883

950 955

936 910

957 967

721 617


Virginia 10 11

871 782

924 901

929 894

966 962

914 917

959 960

708 681

35


36















37



Enrollment Code

Monthly Biweekly


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Alabama


Alaska


Arizona









Arkansas





38


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Alabama




Alaska

4040 40 50+ 50+50+ No



Arizona

4040 40 50+ 50+50+ No










Arkansas

$25$40 $500day x 3 $10 $40$60 Yes





39



Enrollment Code

Monthly Biweekly


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

California
















Colorado




Connecticut


Delaware





40


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

California

HMOPOS National 679 864 849 942 877 875 649


to$1200 Yes

Average
















Colorado

$25$40 30 $10 $25$50 Yes 701 80 804 923 825 889 57





Connecticut

$20$40 10 $15 $40$80 Yes 722 884 873 936 876 879 622



Delaware

4040 40 50+ 50+50+ No





41











Florida


















Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



42


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs



HMOPOS Nationa

30to$60050 to$1200 Yes

l Average 679 864 849 942 877 875 649






4040

$15$30

$20$35

$25$35

Nothing$35

40

$150day x3

10 Plan Allow

$200

$200

50+

$5

$10

Nothing

Nothing

50+50+

$35$100

$35$100

$35$65

$35$65

No

Yes

Yes

Yes

Yes

69

69

648

648

844

844

86

86

872

872

833

833

942

942

925

925

865

865

846

846

914

914

902

902

567

567

54




MD IPAshyHigh

Florida


$70$70

$10$20

$20$30

$25$40

$25$40

$500

$100

$250dayx3

$150day x 3

20

Nothing

$7$17 Net

$12$22Net

$7

$10

$35$65

$30$50$45$65

$35$55$50$70

$30$60

30to$60050 to$1200

Yes

Yes

Yes

Yes

Yes

83

83

583

867

867

846

831

831

876

927

927

937

813

813

867

836

836

841

702

702

677








4040

$15$40

$25$45

$15$25

$15$30

$20$50

$35$55

40

$250dayx3

$300dayx3

$250

Ded + $150x3

Ded + $150x5

20

50+

$5

$10

$15 Tier 1

$3$20

$3$10

$10

50+50+

$30$5030

$40$6030


$40$6020

$50$7020

$40$60

No

No

No

No

No

No

Yes

746

746

855

514

514

877

877

905

808

808

847

847

905

764

764

957

957

953

921

921

919

919

938

827

827

87

87

946

783

783

68

68

755

535

535



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No










5050

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

50

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$10+

$10

$10

$10

$10

$10

$10

$10

$10

$40+$60+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

529

529

86

86

824

824

937

937

846

846

843

843

687

687

43


Georgia













Guam









Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



44


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Georgia


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649




4040

$20$35

$35$55

40

$250day x 4

20

50+

$10

$10

50+50+

$35$100

$40$60

No

Yes

Yes

59 90 878 941 86 857 62



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No










Guam


5050

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$30

$20$35

$15$40

50

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250dayx3

$250dayx3

$200

$10+

$10

$10

$10

$10

$10

$10

$10$20 Comm

$15$25 Comm

$10

$40+$60+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$50 Comm

$40$50 Comm

$2550 of AWP

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

514

794

794

883

845

845

837

85

85

941

935

935

859

884

884

849

839

839

556

625

625


TakeCareshyHigh

TakeCareshyStandard


3030

$5 at FHP$40

$5 at FHP$40

$25$40

30

$100day for 5

$150day for 5

20

NA

$10

$15

$10

NA

$25$50

$40$80

30to$60050 to$1200

NA

Yes

Yes

Yes

687

687

669

669

686

686

904

904

792

792

786

786

571

571


HMSA InshyNetwork

4040

$15$15

40

$100

50+

$7

50+50+

$30$65

No




3030

$20$20

$30$30

30

$100

10

$7 + 20

$10

$15

$45$45

$50$50

$30 + 20$65 + 20 No

Yes

Yes

754

754

826

826

815

815

94

94

875

875

811

811

613

613

45


Idaho








Illinois
















Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



46


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

6

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Idaho


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649






SelectHealthshyHigh


Illinois


4040

$20$30

$20$40

$25$25

$25$35

$15$25

$20$30

$25$40

40

$200

None

$350

$500

$100

$100 after

20

50+

$7

$7

$20

$20

$5 $25$50

$5

$10

50+50+

$25$50

$35$60

$40$60

$40$60

$25$50$50

$25$50

30to$60050 to$1200

No

No

None

Yes

Yes

Yes

Yes

Yes

552

552

659

659

629

629

852

852

86

86

876

876

813

813

869

869

851

851

948

948

941

941

958

958

883

883

912

912

912

912

895

895

881

881

903

903

588

588

692

692

64

64




4040

$20$35

$25$35

40

Nothing

$500

50+

$10 copay

$5

50+50+

$40$60

$40$6025 $6025

No

Yes







30 after ded

$25$50

$25$50

$20$35

$25$40

$35$55

30 after ded

$200day x 5

20

$250day x 3

$500day x 3

20

NA

$7

$7

$10

$10

$10

NA

$35$70

$35$70

$40$60

$40$60

$40$60

NA

Yes

Yes

Yes

Yes

Yes

745 915 88 962 878 868 67



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No







5050

$20$35

$25$40

$15$15

$25$40

$25$50

50

$250day x 3

$500day x 3

None

$450

20

$10+

$10

$10

$10

$7

$10

$40+$60+

$40$60

$40$60

$35$60

$30$60

$35$50

No

Yes

Yes

Yes

Yes

Yes

647

647

665

577

822

822

919

896

788

788

902

86

943

943

957

956

859

859

892

914

834

834

898

918

66

66

732

623

47


Indiana












Iowa












Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



48


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Indiana


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649





4040

$25$50

$25$50

$35$55

40

$200day x 5

20

20

50+

$7

$7

$10

50+50+

$35$70

$35$70

$40$60

No

Yes

Yes

Yes

745 915 88 962 878 868 67









Iowa


5050

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$15

$25$40

50

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

20

20

$10+

$10

$10

$10

$10

$10

$10

$10

$10

$40+$60+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$25$50

30to$60050 to$1200

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

647

647

562

822

822

878

788

788

815

943

943

934

859

859

868

834

834

893

66

66

593









4040

$25$50

$25$50

$25$50

$25$50

$25$45

$0 for 3 then 20

$20$30

40

20

20

$200day x 5

20

Nothing

20 in40 out

$100day x 5

50+

$3 $10

$3 $10

$7

$7

$12

$9

$15

50+50+

$45$70$100

30$5000 Max

$35$70

$35$70

$45$90

$40$70

$30$50

No

Yes

No

Yes

Yes

Yes

Yes

NA

562

562

745

647

647

535

905

905

915

893

893

903

888

888

88

875

875

89

964

964

962

951

951

977

837

837

878

92

92

902

903

903

868

911

911

912

652

652

67

725

725



4040

$25$25

40

$100day x 5

40+

$15

40+40+

$30$50

NA



40+40+

$25$50

40+

20

40+

$10

40+40+

$35$50

NA

Yes 577 896 86 956 914 918 623

49





Kansas








Kentucky








Louisiana









50


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Kansas


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649






4040

$20$35

$30$60

$30$60

$35$55

40

$250day x 4

25

30

20

50+

$10

$3 $12

$3 $12

$10

50+50+

$35$100

$50$75

$5020

$40$60

No

Yes

Yes

Yes

Yes

639

602

602

862

906

906

862

88

88

94

96

96

838

894

894

901

884

884

538

663

663




Kentucky


5050

$20$35

$25$40

$25$40

50

$250day x 3

$500day x 3

20

$10+

$10

$10

$10

$40+$60+

$40$60

$40$60

30to$60050 to$1200

No

Yes

Yes

Yes

676

676

903

903

901

901

951

951

881

881

918

918

729

729








Louisiana


4040

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$25$40

40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

20

50+

$10

$10

$10

$10

$10

$10

$10

50+50+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

30to$60050 to$1200

No

Yes

Yes

Yes

Yes

Yes

Yes








4040

$25$45

$30$55

$20$35

$35$40

$20$35

$35$40

40

Ded+$100

Ded+30

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+

$5

$5

$10

$10

$10

$10

50+50+

$40$100

$40$100

$40$60

$40$60

$40$60

$40$60

No

Yes

Yes

Yes

Yes

Yes

Yes

573

573

874

874

823

823

968

968

831

831

827

827

625

625

51





Maine


Maryland











Massachusetts




52


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Maine


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649


Maryland


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No






4040

$15$30

$20$35

$25$35

Nothing$35

40

$150day x3

10 Plan Allow

$200

$200

50+

$5

$10

Nothing

Nothing

50+50+

$35$100

$35$100

$35$65

$35$65

No

Yes

Yes

Yes

Yes

69

69

648

648

844

844

86

86

872

872

833

833

942

942

925

925

865

865

846

846

914

914

902

902

567

567

54






MD IPAshyHigh

Massachusetts


$70$70

$20$40

$20$40

$10$20

$20$30

$25$40

$25$40

$500

$200day x 3

$200day x 3

$100

$250dayx3

$150day x 3

20

Nothing

$3$15

$3$15

$7$17 Net

$12$22Net

$7

$10

$35$65

$30$60

$30$60

$30$50$45$65

$35$55$50$70

$30$60

30to$60050 to$1200

Yes

Yes

Yes

Yes

Yes

Yes

Yes

563

563

83

83

583

864

864

867

867

846

864

864

831

831

876

969

969

927

927

937

892

892

813

813

867

871

871

836

836

841

606

606

702

702

677



4040

$25$35

40

$150 to $750max

50+

$10

50+50+

$30$60

No

Yes 627 851 882 929 883 801 649

53





Michigan










Minnesota






54


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Michigan


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649










Minnesota


4040

$15$25

$15$25

$10$10

$20$20

$10$20

$15$30

$10$20

$15$15

$25$40

40

Nothing

Nothing

Nothing

$500x3

Nothing

Nothing

None

None

20

50+

$10

$10

$5

$10

$5

$15

$0$8

$10

$10

50+50+

$30$60

$30$60

$15$15

NA$40

$50$50

$50$50

$40$60

$40$40

30to$60050 to$1200

No

Yes

Yes

No

No

Yes

Yes

Yes

Yes

Yes

651

651

742

742

793

793

793

899

899

90

90

888

888

919

875

875

912

912

862

862

92

933

933

952

952

943

943

951

884

884

883

883

899

899

946

937

937

836

836

902

902

919

672

672

795

795

656

656

658





4040

$25$45

$0 for 3 then 20

$25$40

40

Nothing

20 in40 out

20

50+

$12

$9

$10

50+50+

$45$90

$40$70

30to$60050 to$1200

No

Yes

Yes

Yes

647

647

893

893

875

875

951

951

92

92

911

911

725

725


55











Montana


Nebraska


Nevada




New Hampshire



Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



56


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649




4040

$20$35

$25$35

40

$250day x 4

$500

50+

$10

$5

50+50+

$35$100 $40$60

25$6025

No

Yes

Yes

639

647

862

891

862

861

94

961

838

84

901

864

538





30 after ded

$30$60

$30$60

$35$55

30 after ded

25

30

20

NA

$3 $12

$3 $12

$10

NA

$50$75

$5020

$40$60

NA

Yes

Yes

Yes

602

602

906

906

88

88

96

96

894

894

884

884

663

663





Montana


5050

$20$35

$25$40

$25$40

$25$40

50

$250day x 3

$500day x 3

$450

20

$10+

$10

$10

$7

$10

$40+$60+

$40$60

$40$60

$30$60

30to$60050 to$1200

No

Yes

Yes

Yes

Yes

676

676

665

903

903

919

901

901

902

951

951

957

881

881

892

918

918

898

729

729

732


Nebraska


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No


Nevada


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No




New Hampshire


4040

$20$35

$10$25

$25$40

40

$250day x 4

$300

20

50+

$10

$7

$10

50+50+

$35$100

$35$55$100

30to$60050 to$1200

No

Yes

Yes

Yes

602

516

838

696

861

66

923

892

849

892

918

912

636

529


57


New Jersey








New Mexico





Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code


Monthly Biweekly


58


Prescription Drugs


Mail lan

eeded

are

ll icate

r ng rm

ation




order discount

Ove

rall p

satisfaction

Gettin

g n

care

Gettin

g c

quickly

How

we

doctors

commun

Custome

service

Claim

sproce

ssi

Plan

Info

on

Costs

New Jersey


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649







$15$35

$20$20

20 Plan Allow

$150max$450

$5

$20

$35$100

$45$85

Yes

Yes

631

663

852

844

837

851

928

936

895

86

809

828

623



New Mexico


50 of sch

$30$30

$25$40

+50 of sch

$250day x 3

20

NA

$10

$10

NA

$45$85

30to$60050 to$1200

No

Yes

Yes

663 844 851 936 86 828 642




59


New York

























Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



60

North Dakota


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

New York



30to$60050 to$1200 Yes

l vera e 679 864 849 942 877 875 649









4040

$20$35

$15$35

$20$30

$25$40

$25$40

$25$40

$20$20

40

$250day x 4

20 Plan Allow

$100 x 5

$500+10

$500

$500

$150max$450

50+

$10

$5

25

30

$10

$10

$20

50+50+

$35$100

$35$100

2525

3030

$30$50

$30$50

$45$85

No

Yes

Yes

No

No

Yes

Yes

Yes

662

662

729

729

663

848

848

928

928

844

849

849

90

90

851

937

937

949

949

936

888

888

922

922

86

874

874

924

924

828

547

547

70

70






50 of sch

$30$30

$20$40

$30$50

$25$25

+50 of sch

$250day x 3

None

$1000

$250

NA

$10

$15

$15$100Ded

$10

NA

$45$85

$35$75

$30$75

$35$75 $75$100Ded

No

Yes

Yes

Yes

No

663

729

729

735

844

814

814

933

851

786

786

923

936

888

888

952

86

787

787

92

828

848

848

916

642

60

60



2525

$30$50

25

$750

NA

$10

NA

$5050

No












3030

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

30

$500

$750

$500

$750

$500

$750

$500

$750

$500

$750

NA

$5

$5

$5

$5

$5

$5

$5

$5

$5

$5

NA

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

739

739

739

739

739

739

739

739

739

739

934

934

934

934

934

934

934

934

934

934

89

89

89

89

89

89

89

89

89

89

962

962

962

962

962

962

962

962

962

962

896

896

896

896

896

896

896

896

896

896

92

92

92

92

92

92

92

92

92

92

768

768

768

768

768

768

768

768

768

768

61


North Carolina


North Dakota







Ohio








Oklahoma




Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



62


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

North Carolina


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649


North Dakota


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No





4040

$25$45

$0 for 3 then 20

$15$25

40

Nothing

20 in40 out

None

50+

$12

$9

50$600ded

50+50+

$45$90

$40$70

50$600 ded

No

Yes

Yes

None

647

647

893

893

875

875

951

951

92

92

911

911

725

725



2020

$20$30

20

$100day x 5

NA

$15

NA

$30$50

NA



4040

$25$25

40

$100day x 5

40+

$15

40+40+

$30$50

NA


Ohio


40+40+

$25$40

40+

20

40+

$10

40+40+

30to$60050 to$1200

NA


AultCare HMOshyHigh






Oklahoma


4040

$15$20

$20$35

$25$40

$20$20

$30$40

$10$20

$25$40

40

$150

$250day x 3

$500day x 3

$250

$500

$250

20

50+

$15

$10

$10

$10

$15

$15

$10

50+50+

$30$40$55

$40$60

$40$60

$30$30

$40$40

$30$50

30to$60050 to$1200

No

No

Yes

Yes

Yes

Yes

Yes

Yes

877

788

788

744

922

845

845

909

907

889

889

876

941

922

922

951

944

935

935

929

935

906

906

944

853

708

708

745



4040

$15$45

40

$250dymx1000

50+

$4$10

50+50+

$45$70

No

Yes 592 816 839 916 893 872 727

63


Oregon




Pennsylvania









Puerto Rico



Rhode Island


South Carolina



Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



64


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Information

on Costs

Oregon


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649




Pennsylvania


4040

$20$30

$30$40

$25$40

40

$200

$500

20

50+

$15

$20

$10

50+50+

$40$60

$40$60

30to$60050 to$1200

No

Yes

Yes

Yes

768

768

844

844

847

847

916

916

927

927

89

89

683

683









Puerto Rico


4040

$20$35

$15$35

$20$35

$20$35

$25$50

10 after Deduct

20 after Deduct

$5$5

40

$250day x 4

20 Plan Allow

$250day x 4

20aftrDeduct

15 after ded

10 after deduct

20after Deduct

None

50+

$10

$5

$10

30 $5$15

$5

$5 after ded

$5 after ded

$250

50+50+

$35$100

$35$100

$35$100

$35$60

$35$75

$35$75$100

$10$15

40 $40$120 50 $85$250

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

579

579

579

668

699

754

754

806

861

861

861

868

873

908

908

803

835

835

835

85

885

899

899

82

935

935

935

938

957

97

97

938

887

887

887

906

86

913

913

887

899

899

899

902

921

904

904

70

631

631

631

677

671

678

678




Rhode Island


$750$10

$25$40

$750 amp 10 +$10 amp 10 +

None 10 +

20

$5 or $12 NA

$10

NANA

2025 up to$100$175max

30to$60050 to$1200

Yes No

Yes

691 874 844 963 872 75 586


South Carolina


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No


65


South Dakota






Tennessee






Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



66


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

South Dakota



30to$60050 to$1200 Yes

679 864 849 942 877 875 649





4040

$25$45

$20$30

$0 for 3 then 20

40

Nothing

$100day x 5

20 in40 out

50+

$12

$9

$15

50+50+

$45$90

$40$70

$30$50

No

Yes

Yes

NA

647

647

535

893

893

903

875

875

89

951

951

977

92

92

902

911

911

912

725

725



4040

$25$25

40

$100day x 5

40+

$15

40+40+

$30$50

NA

NA

535


Tennessee


40+40+

$25$40

40+

20

40+

$10

40+40+

30to$60050 to$1200

NA





4040

$20$35

$20$35

$25$40

40

$250day x 4

$250day x 3

$500day x 3

50+

$10

$10

$10

50+50+

$35$100

$40$60

$40$60

No

Yes

Yes

Yes

66 875 868 959 889 914 69

67


Texas






















Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



68


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Texas


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649



4040

$5$25$35

40

15

50+

$5

50+50+

$35$60

No


FirstcareshyHigh

FirstcareshyHigh

FirstcareshyHigh

FirstcareshyHigh

FirstcareshyHigh


4040

$30$55

$30$55

$30$55

$30$55

$30$55

$35$55

40

$250day x 5

$250day x 5

$250day x 5

$250day x 5

$250day x 5

20

40

$10

$10

$10

$10

$10

$10

4040

$35$70

$35$70

$35$70

$35$70

$35$70

$40$60

No

Yes

Yes

Yes

Yes

Yes



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No












5050

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$45

$20$40

50

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

10

$250day x 5

$10+

$10

$10

$10

$10

$10

$10

$10

$10

$5

$10

$40+$60+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$45$100

$35$60

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

63

63

702

835

835

862

764

764

863

931

931

937

864

864

875

856

856

87

673

673

569

69



Enrollment Code

Monthly Biweekly


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family








Vermont

Virgin Islands

Utah


70


Prescription Drugs


Mail lan

eeded

are

ll icate

r ng rm

ation




order discount

Ove

rall p

satisfaction

Gettin

g n

care

Gettin

g c

quickly

How

we

doctors

commun

Custome

service

Claim

sproce

ssi

Plan

Info

on

Costs

Utah


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649






Vermont


$20$30

$25$40

$100 after

20

$5$25$50

$10

$25 $50$50

30to$60050 to$1200

Yes

Yes

629 876 851 958 912 903 64


Virgin Islands

4040 40 50+ 50+50+ No


$750$10 $750 amp 10 + $10 amp 10 +

None 10 +

$5 or $12 NA NANA

2025 up to$100$175max

Yes No

691 874 844 963 872 75 586

71


Virginia















Washington










Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



72


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Virginia








$25$40 4040

$15$30

$20$35

$25$35 4040

$5$25$35 4040

$25$35

Nothing$35

20 40

$150day x3

10 Plan Allow

15 40

15 40

$200

$200

$10 50+

$5

$10

$5 40

$5 40

Nothing

Nothing

HMOP

50+50+

$35$100

$35$100

$35$60 4040

$35$60 4040

$35$65

$35$65

30to$60050 to$1200

OS National

Yes No

Yes

Yes

Yes No

Yes No

Yes

Yes

Average

69

69

648

648

679

844

844

86

86

864

872

872

833

833

849

942

942

925

925

942

865

865

846

846

877

914

914

902

902

875

567

567

54

54

649





MD IPAshyHigh




Washington









$70$70

$10$20

$20$30

$25$40

$25$30

$35$35

$25$40 4040

$20$35

$25$25

$25$35

$154 or 2020

$30$30 $30+40+diff

$20$30

$30$40


$20$0childlt22$30


$500

$200 x3 days

$100

$250dayx3

$150day x 3

$150max$750

$20020

20

20 40

$250day x 4

$350

$500

Nothing Nothing

None None

$200

$500

Nothing

$0

$7$17 Net

$12$22Net

$7

$10

$10

$15

$10 50+

$10

$20

$20

$10 Not Covered

$5 Not Covered

$15

$20

$35$65

$30$50$50

$30$50$45$65

$35$55$50$70

$30$60

$40$55

50+50+

$35$100

$40$60

$40$60

Not Covered

NA

$40$60

$40$60

$353050up to $3000

$355050 up to $3000

$35$50 30day $100 90day

$25$50 30day$100 90day

30to$60050 to$1200

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes No

Yes

Yes

Yes

Yes No

Yes No

Yes

Yes

83

83

583

692

692

659

659

798

798

768

768

867

867

846

864

864

86

86

94

94

844

844

833

831

831

876

886

886

869

869

928

928

847

847

927

927

937

969

969

941

941

957

957

916

916

813

813

867

87

87

912

912

931

931

927

927

836

836

841

916

916

881

881

897

897

89

89

702

702

677

674

674

692

692

65

65

683

683

73


West Virginia



Wisconsin









Wyoming





Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



74


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

West Virginia


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649



Wisconsin


4040

$10$20

$25$40

40

$250

20

50+

$15

$10

50+50+

$30$50

30to$60050 to$1200

No

Yes

Yes

744 909 876 951 929 944 745



4040

$25$35

40

15

50+

$5

50+50+

$35$60

No








Wyoming


4040

$25$25

$10$10

$25$45

$0 for 3then 20

$10$10

$10$10

$25$40

40

None

None

Nothing

20 in40 out

Nothing

Nothing

20

40

$10

$5

$12

$9

$10

$10

$10

4040

$20$20

$45$90

$40$70

$20$50

3050

30$75max 50 wmin$50

30to$60050 to$1200

No

Yes

Yes

Yes

Yes

Yes

No

Yes

682

785

647

647

784

601

909

834

893

893

888

857

90

834

875

875

854

822

97

953

951

951

938

96

834

929

92

92

888

863

879

932

911

911

87

866

588

718

725

725

684

686




4040

$20$30

$20$40

40

$200

None

50+

$7

$7

50+50+

$25$50

$35$60

No

No

None

552

552

852

852

813

813

948

948

883

883

895

895

588

588

75











76



















insurance plans

77



ELIGIBILITY

FUNDING







CONTRIBUTIONS

DISTRIBUTIONS







ANNUAL ROLLOVER







78





79












Self only

Self amp family

Self only

Self amp family

Self only

Self amp family





800shy718shy1299

800shy821shy6136

800shy694shy9901

888shy636shy6252

474 475

341 342

481 482

324 325

9742

11021

13642

10454

21915

25172

30912

22700

4496 10115

5087 11618

6296 14267

4825 10477


80














81













Plan Code


Getting needed care


How well doctors


Claims processing






22

34

48

606

623

614

891

873

891

888

851

859

952

923

912

830

863

887

879

865

885

563

602

590


Plan Code


Getting needed care


How well doctors


Claims processing







22

47

TP TU TV

MW

606

664

566

478

891

909

849

875

888

907

864

801

952

925

932

948

830

871

843

856

879

845

853

812

563

680

542

555

82


83



Plan Name

Telephone Number


Self only

Self amp family

Self only

Self amp family

Self only

Self amp family



Alabama


Alaska


Arizona


Arkansas


California


Colorado


Plan Name

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

Telephone Number


F51

JS1

G51

F51

JS1

G51

Self only

F52

JS2

G52

F52

JS2

G52

Self amp family

16322

22787

21977

16322

22787

21977

Self only

39021

53701

51861

39021

53701

51861

Self amp family

7533

10517

10143

7533

10517

10143

Self only

18010

24785

23936

18010

24785

23936

Self amp family


84

Benefit Type


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs



Alabama


Alaska


Arizona


Arkansas


California


Colorado


Plan Name







Benefit Type

$8333$16666 $8333$16666

$8333$16666 $8333$16666

$8333$16666 $8333$16666

$8333$16666 $8333$16666

$8333$16666 $8333$16666

$8333$16666 $8333$16666


$1000$2000 $1000$2000

$1000$2000 $1000$2000

$1000$2000 $1000$2000

$1000$2000 $1000$2000

$1000$2000 $1000$2000

$1000$2000 $1000$2000

CY Ded SelfFamily

$4000$8000 $5000$10000

$4000$8000 $5000$10000

$4000$8000 $5000$10000

$4000$8000 $5000$10000

$4000$8000 $5000$10000

$4000$8000 $5000$10000


15 40

15 40

15 40

15 40

15 40

15 40

Office Visit

15 40

15 40

15 40

15 40

15 40

15 40

Inpatient Hospital

15 40

15 40

15 40

15 40

15 40

15 40

Outpatient Surgery

Nothing FundDed40

Nothing FundDed40

Nothing FundDed40

Nothing FundDed40

Nothing FundDed40

Nothing FundDed40

Preventive Services

$10$35$60 40+40+40+

$10$35$60 40+40+40+

$10$35$60 40+40+40+

$10$35$60 40+40+40+

$10$35$6 40+40+40+

$10$35$60 40+40+40+

Prescription Drugs

Levels I II III

85



Connecticut


Delaware





Florida





Georgia




Guam


Plan Name

877shy459shy6604

877shy459shy6604

877shy459shy6604

888shy789shy9065

877shy459shy6604

800shy441shy5501

888shy393shy6765

888shy393shy6765

877shy459shy6604

888shy393shy6765

888shy393shy6765

671shy647shy3526

Telephone Number


EP1

EP1

F51

B61

F51

J41

MJ1

QP1

F51

AD1

LM1

KX1

Self only

EP2

EP2

F52

B62

F52

J42

MJ2

QP2

F52

AD2

LM2

KX2

Self amp family

20174

20174

16322

14018

16322

13979

12818

10987

16322

11598

12208

6822

Self only

47770

47770

39021

31268

39021

43929

28521

24447

39021

25804

27163

17900

Self amp family

9311

9311

7533

6470

7533

6452

5916

5071

7533

5353

5634

3148

Self only

22048

22048

18010

14431

18010

20275

13163

11283

18010

11910

12537

8261

Self amp family


86

Connecticut


Delaware





Florida





Georgia




Guam


Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type


87




Idaho



Illinois




Indiana



Iowa



Kansas




Plan Name

877shy459shy6604

877shy459shy6604

800shy377shy4161

877shy459shy6604

888shy393shy6765

888shy393shy6765

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy257shy4692

877shy459shy6604

800shy969shy3343

888shy393shy6765

Telephone Number


JS1

H41

9K4

H41

GB1

MW1

JS1

MW1

H41

SV4

G51

9H1

PH1

Self only

JS2

H42

9K5

H42

GB2

MW2

JS2

MW2

H42

SV5

G52

9H2

PH2

Self amp family

22787

16237

8704

16237

12208

12208

22787

12208

16237

8970

21977

12747

10987

Self only

53701

38826

18033

38826

27163

27162

53701

27162

38826

21408

51861

29956

24447

Self amp family

10517

7494

4017

7494

5634

5634

10517

5634

7494

4140

10143

5883

5071

Self only

24785

17920

8323

17920

12537

12536

24785

12536

17920

9880

23936

13826

11283

Self amp family


88


Idaho



Illinois




Indiana



Iowa



Kansas




Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

89



Kentucky




Maine









Plan Name

877shy459shy6604

888shy393shy6765

877shy459shy6604

877shy459shy6604

877shy459shy6604

888shy789shy9065

800shy833shy7423

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

Telephone Number


H41

6N1

F51

EP1

F51

B61

GZ1

EP1

G51

H41

H41

Self only

H42

6N2

F52

EP2

F52

B62

GZ2

EP2

G52

H42

H42

Self amp family

16237

10987

16322

20174

16322

14018

11980

20174

21977

16237

16237

Self only

38826

24447

39021

47770

39021

31268

26835

47770

51861

38826

38826

Self amp family

7494

5071

7533

9311

7533

6470

5529

9311

10143

7494

7494

Self only

17920

11283

18010

22048

18010

14431

12385

22048

23936

17920

17920

Self amp family


90

Kentucky




Maine









Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

91






Nebraska


Nevada


New Hampshire


New Jersey


New Mexico




Plan Name


877shy459shy6604

800shy969shy3343

888shy393shy6765

77shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

800shy501shy3439

Telephone Number


G51

9H1

PH1

H41

H41

G51

EP1

EP1

G51

EP1

QA4

Self only

G52

9H2

PH2

H42

H42

G52

EP2

EP2

G52

EP2

QA5

Self amp family

21977

12747

10987

16237

16237

21977

20174

20174

21977

20174

9575

Self only

51861

29956

24447

38826

38826

51861

47770

47770

51861

47770

24919

Self amp family

10143

5883

5071

7494

7494

10143

9311

9311

10143

9311

4419

Self only

23936

13826

11283

17920

17920

23936

22048

22048

23936

22048

11501

Self amp family


92





Nebraska


Nevada


New Hampshire


New Jersey


New Mexico




Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

93



North Carolina


North Dakota






Pennsylvania




Rhode Island


South Carolina


Plan Name

877shy459shy6604

877shy459shy6604

877shy459shy6604

330shy363shy6360

877shy459shy6604

877shy459shy6604

877shy459shy6604

866shy351shy5946

888shy876shy2756

877shy459shy6604

877shy459shy6604

Telephone Number


F51

H41

JS1

3A4

JS1

H41

H41

Y61

8W4

EP1

JS1

Self only

F52

H42

JS2

3A5

JS2

H42

H42

Y62

8W5

EP2

JS2

Self amp family

16322

16237

22787

8669

22787

16237

16237

12298

12448

20174

22787

Self only

39021

38826

53701

17501

53701

38826

38826

28345

28053

47770

53701

Self amp family

7533

7494

10517

4001

10517

7494

7494

5676

5745

9311

10517

Self only

18010

17920

24785

8077

24785

17920

17920

13082

12948

22048

24785

Self amp family


94

North Carolina


North Dakota






Pennsylvania




Rhode Island


South Carolina


Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Benefit Type

Prescription Drugs

Levels I II III




30 after deduct

95



South Dakota


Tennessee








Vermont




Plan Name

877shy459shy6604

877shy459shy6604

877shy459shy6604

888shy393shy6765

888shy393shy6765

888shy393shy6765

877shy459shy6604

800shy377shy4161

877shy459shy6604

877shy459shy6604

888shy789shy9065

Telephone Number


G51

G51

JS1

TP1

TU1

TV1

G51

9K4

EP1

F51

B61

Self only

G52

G52

JS2

TP2

TU2

TV2

G52

9K5

EP2

F52

B62

Self amp family

21977

16322

22787

12208

12208

13429

21977

8704

20174

16322

14018

Self only

51861

39021

53701

27163

27162

29879

51861

18033

47770

39021

31268

Self amp family

10143

7533

10517

5634

5634

6198

10143

4017

9311

7533

6470

Self only

23936

18010

24785

12537

12536

13790

23936

8323

22048

18010

14431

Self amp family


96

South Dakota


Tennessee








Vermont




Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

97







Wyoming



Plan Name

877shy459shy6604

800shy552shy7114

877shy459shy6604

877shy459shy6604

877shy459shy6604

800shy377shy4161

Telephone Number


G51

L14

F51

JS1

H41

9K4

Self only

G52

L15

F52

JS2

H42

9K5

Self amp family

21977

10262

16322

22787

16237

8704

Self only

51861

22425

39021

53701

38826

18033

Self amp family

10143

4736

7533

10517

7494

4017

Self only

23936

10350

18010

24785

17920

8323

Self amp family


98





Wyoming



Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

$10$35$50 30day $100 90day

99


100

Appendix F


Waiting Periods





Contributions


Salary Deduction





101


















102










No Yes No No No




Yes Yes No No No


No No No No Yes


or spouse)

No No No Yes No



Yes No No No No


Yes Yes Yes No No


No No No Yes No







103



Reading the Chart


Dental Insurance









Vision Insurance



104



Plan Name

Telephone amp

Website


Class A

Class B

Class C

Class D

Deductible





0 40 60 50 $0




















105



Plan Name

Telephone amp

Website


Class A

Class B

Class C

Class D

Deductible


GEHA Standard






0 20 50 30 $0


0 20 50 30 $0












uccifedvipcom



20 40 60 50 $0


106



Plan Name

You pay

Telephone amp

Website

Class A

Class B

Class C

Class D Deductible













sssprcom


0

0

0

0

0

flat rate

Flat Rate

Approx 30

0

0

30

flat rate

flat rate

Flat Rate

Approx 50

0

0

60 30

flat rate

flat rate

Flat Rate

Approx 60

0

0

50

flat rate

flat rate

$0

$0


$0

$0

$0






107





Additional Features


Aetna Vision High


FEP BlueVision High
















$0

$0


Every24 months

Every 12 months

Every 24 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

108





Additional Features















Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

109



110


AL 356shy358 1 1 1 1 1 1 1 1 1 1 NA NA 3 NA NA



AZ 850shy853 3 5 5 2 2 2 2 1 1 1 NA NA 4 NA NA



CA 919shy921 3 5 5 5 5 4 4 4 4 4 NA NA 5 NA NA


CA 942 956shy958 4 5 5 5 5 4 4 4 4 4 NA NA 5 NA NA


CO 800shy806 3 4 4 3 3 4 4 4 4 3 NA NA 5 NA NA



CT 064shy069 3 5 5 5 5 5 5 5 5 5 NA NA NA 1 NA



FL 330shy334 2 4 4 3 3 3 3 3 3 3 NA NA 2 NA NA


GA 300shy303 305 311 399 3 2 2 2 2 3 3 2 2 1 NA NA 2 NA NA






IL 600shy608 2 2 2 3 3 3 3 4 4 3 NA NA 2 NA NA


IN 460shy462 472 2 1 1 1 1 2 2 1 1 1 NA NA 3 NA NA

IN 463shy464 2 2 2 3 3 3 3 4 4 3 NA NA 2 NA NA

IN 470 2 1 1 1 1 2 2 1 1 1 NA NA 1 NA NA



KY 410 452 459 2 1 1 1 1 2 2 1 1 1 NA NA 1 NA NA







111




MD 200202shy212 214 217 2 5 5 3 3 4 4 4 4 4 4 4 3 NA NA

MD 219 2 4 4 3 3 3 3 3 3 2 5 5 NA NA NA


ME 038 5 5 5 5 5 4 4 5 5 5 NA NA NA NA NA









NC 275shy277 283 4 2 2 2 2 2 2 1 1 2 NA NA 5 NA NA






NJ 3 5 5 5 5 5 5 5 5 5 NA NA NA 1 NA

NJ 080shy084 2 4 4 3 3 3 3 3 3 2 5 5 NA NA NA





NY 063 5 5 5 5 5 4 4 5 5 5 NA NA NA 1 NA

NY 140shy143 4 5 5 3 3 2 2 2 2 3 NA NA NA 1 NA


OH 430shy432 2 1 1 1 1 2 2 1 1 2 NA NA 2 NA NA

OH 440shy443 2 1 1 1 1 2 2 1 1 3 NA NA 2 NA NA

OH 450shy452 2 1 1 1 1 2 2 1 1 1 NA NA 1 NA NA

OH 453shy455 2 1 1 1 1 2 2 1 1 2 NA NA 1 NA NA




070072shy075077shy079085shy089



112




PA 153shy154 156 160shy162 1 2 2 1 1 1 1 1 1 1 1 1 NA NA NA

PA 173shy174 2 5 5 3 3 4 4 4 4 4 4 4 NA NA NA

PA 183 3 5 5 5 5 5 5 5 5 5 1 1 NA 1 NA

PA 189shy196 2 4 4 3 3 3 3 3 3 2 5 5 NA NA NA






TN 422 1 1 1 1 1 1 1 1 1 1 NA NA 1 NA NA


TX 739 2 3 3 1 1 2 2 1 1 1 NA NA 3 NA NA


TX 770 772shy775 2 2 2 1 1 2 2 1 1 1 NA NA 1 NA NA



VA 200shy205 220shy227 2 5 5 3 3 4 4 4 4 4 4 4 3 NA NA

VA 231shy232 238 3 3 3 2 2 2 2 1 1 2 3 3 3 NA NA





WA 986 4 5 5 3 3 3 3 4 4 5 NA NA NA NA NA



WI 540 2 4 4 4 4 3 3 4 4 3 NA NA NA NA NA


WV 254 2 5 5 3 3 4 4 4 4 4 NA NA 3 NA NA


WY 834 4 5 5 3 3 2 2 1 1 2 NA NA NA NA NA





Intershynational



113113

Aetna PPO

Delta Dental PPO

Delta Dental PPO

FEP BlueDental PPO

FEP BlueDental PPO

GEHA PPO

GEHA PPO

MetLife PPO

MetLife PPO












1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

$1288 $1418 $1510 $1666 $1809

$871 $949 $1024 $1080 $1234

$1669 $1831 $2008 $2136 $2485

$939 $1069 $1184 $1249 $1381

$1634 $1860 $2061 $2177 $2408

$900 $989 $1124 $1213 $1347

$1525 $1677 $1904 $2056 $2284

$868 $940 $1044 $1159 $1273

$1606 $1797 $1959 $2121 $2374

$1372 $1541 $1710 $1880 $2049

$2578 $2840 $3022 $3334 $3621

$1744 $1901 $2049 $2160 $2470

$3340 $3663 $4018 $4275 $4973

$1881 $2139 $2370 $2500 $2765

$3270 $3721 $4124 $4357 $4818

$1803 $1981 $2249 $2428 $2697

$3053 $3357 $3812 $4115 $4572

$1738 $1883 $2089 $2320 $2548

$3214 $3597 $3920 $4244 $4750

$2747 $3085 $3422 $3761 $4099

$3867 $4258 $4532 $5001 $5430

$2615 $2850 $3074 $3240 $3704

$5009 $5494 $6026 $6412 $7458

$2820 $3208 $3554 $3749 $4146

$4904 $5581 $6185 $6534 $7226

$2705 $2970 $3372 $3641 $4043

$4579 $5038 $5716 $6174 $6859

$2606 $2823 $3133 $3479 $3821

$4820 $5394 $5879 $6366 $7124

$4118 $4625 $5134 $5641 $6148

$2791 $3073 $3272 $3610 $3919

$1887 $2056 $2219 $2340 $2674

$3616 $3967 $4351 $4628 $5384

$2035 $2316 $2565 $2706 $2992

$3540 $4030 $4466 $4717 $5217

$1950 $2143 $2435 $2628 $2919

$3304 $3634 $4125 $4455 $4949

$1881 $2037 $2262 $2511 $2758

$3480 $3894 $4245 $4596 $5144

$2973 $3339 $3705 $4073 $4440

$5587 $6153 $6549 $7224 $7846

$3779 $4119 $4440 $4680 $5352

$7237 $7937 $8706 $9263 $10775

$4076 $4635 $5135 $5417 $5991

$7085 $8062 $8935 $9440 $10439

$3907 $4292 $4873 $5261 $5844

$6615 $7274 $8259 $8916 $9906

$3766 $4080 $4526 $5027 $5521

$6964 $7794 $8493 $9195 $10292

$5952 $6684 $7414 $8149 $8881

$8378 $9226 $9819 $10835 $11765

$5666 $6175 $6660 $7020 $8025

$10853 $11904 $13056 $13893 $16159

$6110 $6951 $7700 $8123 $8983

$10625 $12092 $13401 $14157 $15656

$5861 $6435 $7306 $7889 $8760

$9921 $10916 $12385 $13377 $14861

$5646 $6117 $6788 $7538 $8279

$10443 $11687 $12738 $13793 $15435

$8922 $10021 $11124 $12222 $13321





Self amp Family




Dominion Dental HMO

Dominion Dental HMO

EmblemHealth PPO

Humana

Triple S Salud PPO










1 2 3 4 5

1 2 3 4 5

1

1 2 3 4 5

1

$596 $622 $694 $829 $884

$1018 $1055 $1109 $1291 $1517

$1826

$990 $1048 $1136 $1378 $1475

$454

$1194 $1246 $1391 $1660 $1771

$2038 $2113 $2221 $2585 $3037

$3652

$1982 $2098 $2273 $2759 $2952

$910

$1790 $1868 $2085 $2489 $2655

$3056 $3168 $3330 $3876 $4554

$5478

$2971 $3146 $3409 $4136 $4428

$1191

$1291 $1348 $1504 $1796 $1915

$2206 $2286 $2403 $2797 $3287

$3956

$2145 $2271 $2461 $2986 $3196

$984

$2587 $2700 $3014 $3597 $3837

$4416 $4578 $4812 $5601 $6580

$7913

$4294 $4546 $4925 $5978 $6396

$1972

$3878 $4047 $4518 $5393 $5753

$6621 $6864 $7215 $8398 $9867

$11869

$6437 $6816 $7386 $8961 $9594

$2581





Self amp Family


114

Aetna


Delta Dental High


FEP BlueDental High

GEHA Standard

GEHA High

MetLife Standard

MetLife High

United Concordia

$1418

$1234

$2485

$1381

$2408

$900

$1525

$1273

$2374

$2049

$2840

$2470

$4973

$2765

$4818

$1803

$3053

$2548

$4750

$4099

$4258

$3704

$7458

$4146

$7226

$2705

$4579

$3821

$7124

$6148

$3073

$2674

$5384

$2992

$5217

$1950

$3304

$2758

$5144

$4440

$9226

$8025

$16159

$8983

$15656

$5861

$9921

$8279

$15435

$13321




Self amp Family

$6153

$5352

$10775

$5991

$10439

$3907

$6615

$5521

$10292

$8881


Premium Rate Charts


Aetna Vision

FEP BlueVision








$680 $1328

$800 $1012

$622 $884

$771 $1339

$1304 $2533

$1601 $2028

$1220 $1729

$1547 $2685

$1913 $3716

$2401 $3042

$1814 $2572

$2321 $4026

$314 $613

$369 $467

$287 $408

$356 $618

Standard High

Standard High

Standard High

Standard High

$602 $1169

$739 $936

$563 $798

$714 $1239

$883 $1715

$1108 $1404

$837 $1187

$1071 $1858







Aetna Vision

FEP BlueVision








$680 $1328

$800 $1012

$622 $884

$771 $1339

$1304 $2533

$1601 $2028

$1220 $1729

$1547 $2685

$1913 $3716

$2401 $3042

$1814 $2572

$2321 $4026

$314 $613

$369 $467

$287 $408

$356 $618

Standard High

Standard High

Standard High

Standard High

$602 $1169

$739 $936

$563 $798

$714 $1239

$883 $1715

$1108 $1404

$837 $1187

$1071 $1858






115

______________________________________________________________________________________________________________

























116
























117

Summary Information

























19121-c1-30 (70-10)_0

19121-pg31-36 (70-10)_0

19121-pg37-100 (70-10)_0

19121-pg101-118 (70-10)_0
















3


Current Employees




























4

















5







FSAFEDS




6



FEGLI












7






Key FEHB facts













8














9










10















11






Key FEDVIP facts













12

















13














14

















15





Key FSAFEDS facts










16













17















18


How do I enroll










19




Key FEGLI facts



















20











How do I enroll








21




Key FLTCIP facts












22





How do I apply








23


24


















25







donrsquot



















26












27


Definitions













28















Yes

Yes

Yes

Not Applicable

Yes

No

Yes

Not Applicable

Yes

Yes

Yes

No

Yes

Not Applicable

Yes

Yes

Yes

No

Yes1

Not Applicable

Yes

Not Applicable

Yes

Yes2



29













30










31













Telephone Number

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family






MHBP shystd

MHBP shyValue Plan

NALC shyhigh

NALC Value Option

SAMBA shyhigh

SAMBA shystd






800shy222shy2798

Local phone

Local phone

800shy821shy6136

800shy821shy6136

800shy410shy7778

800shy410shy7778

888shy636shy6252

888shy636shy6252

800shy638shy6589

800shy638shy6589

888shy438shy9135

202shy833shy4910

800shy424shy8196

800shy638shy8432

471

104

111

311

314

454

414

321

KM1

441

444

421

401

431

381

472

105

112

312

315

455

415

322

KM2

442

445

422

402

432

382

13670

19028

13209

20317

10418

20913

11302

16122

9001

27523

13171

15613

12535

11170

18913

30910

44412

30930

48310

23691

50565

26946

32727

19546

70356

30081

39039

30885

23316

30210

6309

8782

6096

9377

4808

9652

5216

7441

4154

12703

6079

7206

5785

5155

8729

14266

20498

14275

22297

10934

23338

12436

15105

9021

32472

13884

18018

14255

10761

13943


32




APWU shyhigh

BCBS shystd

BCBS shybasic

GEHA shyhigh

GEHA shystd

MHBP shystd

MHBP shyValue

NALC shyhigh

NALC Value

SAMBA shyhigh

SAMBA shystd

CRHP

FS

PCABP

Rural

Plan

PPO NonshyPPO

PPO NonshyPPO

PPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

NonshyPPO PPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

Benefit Type


$350 None $250 $350 None $350 + 35+


$350 None $100 $350 None $300


$400 None $200 $600 None $500


$300 None $200 $300 None $350

$4000 None 50 $2000 None 20

$300 None $200 $300 None $300


$350 None $200 $400 None $400



$350 $200 $100 $400 $200 $300

Deductible

Calendar Year

Prescription Drug

Hospital Inpatient

Per Person

$18 10 10 $8 2525 Yes 30+diff 30+diff 30 50 5050 Yes







$20 15 Nothing 20 3045 Yes 30 30 30 45+ 45+45+ Yes

50 50 50 50 5050+ No 20 20 20 $10 $40$60 No






$20 10 Nothing 30 3030 Yes 25 25 25 30 3030 Yes



RampB

Prescription Drugs



Office Visits


T2 $45 T3 50($55Min) T4 $50to$140 T5 $70to$195


33













Plan Code


Getting needed care


How well doctors


Claims processing





47

10 835 946 917 955 926 956 703



10

11

31

757

838

896

934

891

922

95

961

921

912

936

929

643

699


31

31 725 907 895 949 875 926 688

MHBP shystd

31

45 84 938 916 935 906 954 696

MHBP shyValue Plan

45

41 63 908 857 929 866 887 636

NALC shyhigh

41

32 856 936 922 959 934 965 771


32

KM

SAMBA shyhigh

KM

44 897 947 943 96 946 953 789

SAMBA shystd

44

44 816 93 905 956 911 946 757



44

42

roups

verage

837

805

941

927

945

917

962

951

94

911

927

934

747

716


42

40 798 898 909 935 892 889 721


40

43


43

38 865 946 947 967 928 966 773 38

34



Plan Name Location


Plan Code


Getting needed care


How well doctors


Claims processing




Arizona 10 11

851 747

905 898

919 884

933 923

938 914

969 928

724 680


California 10 11

809 705

915 873

897 840

954 943

881 910

937 912

677 616



768 691

935 893

930 874

951 940

882 881

898 922

657 622


Florida 10 11

864 806

942 916

922 894

952 947

934 916

954 937

733 660


Illinois 10 11

861 796

933 912

934 881

955 950

901 936

972 938

712 653


Maryland 10 11

857 770

931 897

917 898

954 940

897 921

956 967

713 666


Texas 10 11

887 825

934 898

931 883

950 955

936 910

957 967

721 617


Virginia 10 11

871 782

924 901

929 894

966 962

914 917

959 960

708 681

35


36















37



Enrollment Code

Monthly Biweekly


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Alabama


Alaska


Arizona









Arkansas





38


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Alabama




Alaska

4040 40 50+ 50+50+ No



Arizona

4040 40 50+ 50+50+ No










Arkansas

$25$40 $500day x 3 $10 $40$60 Yes





39



Enrollment Code

Monthly Biweekly


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

California
















Colorado




Connecticut


Delaware





40


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

California

HMOPOS National 679 864 849 942 877 875 649


to$1200 Yes

Average
















Colorado

$25$40 30 $10 $25$50 Yes 701 80 804 923 825 889 57





Connecticut

$20$40 10 $15 $40$80 Yes 722 884 873 936 876 879 622



Delaware

4040 40 50+ 50+50+ No





41











Florida


















Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



42


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs



HMOPOS Nationa

30to$60050 to$1200 Yes

l Average 679 864 849 942 877 875 649






4040

$15$30

$20$35

$25$35

Nothing$35

40

$150day x3

10 Plan Allow

$200

$200

50+

$5

$10

Nothing

Nothing

50+50+

$35$100

$35$100

$35$65

$35$65

No

Yes

Yes

Yes

Yes

69

69

648

648

844

844

86

86

872

872

833

833

942

942

925

925

865

865

846

846

914

914

902

902

567

567

54




MD IPAshyHigh

Florida


$70$70

$10$20

$20$30

$25$40

$25$40

$500

$100

$250dayx3

$150day x 3

20

Nothing

$7$17 Net

$12$22Net

$7

$10

$35$65

$30$50$45$65

$35$55$50$70

$30$60

30to$60050 to$1200

Yes

Yes

Yes

Yes

Yes

83

83

583

867

867

846

831

831

876

927

927

937

813

813

867

836

836

841

702

702

677








4040

$15$40

$25$45

$15$25

$15$30

$20$50

$35$55

40

$250dayx3

$300dayx3

$250

Ded + $150x3

Ded + $150x5

20

50+

$5

$10

$15 Tier 1

$3$20

$3$10

$10

50+50+

$30$5030

$40$6030


$40$6020

$50$7020

$40$60

No

No

No

No

No

No

Yes

746

746

855

514

514

877

877

905

808

808

847

847

905

764

764

957

957

953

921

921

919

919

938

827

827

87

87

946

783

783

68

68

755

535

535



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No










5050

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

50

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$10+

$10

$10

$10

$10

$10

$10

$10

$10

$40+$60+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

529

529

86

86

824

824

937

937

846

846

843

843

687

687

43


Georgia













Guam









Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



44


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Georgia


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649




4040

$20$35

$35$55

40

$250day x 4

20

50+

$10

$10

50+50+

$35$100

$40$60

No

Yes

Yes

59 90 878 941 86 857 62



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No










Guam


5050

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$30

$20$35

$15$40

50

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250dayx3

$250dayx3

$200

$10+

$10

$10

$10

$10

$10

$10

$10$20 Comm

$15$25 Comm

$10

$40+$60+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$50 Comm

$40$50 Comm

$2550 of AWP

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

514

794

794

883

845

845

837

85

85

941

935

935

859

884

884

849

839

839

556

625

625


TakeCareshyHigh

TakeCareshyStandard


3030

$5 at FHP$40

$5 at FHP$40

$25$40

30

$100day for 5

$150day for 5

20

NA

$10

$15

$10

NA

$25$50

$40$80

30to$60050 to$1200

NA

Yes

Yes

Yes

687

687

669

669

686

686

904

904

792

792

786

786

571

571


HMSA InshyNetwork

4040

$15$15

40

$100

50+

$7

50+50+

$30$65

No




3030

$20$20

$30$30

30

$100

10

$7 + 20

$10

$15

$45$45

$50$50

$30 + 20$65 + 20 No

Yes

Yes

754

754

826

826

815

815

94

94

875

875

811

811

613

613

45


Idaho








Illinois
















Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



46


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

6

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Idaho


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649






SelectHealthshyHigh


Illinois


4040

$20$30

$20$40

$25$25

$25$35

$15$25

$20$30

$25$40

40

$200

None

$350

$500

$100

$100 after

20

50+

$7

$7

$20

$20

$5 $25$50

$5

$10

50+50+

$25$50

$35$60

$40$60

$40$60

$25$50$50

$25$50

30to$60050 to$1200

No

No

None

Yes

Yes

Yes

Yes

Yes

552

552

659

659

629

629

852

852

86

86

876

876

813

813

869

869

851

851

948

948

941

941

958

958

883

883

912

912

912

912

895

895

881

881

903

903

588

588

692

692

64

64




4040

$20$35

$25$35

40

Nothing

$500

50+

$10 copay

$5

50+50+

$40$60

$40$6025 $6025

No

Yes







30 after ded

$25$50

$25$50

$20$35

$25$40

$35$55

30 after ded

$200day x 5

20

$250day x 3

$500day x 3

20

NA

$7

$7

$10

$10

$10

NA

$35$70

$35$70

$40$60

$40$60

$40$60

NA

Yes

Yes

Yes

Yes

Yes

745 915 88 962 878 868 67



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No







5050

$20$35

$25$40

$15$15

$25$40

$25$50

50

$250day x 3

$500day x 3

None

$450

20

$10+

$10

$10

$10

$7

$10

$40+$60+

$40$60

$40$60

$35$60

$30$60

$35$50

No

Yes

Yes

Yes

Yes

Yes

647

647

665

577

822

822

919

896

788

788

902

86

943

943

957

956

859

859

892

914

834

834

898

918

66

66

732

623

47


Indiana












Iowa












Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



48


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Indiana


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649





4040

$25$50

$25$50

$35$55

40

$200day x 5

20

20

50+

$7

$7

$10

50+50+

$35$70

$35$70

$40$60

No

Yes

Yes

Yes

745 915 88 962 878 868 67









Iowa


5050

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$15

$25$40

50

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

20

20

$10+

$10

$10

$10

$10

$10

$10

$10

$10

$40+$60+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$25$50

30to$60050 to$1200

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

647

647

562

822

822

878

788

788

815

943

943

934

859

859

868

834

834

893

66

66

593









4040

$25$50

$25$50

$25$50

$25$50

$25$45

$0 for 3 then 20

$20$30

40

20

20

$200day x 5

20

Nothing

20 in40 out

$100day x 5

50+

$3 $10

$3 $10

$7

$7

$12

$9

$15

50+50+

$45$70$100

30$5000 Max

$35$70

$35$70

$45$90

$40$70

$30$50

No

Yes

No

Yes

Yes

Yes

Yes

NA

562

562

745

647

647

535

905

905

915

893

893

903

888

888

88

875

875

89

964

964

962

951

951

977

837

837

878

92

92

902

903

903

868

911

911

912

652

652

67

725

725



4040

$25$25

40

$100day x 5

40+

$15

40+40+

$30$50

NA



40+40+

$25$50

40+

20

40+

$10

40+40+

$35$50

NA

Yes 577 896 86 956 914 918 623

49





Kansas








Kentucky








Louisiana









50


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Kansas


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649






4040

$20$35

$30$60

$30$60

$35$55

40

$250day x 4

25

30

20

50+

$10

$3 $12

$3 $12

$10

50+50+

$35$100

$50$75

$5020

$40$60

No

Yes

Yes

Yes

Yes

639

602

602

862

906

906

862

88

88

94

96

96

838

894

894

901

884

884

538

663

663




Kentucky


5050

$20$35

$25$40

$25$40

50

$250day x 3

$500day x 3

20

$10+

$10

$10

$10

$40+$60+

$40$60

$40$60

30to$60050 to$1200

No

Yes

Yes

Yes

676

676

903

903

901

901

951

951

881

881

918

918

729

729








Louisiana


4040

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$25$40

40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

20

50+

$10

$10

$10

$10

$10

$10

$10

50+50+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

30to$60050 to$1200

No

Yes

Yes

Yes

Yes

Yes

Yes








4040

$25$45

$30$55

$20$35

$35$40

$20$35

$35$40

40

Ded+$100

Ded+30

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+

$5

$5

$10

$10

$10

$10

50+50+

$40$100

$40$100

$40$60

$40$60

$40$60

$40$60

No

Yes

Yes

Yes

Yes

Yes

Yes

573

573

874

874

823

823

968

968

831

831

827

827

625

625

51





Maine


Maryland











Massachusetts




52


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Maine


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649


Maryland


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No






4040

$15$30

$20$35

$25$35

Nothing$35

40

$150day x3

10 Plan Allow

$200

$200

50+

$5

$10

Nothing

Nothing

50+50+

$35$100

$35$100

$35$65

$35$65

No

Yes

Yes

Yes

Yes

69

69

648

648

844

844

86

86

872

872

833

833

942

942

925

925

865

865

846

846

914

914

902

902

567

567

54






MD IPAshyHigh

Massachusetts


$70$70

$20$40

$20$40

$10$20

$20$30

$25$40

$25$40

$500

$200day x 3

$200day x 3

$100

$250dayx3

$150day x 3

20

Nothing

$3$15

$3$15

$7$17 Net

$12$22Net

$7

$10

$35$65

$30$60

$30$60

$30$50$45$65

$35$55$50$70

$30$60

30to$60050 to$1200

Yes

Yes

Yes

Yes

Yes

Yes

Yes

563

563

83

83

583

864

864

867

867

846

864

864

831

831

876

969

969

927

927

937

892

892

813

813

867

871

871

836

836

841

606

606

702

702

677



4040

$25$35

40

$150 to $750max

50+

$10

50+50+

$30$60

No

Yes 627 851 882 929 883 801 649

53





Michigan










Minnesota






54


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Michigan


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649










Minnesota


4040

$15$25

$15$25

$10$10

$20$20

$10$20

$15$30

$10$20

$15$15

$25$40

40

Nothing

Nothing

Nothing

$500x3

Nothing

Nothing

None

None

20

50+

$10

$10

$5

$10

$5

$15

$0$8

$10

$10

50+50+

$30$60

$30$60

$15$15

NA$40

$50$50

$50$50

$40$60

$40$40

30to$60050 to$1200

No

Yes

Yes

No

No

Yes

Yes

Yes

Yes

Yes

651

651

742

742

793

793

793

899

899

90

90

888

888

919

875

875

912

912

862

862

92

933

933

952

952

943

943

951

884

884

883

883

899

899

946

937

937

836

836

902

902

919

672

672

795

795

656

656

658





4040

$25$45

$0 for 3 then 20

$25$40

40

Nothing

20 in40 out

20

50+

$12

$9

$10

50+50+

$45$90

$40$70

30to$60050 to$1200

No

Yes

Yes

Yes

647

647

893

893

875

875

951

951

92

92

911

911

725

725


55











Montana


Nebraska


Nevada




New Hampshire



Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



56


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649




4040

$20$35

$25$35

40

$250day x 4

$500

50+

$10

$5

50+50+

$35$100 $40$60

25$6025

No

Yes

Yes

639

647

862

891

862

861

94

961

838

84

901

864

538





30 after ded

$30$60

$30$60

$35$55

30 after ded

25

30

20

NA

$3 $12

$3 $12

$10

NA

$50$75

$5020

$40$60

NA

Yes

Yes

Yes

602

602

906

906

88

88

96

96

894

894

884

884

663

663





Montana


5050

$20$35

$25$40

$25$40

$25$40

50

$250day x 3

$500day x 3

$450

20

$10+

$10

$10

$7

$10

$40+$60+

$40$60

$40$60

$30$60

30to$60050 to$1200

No

Yes

Yes

Yes

Yes

676

676

665

903

903

919

901

901

902

951

951

957

881

881

892

918

918

898

729

729

732


Nebraska


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No


Nevada


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No




New Hampshire


4040

$20$35

$10$25

$25$40

40

$250day x 4

$300

20

50+

$10

$7

$10

50+50+

$35$100

$35$55$100

30to$60050 to$1200

No

Yes

Yes

Yes

602

516

838

696

861

66

923

892

849

892

918

912

636

529


57


New Jersey








New Mexico





Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code


Monthly Biweekly


58


Prescription Drugs


Mail lan

eeded

are

ll icate

r ng rm

ation




order discount

Ove

rall p

satisfaction

Gettin

g n

care

Gettin

g c

quickly

How

we

doctors

commun

Custome

service

Claim

sproce

ssi

Plan

Info

on

Costs

New Jersey


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649







$15$35

$20$20

20 Plan Allow

$150max$450

$5

$20

$35$100

$45$85

Yes

Yes

631

663

852

844

837

851

928

936

895

86

809

828

623



New Mexico


50 of sch

$30$30

$25$40

+50 of sch

$250day x 3

20

NA

$10

$10

NA

$45$85

30to$60050 to$1200

No

Yes

Yes

663 844 851 936 86 828 642




59


New York

























Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



60

North Dakota


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

New York



30to$60050 to$1200 Yes

l vera e 679 864 849 942 877 875 649









4040

$20$35

$15$35

$20$30

$25$40

$25$40

$25$40

$20$20

40

$250day x 4

20 Plan Allow

$100 x 5

$500+10

$500

$500

$150max$450

50+

$10

$5

25

30

$10

$10

$20

50+50+

$35$100

$35$100

2525

3030

$30$50

$30$50

$45$85

No

Yes

Yes

No

No

Yes

Yes

Yes

662

662

729

729

663

848

848

928

928

844

849

849

90

90

851

937

937

949

949

936

888

888

922

922

86

874

874

924

924

828

547

547

70

70






50 of sch

$30$30

$20$40

$30$50

$25$25

+50 of sch

$250day x 3

None

$1000

$250

NA

$10

$15

$15$100Ded

$10

NA

$45$85

$35$75

$30$75

$35$75 $75$100Ded

No

Yes

Yes

Yes

No

663

729

729

735

844

814

814

933

851

786

786

923

936

888

888

952

86

787

787

92

828

848

848

916

642

60

60



2525

$30$50

25

$750

NA

$10

NA

$5050

No












3030

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

30

$500

$750

$500

$750

$500

$750

$500

$750

$500

$750

NA

$5

$5

$5

$5

$5

$5

$5

$5

$5

$5

NA

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

739

739

739

739

739

739

739

739

739

739

934

934

934

934

934

934

934

934

934

934

89

89

89

89

89

89

89

89

89

89

962

962

962

962

962

962

962

962

962

962

896

896

896

896

896

896

896

896

896

896

92

92

92

92

92

92

92

92

92

92

768

768

768

768

768

768

768

768

768

768

61


North Carolina


North Dakota







Ohio








Oklahoma




Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



62


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

North Carolina


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649


North Dakota


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No





4040

$25$45

$0 for 3 then 20

$15$25

40

Nothing

20 in40 out

None

50+

$12

$9

50$600ded

50+50+

$45$90

$40$70

50$600 ded

No

Yes

Yes

None

647

647

893

893

875

875

951

951

92

92

911

911

725

725



2020

$20$30

20

$100day x 5

NA

$15

NA

$30$50

NA



4040

$25$25

40

$100day x 5

40+

$15

40+40+

$30$50

NA


Ohio


40+40+

$25$40

40+

20

40+

$10

40+40+

30to$60050 to$1200

NA


AultCare HMOshyHigh






Oklahoma


4040

$15$20

$20$35

$25$40

$20$20

$30$40

$10$20

$25$40

40

$150

$250day x 3

$500day x 3

$250

$500

$250

20

50+

$15

$10

$10

$10

$15

$15

$10

50+50+

$30$40$55

$40$60

$40$60

$30$30

$40$40

$30$50

30to$60050 to$1200

No

No

Yes

Yes

Yes

Yes

Yes

Yes

877

788

788

744

922

845

845

909

907

889

889

876

941

922

922

951

944

935

935

929

935

906

906

944

853

708

708

745



4040

$15$45

40

$250dymx1000

50+

$4$10

50+50+

$45$70

No

Yes 592 816 839 916 893 872 727

63


Oregon




Pennsylvania









Puerto Rico



Rhode Island


South Carolina



Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



64


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Information

on Costs

Oregon


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649




Pennsylvania


4040

$20$30

$30$40

$25$40

40

$200

$500

20

50+

$15

$20

$10

50+50+

$40$60

$40$60

30to$60050 to$1200

No

Yes

Yes

Yes

768

768

844

844

847

847

916

916

927

927

89

89

683

683









Puerto Rico


4040

$20$35

$15$35

$20$35

$20$35

$25$50

10 after Deduct

20 after Deduct

$5$5

40

$250day x 4

20 Plan Allow

$250day x 4

20aftrDeduct

15 after ded

10 after deduct

20after Deduct

None

50+

$10

$5

$10

30 $5$15

$5

$5 after ded

$5 after ded

$250

50+50+

$35$100

$35$100

$35$100

$35$60

$35$75

$35$75$100

$10$15

40 $40$120 50 $85$250

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

579

579

579

668

699

754

754

806

861

861

861

868

873

908

908

803

835

835

835

85

885

899

899

82

935

935

935

938

957

97

97

938

887

887

887

906

86

913

913

887

899

899

899

902

921

904

904

70

631

631

631

677

671

678

678




Rhode Island


$750$10

$25$40

$750 amp 10 +$10 amp 10 +

None 10 +

20

$5 or $12 NA

$10

NANA

2025 up to$100$175max

30to$60050 to$1200

Yes No

Yes

691 874 844 963 872 75 586


South Carolina


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No


65


South Dakota






Tennessee






Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



66


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

South Dakota



30to$60050 to$1200 Yes

679 864 849 942 877 875 649





4040

$25$45

$20$30

$0 for 3 then 20

40

Nothing

$100day x 5

20 in40 out

50+

$12

$9

$15

50+50+

$45$90

$40$70

$30$50

No

Yes

Yes

NA

647

647

535

893

893

903

875

875

89

951

951

977

92

92

902

911

911

912

725

725



4040

$25$25

40

$100day x 5

40+

$15

40+40+

$30$50

NA

NA

535


Tennessee


40+40+

$25$40

40+

20

40+

$10

40+40+

30to$60050 to$1200

NA





4040

$20$35

$20$35

$25$40

40

$250day x 4

$250day x 3

$500day x 3

50+

$10

$10

$10

50+50+

$35$100

$40$60

$40$60

No

Yes

Yes

Yes

66 875 868 959 889 914 69

67


Texas






















Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



68


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Texas


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649



4040

$5$25$35

40

15

50+

$5

50+50+

$35$60

No


FirstcareshyHigh

FirstcareshyHigh

FirstcareshyHigh

FirstcareshyHigh

FirstcareshyHigh


4040

$30$55

$30$55

$30$55

$30$55

$30$55

$35$55

40

$250day x 5

$250day x 5

$250day x 5

$250day x 5

$250day x 5

20

40

$10

$10

$10

$10

$10

$10

4040

$35$70

$35$70

$35$70

$35$70

$35$70

$40$60

No

Yes

Yes

Yes

Yes

Yes



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No












5050

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$45

$20$40

50

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

10

$250day x 5

$10+

$10

$10

$10

$10

$10

$10

$10

$10

$5

$10

$40+$60+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$45$100

$35$60

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

63

63

702

835

835

862

764

764

863

931

931

937

864

864

875

856

856

87

673

673

569

69



Enrollment Code

Monthly Biweekly


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family








Vermont

Virgin Islands

Utah


70


Prescription Drugs


Mail lan

eeded

are

ll icate

r ng rm

ation




order discount

Ove

rall p

satisfaction

Gettin

g n

care

Gettin

g c

quickly

How

we

doctors

commun

Custome

service

Claim

sproce

ssi

Plan

Info

on

Costs

Utah


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649






Vermont


$20$30

$25$40

$100 after

20

$5$25$50

$10

$25 $50$50

30to$60050 to$1200

Yes

Yes

629 876 851 958 912 903 64


Virgin Islands

4040 40 50+ 50+50+ No


$750$10 $750 amp 10 + $10 amp 10 +

None 10 +

$5 or $12 NA NANA

2025 up to$100$175max

Yes No

691 874 844 963 872 75 586

71


Virginia















Washington










Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



72


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Virginia








$25$40 4040

$15$30

$20$35

$25$35 4040

$5$25$35 4040

$25$35

Nothing$35

20 40

$150day x3

10 Plan Allow

15 40

15 40

$200

$200

$10 50+

$5

$10

$5 40

$5 40

Nothing

Nothing

HMOP

50+50+

$35$100

$35$100

$35$60 4040

$35$60 4040

$35$65

$35$65

30to$60050 to$1200

OS National

Yes No

Yes

Yes

Yes No

Yes No

Yes

Yes

Average

69

69

648

648

679

844

844

86

86

864

872

872

833

833

849

942

942

925

925

942

865

865

846

846

877

914

914

902

902

875

567

567

54

54

649





MD IPAshyHigh




Washington









$70$70

$10$20

$20$30

$25$40

$25$30

$35$35

$25$40 4040

$20$35

$25$25

$25$35

$154 or 2020

$30$30 $30+40+diff

$20$30

$30$40


$20$0childlt22$30


$500

$200 x3 days

$100

$250dayx3

$150day x 3

$150max$750

$20020

20

20 40

$250day x 4

$350

$500

Nothing Nothing

None None

$200

$500

Nothing

$0

$7$17 Net

$12$22Net

$7

$10

$10

$15

$10 50+

$10

$20

$20

$10 Not Covered

$5 Not Covered

$15

$20

$35$65

$30$50$50

$30$50$45$65

$35$55$50$70

$30$60

$40$55

50+50+

$35$100

$40$60

$40$60

Not Covered

NA

$40$60

$40$60

$353050up to $3000

$355050 up to $3000

$35$50 30day $100 90day

$25$50 30day$100 90day

30to$60050 to$1200

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes No

Yes

Yes

Yes

Yes No

Yes No

Yes

Yes

83

83

583

692

692

659

659

798

798

768

768

867

867

846

864

864

86

86

94

94

844

844

833

831

831

876

886

886

869

869

928

928

847

847

927

927

937

969

969

941

941

957

957

916

916

813

813

867

87

87

912

912

931

931

927

927

836

836

841

916

916

881

881

897

897

89

89

702

702

677

674

674

692

692

65

65

683

683

73


West Virginia



Wisconsin









Wyoming





Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



74


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

West Virginia


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649



Wisconsin


4040

$10$20

$25$40

40

$250

20

50+

$15

$10

50+50+

$30$50

30to$60050 to$1200

No

Yes

Yes

744 909 876 951 929 944 745



4040

$25$35

40

15

50+

$5

50+50+

$35$60

No








Wyoming


4040

$25$25

$10$10

$25$45

$0 for 3then 20

$10$10

$10$10

$25$40

40

None

None

Nothing

20 in40 out

Nothing

Nothing

20

40

$10

$5

$12

$9

$10

$10

$10

4040

$20$20

$45$90

$40$70

$20$50

3050

30$75max 50 wmin$50

30to$60050 to$1200

No

Yes

Yes

Yes

Yes

Yes

No

Yes

682

785

647

647

784

601

909

834

893

893

888

857

90

834

875

875

854

822

97

953

951

951

938

96

834

929

92

92

888

863

879

932

911

911

87

866

588

718

725

725

684

686




4040

$20$30

$20$40

40

$200

None

50+

$7

$7

50+50+

$25$50

$35$60

No

No

None

552

552

852

852

813

813

948

948

883

883

895

895

588

588

75











76



















insurance plans

77



ELIGIBILITY

FUNDING







CONTRIBUTIONS

DISTRIBUTIONS







ANNUAL ROLLOVER







78





79












Self only

Self amp family

Self only

Self amp family

Self only

Self amp family





800shy718shy1299

800shy821shy6136

800shy694shy9901

888shy636shy6252

474 475

341 342

481 482

324 325

9742

11021

13642

10454

21915

25172

30912

22700

4496 10115

5087 11618

6296 14267

4825 10477


80














81













Plan Code


Getting needed care


How well doctors


Claims processing






22

34

48

606

623

614

891

873

891

888

851

859

952

923

912

830

863

887

879

865

885

563

602

590


Plan Code


Getting needed care


How well doctors


Claims processing







22

47

TP TU TV

MW

606

664

566

478

891

909

849

875

888

907

864

801

952

925

932

948

830

871

843

856

879

845

853

812

563

680

542

555

82


83



Plan Name

Telephone Number


Self only

Self amp family

Self only

Self amp family

Self only

Self amp family



Alabama


Alaska


Arizona


Arkansas


California


Colorado


Plan Name

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

Telephone Number


F51

JS1

G51

F51

JS1

G51

Self only

F52

JS2

G52

F52

JS2

G52

Self amp family

16322

22787

21977

16322

22787

21977

Self only

39021

53701

51861

39021

53701

51861

Self amp family

7533

10517

10143

7533

10517

10143

Self only

18010

24785

23936

18010

24785

23936

Self amp family


84

Benefit Type


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs



Alabama


Alaska


Arizona


Arkansas


California


Colorado


Plan Name







Benefit Type

$8333$16666 $8333$16666

$8333$16666 $8333$16666

$8333$16666 $8333$16666

$8333$16666 $8333$16666

$8333$16666 $8333$16666

$8333$16666 $8333$16666


$1000$2000 $1000$2000

$1000$2000 $1000$2000

$1000$2000 $1000$2000

$1000$2000 $1000$2000

$1000$2000 $1000$2000

$1000$2000 $1000$2000

CY Ded SelfFamily

$4000$8000 $5000$10000

$4000$8000 $5000$10000

$4000$8000 $5000$10000

$4000$8000 $5000$10000

$4000$8000 $5000$10000

$4000$8000 $5000$10000


15 40

15 40

15 40

15 40

15 40

15 40

Office Visit

15 40

15 40

15 40

15 40

15 40

15 40

Inpatient Hospital

15 40

15 40

15 40

15 40

15 40

15 40

Outpatient Surgery

Nothing FundDed40

Nothing FundDed40

Nothing FundDed40

Nothing FundDed40

Nothing FundDed40

Nothing FundDed40

Preventive Services

$10$35$60 40+40+40+

$10$35$60 40+40+40+

$10$35$60 40+40+40+

$10$35$60 40+40+40+

$10$35$6 40+40+40+

$10$35$60 40+40+40+

Prescription Drugs

Levels I II III

85



Connecticut


Delaware





Florida





Georgia




Guam


Plan Name

877shy459shy6604

877shy459shy6604

877shy459shy6604

888shy789shy9065

877shy459shy6604

800shy441shy5501

888shy393shy6765

888shy393shy6765

877shy459shy6604

888shy393shy6765

888shy393shy6765

671shy647shy3526

Telephone Number


EP1

EP1

F51

B61

F51

J41

MJ1

QP1

F51

AD1

LM1

KX1

Self only

EP2

EP2

F52

B62

F52

J42

MJ2

QP2

F52

AD2

LM2

KX2

Self amp family

20174

20174

16322

14018

16322

13979

12818

10987

16322

11598

12208

6822

Self only

47770

47770

39021

31268

39021

43929

28521

24447

39021

25804

27163

17900

Self amp family

9311

9311

7533

6470

7533

6452

5916

5071

7533

5353

5634

3148

Self only

22048

22048

18010

14431

18010

20275

13163

11283

18010

11910

12537

8261

Self amp family


86

Connecticut


Delaware





Florida





Georgia




Guam


Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type


87




Idaho



Illinois




Indiana



Iowa



Kansas




Plan Name

877shy459shy6604

877shy459shy6604

800shy377shy4161

877shy459shy6604

888shy393shy6765

888shy393shy6765

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy257shy4692

877shy459shy6604

800shy969shy3343

888shy393shy6765

Telephone Number


JS1

H41

9K4

H41

GB1

MW1

JS1

MW1

H41

SV4

G51

9H1

PH1

Self only

JS2

H42

9K5

H42

GB2

MW2

JS2

MW2

H42

SV5

G52

9H2

PH2

Self amp family

22787

16237

8704

16237

12208

12208

22787

12208

16237

8970

21977

12747

10987

Self only

53701

38826

18033

38826

27163

27162

53701

27162

38826

21408

51861

29956

24447

Self amp family

10517

7494

4017

7494

5634

5634

10517

5634

7494

4140

10143

5883

5071

Self only

24785

17920

8323

17920

12537

12536

24785

12536

17920

9880

23936

13826

11283

Self amp family


88


Idaho



Illinois




Indiana



Iowa



Kansas




Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

89



Kentucky




Maine









Plan Name

877shy459shy6604

888shy393shy6765

877shy459shy6604

877shy459shy6604

877shy459shy6604

888shy789shy9065

800shy833shy7423

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

Telephone Number


H41

6N1

F51

EP1

F51

B61

GZ1

EP1

G51

H41

H41

Self only

H42

6N2

F52

EP2

F52

B62

GZ2

EP2

G52

H42

H42

Self amp family

16237

10987

16322

20174

16322

14018

11980

20174

21977

16237

16237

Self only

38826

24447

39021

47770

39021

31268

26835

47770

51861

38826

38826

Self amp family

7494

5071

7533

9311

7533

6470

5529

9311

10143

7494

7494

Self only

17920

11283

18010

22048

18010

14431

12385

22048

23936

17920

17920

Self amp family


90

Kentucky




Maine









Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

91






Nebraska


Nevada


New Hampshire


New Jersey


New Mexico




Plan Name


877shy459shy6604

800shy969shy3343

888shy393shy6765

77shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

800shy501shy3439

Telephone Number


G51

9H1

PH1

H41

H41

G51

EP1

EP1

G51

EP1

QA4

Self only

G52

9H2

PH2

H42

H42

G52

EP2

EP2

G52

EP2

QA5

Self amp family

21977

12747

10987

16237

16237

21977

20174

20174

21977

20174

9575

Self only

51861

29956

24447

38826

38826

51861

47770

47770

51861

47770

24919

Self amp family

10143

5883

5071

7494

7494

10143

9311

9311

10143

9311

4419

Self only

23936

13826

11283

17920

17920

23936

22048

22048

23936

22048

11501

Self amp family


92





Nebraska


Nevada


New Hampshire


New Jersey


New Mexico




Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

93



North Carolina


North Dakota






Pennsylvania




Rhode Island


South Carolina


Plan Name

877shy459shy6604

877shy459shy6604

877shy459shy6604

330shy363shy6360

877shy459shy6604

877shy459shy6604

877shy459shy6604

866shy351shy5946

888shy876shy2756

877shy459shy6604

877shy459shy6604

Telephone Number


F51

H41

JS1

3A4

JS1

H41

H41

Y61

8W4

EP1

JS1

Self only

F52

H42

JS2

3A5

JS2

H42

H42

Y62

8W5

EP2

JS2

Self amp family

16322

16237

22787

8669

22787

16237

16237

12298

12448

20174

22787

Self only

39021

38826

53701

17501

53701

38826

38826

28345

28053

47770

53701

Self amp family

7533

7494

10517

4001

10517

7494

7494

5676

5745

9311

10517

Self only

18010

17920

24785

8077

24785

17920

17920

13082

12948

22048

24785

Self amp family


94

North Carolina


North Dakota






Pennsylvania




Rhode Island


South Carolina


Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Benefit Type

Prescription Drugs

Levels I II III




30 after deduct

95



South Dakota


Tennessee








Vermont




Plan Name

877shy459shy6604

877shy459shy6604

877shy459shy6604

888shy393shy6765

888shy393shy6765

888shy393shy6765

877shy459shy6604

800shy377shy4161

877shy459shy6604

877shy459shy6604

888shy789shy9065

Telephone Number


G51

G51

JS1

TP1

TU1

TV1

G51

9K4

EP1

F51

B61

Self only

G52

G52

JS2

TP2

TU2

TV2

G52

9K5

EP2

F52

B62

Self amp family

21977

16322

22787

12208

12208

13429

21977

8704

20174

16322

14018

Self only

51861

39021

53701

27163

27162

29879

51861

18033

47770

39021

31268

Self amp family

10143

7533

10517

5634

5634

6198

10143

4017

9311

7533

6470

Self only

23936

18010

24785

12537

12536

13790

23936

8323

22048

18010

14431

Self amp family


96

South Dakota


Tennessee








Vermont




Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

97







Wyoming



Plan Name

877shy459shy6604

800shy552shy7114

877shy459shy6604

877shy459shy6604

877shy459shy6604

800shy377shy4161

Telephone Number


G51

L14

F51

JS1

H41

9K4

Self only

G52

L15

F52

JS2

H42

9K5

Self amp family

21977

10262

16322

22787

16237

8704

Self only

51861

22425

39021

53701

38826

18033

Self amp family

10143

4736

7533

10517

7494

4017

Self only

23936

10350

18010

24785

17920

8323

Self amp family


98





Wyoming



Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

$10$35$50 30day $100 90day

99


100

Appendix F


Waiting Periods





Contributions


Salary Deduction





101


















102










No Yes No No No




Yes Yes No No No


No No No No Yes


or spouse)

No No No Yes No



Yes No No No No


Yes Yes Yes No No


No No No Yes No







103



Reading the Chart


Dental Insurance









Vision Insurance



104



Plan Name

Telephone amp

Website


Class A

Class B

Class C

Class D

Deductible





0 40 60 50 $0




















105



Plan Name

Telephone amp

Website


Class A

Class B

Class C

Class D

Deductible


GEHA Standard






0 20 50 30 $0


0 20 50 30 $0












uccifedvipcom



20 40 60 50 $0


106



Plan Name

You pay

Telephone amp

Website

Class A

Class B

Class C

Class D Deductible













sssprcom


0

0

0

0

0

flat rate

Flat Rate

Approx 30

0

0

30

flat rate

flat rate

Flat Rate

Approx 50

0

0

60 30

flat rate

flat rate

Flat Rate

Approx 60

0

0

50

flat rate

flat rate

$0

$0


$0

$0

$0






107





Additional Features


Aetna Vision High


FEP BlueVision High
















$0

$0


Every24 months

Every 12 months

Every 24 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

108





Additional Features















Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

109



110


AL 356shy358 1 1 1 1 1 1 1 1 1 1 NA NA 3 NA NA



AZ 850shy853 3 5 5 2 2 2 2 1 1 1 NA NA 4 NA NA



CA 919shy921 3 5 5 5 5 4 4 4 4 4 NA NA 5 NA NA


CA 942 956shy958 4 5 5 5 5 4 4 4 4 4 NA NA 5 NA NA


CO 800shy806 3 4 4 3 3 4 4 4 4 3 NA NA 5 NA NA



CT 064shy069 3 5 5 5 5 5 5 5 5 5 NA NA NA 1 NA



FL 330shy334 2 4 4 3 3 3 3 3 3 3 NA NA 2 NA NA


GA 300shy303 305 311 399 3 2 2 2 2 3 3 2 2 1 NA NA 2 NA NA






IL 600shy608 2 2 2 3 3 3 3 4 4 3 NA NA 2 NA NA


IN 460shy462 472 2 1 1 1 1 2 2 1 1 1 NA NA 3 NA NA

IN 463shy464 2 2 2 3 3 3 3 4 4 3 NA NA 2 NA NA

IN 470 2 1 1 1 1 2 2 1 1 1 NA NA 1 NA NA



KY 410 452 459 2 1 1 1 1 2 2 1 1 1 NA NA 1 NA NA







111




MD 200202shy212 214 217 2 5 5 3 3 4 4 4 4 4 4 4 3 NA NA

MD 219 2 4 4 3 3 3 3 3 3 2 5 5 NA NA NA


ME 038 5 5 5 5 5 4 4 5 5 5 NA NA NA NA NA









NC 275shy277 283 4 2 2 2 2 2 2 1 1 2 NA NA 5 NA NA






NJ 3 5 5 5 5 5 5 5 5 5 NA NA NA 1 NA

NJ 080shy084 2 4 4 3 3 3 3 3 3 2 5 5 NA NA NA





NY 063 5 5 5 5 5 4 4 5 5 5 NA NA NA 1 NA

NY 140shy143 4 5 5 3 3 2 2 2 2 3 NA NA NA 1 NA


OH 430shy432 2 1 1 1 1 2 2 1 1 2 NA NA 2 NA NA

OH 440shy443 2 1 1 1 1 2 2 1 1 3 NA NA 2 NA NA

OH 450shy452 2 1 1 1 1 2 2 1 1 1 NA NA 1 NA NA

OH 453shy455 2 1 1 1 1 2 2 1 1 2 NA NA 1 NA NA




070072shy075077shy079085shy089



112




PA 153shy154 156 160shy162 1 2 2 1 1 1 1 1 1 1 1 1 NA NA NA

PA 173shy174 2 5 5 3 3 4 4 4 4 4 4 4 NA NA NA

PA 183 3 5 5 5 5 5 5 5 5 5 1 1 NA 1 NA

PA 189shy196 2 4 4 3 3 3 3 3 3 2 5 5 NA NA NA






TN 422 1 1 1 1 1 1 1 1 1 1 NA NA 1 NA NA


TX 739 2 3 3 1 1 2 2 1 1 1 NA NA 3 NA NA


TX 770 772shy775 2 2 2 1 1 2 2 1 1 1 NA NA 1 NA NA



VA 200shy205 220shy227 2 5 5 3 3 4 4 4 4 4 4 4 3 NA NA

VA 231shy232 238 3 3 3 2 2 2 2 1 1 2 3 3 3 NA NA





WA 986 4 5 5 3 3 3 3 4 4 5 NA NA NA NA NA



WI 540 2 4 4 4 4 3 3 4 4 3 NA NA NA NA NA


WV 254 2 5 5 3 3 4 4 4 4 4 NA NA 3 NA NA


WY 834 4 5 5 3 3 2 2 1 1 2 NA NA NA NA NA





Intershynational



113113

Aetna PPO

Delta Dental PPO

Delta Dental PPO

FEP BlueDental PPO

FEP BlueDental PPO

GEHA PPO

GEHA PPO

MetLife PPO

MetLife PPO












1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

$1288 $1418 $1510 $1666 $1809

$871 $949 $1024 $1080 $1234

$1669 $1831 $2008 $2136 $2485

$939 $1069 $1184 $1249 $1381

$1634 $1860 $2061 $2177 $2408

$900 $989 $1124 $1213 $1347

$1525 $1677 $1904 $2056 $2284

$868 $940 $1044 $1159 $1273

$1606 $1797 $1959 $2121 $2374

$1372 $1541 $1710 $1880 $2049

$2578 $2840 $3022 $3334 $3621

$1744 $1901 $2049 $2160 $2470

$3340 $3663 $4018 $4275 $4973

$1881 $2139 $2370 $2500 $2765

$3270 $3721 $4124 $4357 $4818

$1803 $1981 $2249 $2428 $2697

$3053 $3357 $3812 $4115 $4572

$1738 $1883 $2089 $2320 $2548

$3214 $3597 $3920 $4244 $4750

$2747 $3085 $3422 $3761 $4099

$3867 $4258 $4532 $5001 $5430

$2615 $2850 $3074 $3240 $3704

$5009 $5494 $6026 $6412 $7458

$2820 $3208 $3554 $3749 $4146

$4904 $5581 $6185 $6534 $7226

$2705 $2970 $3372 $3641 $4043

$4579 $5038 $5716 $6174 $6859

$2606 $2823 $3133 $3479 $3821

$4820 $5394 $5879 $6366 $7124

$4118 $4625 $5134 $5641 $6148

$2791 $3073 $3272 $3610 $3919

$1887 $2056 $2219 $2340 $2674

$3616 $3967 $4351 $4628 $5384

$2035 $2316 $2565 $2706 $2992

$3540 $4030 $4466 $4717 $5217

$1950 $2143 $2435 $2628 $2919

$3304 $3634 $4125 $4455 $4949

$1881 $2037 $2262 $2511 $2758

$3480 $3894 $4245 $4596 $5144

$2973 $3339 $3705 $4073 $4440

$5587 $6153 $6549 $7224 $7846

$3779 $4119 $4440 $4680 $5352

$7237 $7937 $8706 $9263 $10775

$4076 $4635 $5135 $5417 $5991

$7085 $8062 $8935 $9440 $10439

$3907 $4292 $4873 $5261 $5844

$6615 $7274 $8259 $8916 $9906

$3766 $4080 $4526 $5027 $5521

$6964 $7794 $8493 $9195 $10292

$5952 $6684 $7414 $8149 $8881

$8378 $9226 $9819 $10835 $11765

$5666 $6175 $6660 $7020 $8025

$10853 $11904 $13056 $13893 $16159

$6110 $6951 $7700 $8123 $8983

$10625 $12092 $13401 $14157 $15656

$5861 $6435 $7306 $7889 $8760

$9921 $10916 $12385 $13377 $14861

$5646 $6117 $6788 $7538 $8279

$10443 $11687 $12738 $13793 $15435

$8922 $10021 $11124 $12222 $13321





Self amp Family




Dominion Dental HMO

Dominion Dental HMO

EmblemHealth PPO

Humana

Triple S Salud PPO










1 2 3 4 5

1 2 3 4 5

1

1 2 3 4 5

1

$596 $622 $694 $829 $884

$1018 $1055 $1109 $1291 $1517

$1826

$990 $1048 $1136 $1378 $1475

$454

$1194 $1246 $1391 $1660 $1771

$2038 $2113 $2221 $2585 $3037

$3652

$1982 $2098 $2273 $2759 $2952

$910

$1790 $1868 $2085 $2489 $2655

$3056 $3168 $3330 $3876 $4554

$5478

$2971 $3146 $3409 $4136 $4428

$1191

$1291 $1348 $1504 $1796 $1915

$2206 $2286 $2403 $2797 $3287

$3956

$2145 $2271 $2461 $2986 $3196

$984

$2587 $2700 $3014 $3597 $3837

$4416 $4578 $4812 $5601 $6580

$7913

$4294 $4546 $4925 $5978 $6396

$1972

$3878 $4047 $4518 $5393 $5753

$6621 $6864 $7215 $8398 $9867

$11869

$6437 $6816 $7386 $8961 $9594

$2581





Self amp Family


114

Aetna


Delta Dental High


FEP BlueDental High

GEHA Standard

GEHA High

MetLife Standard

MetLife High

United Concordia

$1418

$1234

$2485

$1381

$2408

$900

$1525

$1273

$2374

$2049

$2840

$2470

$4973

$2765

$4818

$1803

$3053

$2548

$4750

$4099

$4258

$3704

$7458

$4146

$7226

$2705

$4579

$3821

$7124

$6148

$3073

$2674

$5384

$2992

$5217

$1950

$3304

$2758

$5144

$4440

$9226

$8025

$16159

$8983

$15656

$5861

$9921

$8279

$15435

$13321




Self amp Family

$6153

$5352

$10775

$5991

$10439

$3907

$6615

$5521

$10292

$8881


Premium Rate Charts


Aetna Vision

FEP BlueVision








$680 $1328

$800 $1012

$622 $884

$771 $1339

$1304 $2533

$1601 $2028

$1220 $1729

$1547 $2685

$1913 $3716

$2401 $3042

$1814 $2572

$2321 $4026

$314 $613

$369 $467

$287 $408

$356 $618

Standard High

Standard High

Standard High

Standard High

$602 $1169

$739 $936

$563 $798

$714 $1239

$883 $1715

$1108 $1404

$837 $1187

$1071 $1858







Aetna Vision

FEP BlueVision








$680 $1328

$800 $1012

$622 $884

$771 $1339

$1304 $2533

$1601 $2028

$1220 $1729

$1547 $2685

$1913 $3716

$2401 $3042

$1814 $2572

$2321 $4026

$314 $613

$369 $467

$287 $408

$356 $618

Standard High

Standard High

Standard High

Standard High

$602 $1169

$739 $936

$563 $798

$714 $1239

$883 $1715

$1108 $1404

$837 $1187

$1071 $1858






115

______________________________________________________________________________________________________________

























116
























117

Summary Information

























19121-c1-30 (70-10)_0

19121-pg31-36 (70-10)_0

19121-pg37-100 (70-10)_0

19121-pg101-118 (70-10)_0


Current Employees




























4

















5







FSAFEDS




6



FEGLI












7






Key FEHB facts













8














9










10















11






Key FEDVIP facts













12

















13














14

















15





Key FSAFEDS facts










16













17















18


How do I enroll










19




Key FEGLI facts



















20











How do I enroll








21




Key FLTCIP facts












22





How do I apply








23


24


















25







donrsquot



















26












27


Definitions













28















Yes

Yes

Yes

Not Applicable

Yes

No

Yes

Not Applicable

Yes

Yes

Yes

No

Yes

Not Applicable

Yes

Yes

Yes

No

Yes1

Not Applicable

Yes

Not Applicable

Yes

Yes2



29













30










31













Telephone Number

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family






MHBP shystd

MHBP shyValue Plan

NALC shyhigh

NALC Value Option

SAMBA shyhigh

SAMBA shystd






800shy222shy2798

Local phone

Local phone

800shy821shy6136

800shy821shy6136

800shy410shy7778

800shy410shy7778

888shy636shy6252

888shy636shy6252

800shy638shy6589

800shy638shy6589

888shy438shy9135

202shy833shy4910

800shy424shy8196

800shy638shy8432

471

104

111

311

314

454

414

321

KM1

441

444

421

401

431

381

472

105

112

312

315

455

415

322

KM2

442

445

422

402

432

382

13670

19028

13209

20317

10418

20913

11302

16122

9001

27523

13171

15613

12535

11170

18913

30910

44412

30930

48310

23691

50565

26946

32727

19546

70356

30081

39039

30885

23316

30210

6309

8782

6096

9377

4808

9652

5216

7441

4154

12703

6079

7206

5785

5155

8729

14266

20498

14275

22297

10934

23338

12436

15105

9021

32472

13884

18018

14255

10761

13943


32




APWU shyhigh

BCBS shystd

BCBS shybasic

GEHA shyhigh

GEHA shystd

MHBP shystd

MHBP shyValue

NALC shyhigh

NALC Value

SAMBA shyhigh

SAMBA shystd

CRHP

FS

PCABP

Rural

Plan

PPO NonshyPPO

PPO NonshyPPO

PPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

NonshyPPO PPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

Benefit Type


$350 None $250 $350 None $350 + 35+


$350 None $100 $350 None $300


$400 None $200 $600 None $500


$300 None $200 $300 None $350

$4000 None 50 $2000 None 20

$300 None $200 $300 None $300


$350 None $200 $400 None $400



$350 $200 $100 $400 $200 $300

Deductible

Calendar Year

Prescription Drug

Hospital Inpatient

Per Person

$18 10 10 $8 2525 Yes 30+diff 30+diff 30 50 5050 Yes







$20 15 Nothing 20 3045 Yes 30 30 30 45+ 45+45+ Yes

50 50 50 50 5050+ No 20 20 20 $10 $40$60 No






$20 10 Nothing 30 3030 Yes 25 25 25 30 3030 Yes



RampB

Prescription Drugs



Office Visits


T2 $45 T3 50($55Min) T4 $50to$140 T5 $70to$195


33













Plan Code


Getting needed care


How well doctors


Claims processing





47

10 835 946 917 955 926 956 703



10

11

31

757

838

896

934

891

922

95

961

921

912

936

929

643

699


31

31 725 907 895 949 875 926 688

MHBP shystd

31

45 84 938 916 935 906 954 696

MHBP shyValue Plan

45

41 63 908 857 929 866 887 636

NALC shyhigh

41

32 856 936 922 959 934 965 771


32

KM

SAMBA shyhigh

KM

44 897 947 943 96 946 953 789

SAMBA shystd

44

44 816 93 905 956 911 946 757



44

42

roups

verage

837

805

941

927

945

917

962

951

94

911

927

934

747

716


42

40 798 898 909 935 892 889 721


40

43


43

38 865 946 947 967 928 966 773 38

34



Plan Name Location


Plan Code


Getting needed care


How well doctors


Claims processing




Arizona 10 11

851 747

905 898

919 884

933 923

938 914

969 928

724 680


California 10 11

809 705

915 873

897 840

954 943

881 910

937 912

677 616



768 691

935 893

930 874

951 940

882 881

898 922

657 622


Florida 10 11

864 806

942 916

922 894

952 947

934 916

954 937

733 660


Illinois 10 11

861 796

933 912

934 881

955 950

901 936

972 938

712 653


Maryland 10 11

857 770

931 897

917 898

954 940

897 921

956 967

713 666


Texas 10 11

887 825

934 898

931 883

950 955

936 910

957 967

721 617


Virginia 10 11

871 782

924 901

929 894

966 962

914 917

959 960

708 681

35


36















37



Enrollment Code

Monthly Biweekly


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Alabama


Alaska


Arizona









Arkansas





38


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Alabama




Alaska

4040 40 50+ 50+50+ No



Arizona

4040 40 50+ 50+50+ No










Arkansas

$25$40 $500day x 3 $10 $40$60 Yes





39



Enrollment Code

Monthly Biweekly


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

California
















Colorado




Connecticut


Delaware





40


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

California

HMOPOS National 679 864 849 942 877 875 649


to$1200 Yes

Average
















Colorado

$25$40 30 $10 $25$50 Yes 701 80 804 923 825 889 57





Connecticut

$20$40 10 $15 $40$80 Yes 722 884 873 936 876 879 622



Delaware

4040 40 50+ 50+50+ No





41











Florida


















Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



42


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs



HMOPOS Nationa

30to$60050 to$1200 Yes

l Average 679 864 849 942 877 875 649






4040

$15$30

$20$35

$25$35

Nothing$35

40

$150day x3

10 Plan Allow

$200

$200

50+

$5

$10

Nothing

Nothing

50+50+

$35$100

$35$100

$35$65

$35$65

No

Yes

Yes

Yes

Yes

69

69

648

648

844

844

86

86

872

872

833

833

942

942

925

925

865

865

846

846

914

914

902

902

567

567

54




MD IPAshyHigh

Florida


$70$70

$10$20

$20$30

$25$40

$25$40

$500

$100

$250dayx3

$150day x 3

20

Nothing

$7$17 Net

$12$22Net

$7

$10

$35$65

$30$50$45$65

$35$55$50$70

$30$60

30to$60050 to$1200

Yes

Yes

Yes

Yes

Yes

83

83

583

867

867

846

831

831

876

927

927

937

813

813

867

836

836

841

702

702

677








4040

$15$40

$25$45

$15$25

$15$30

$20$50

$35$55

40

$250dayx3

$300dayx3

$250

Ded + $150x3

Ded + $150x5

20

50+

$5

$10

$15 Tier 1

$3$20

$3$10

$10

50+50+

$30$5030

$40$6030


$40$6020

$50$7020

$40$60

No

No

No

No

No

No

Yes

746

746

855

514

514

877

877

905

808

808

847

847

905

764

764

957

957

953

921

921

919

919

938

827

827

87

87

946

783

783

68

68

755

535

535



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No










5050

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

50

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$10+

$10

$10

$10

$10

$10

$10

$10

$10

$40+$60+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

529

529

86

86

824

824

937

937

846

846

843

843

687

687

43


Georgia













Guam









Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



44


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Georgia


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649




4040

$20$35

$35$55

40

$250day x 4

20

50+

$10

$10

50+50+

$35$100

$40$60

No

Yes

Yes

59 90 878 941 86 857 62



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No










Guam


5050

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$30

$20$35

$15$40

50

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250dayx3

$250dayx3

$200

$10+

$10

$10

$10

$10

$10

$10

$10$20 Comm

$15$25 Comm

$10

$40+$60+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$50 Comm

$40$50 Comm

$2550 of AWP

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

514

794

794

883

845

845

837

85

85

941

935

935

859

884

884

849

839

839

556

625

625


TakeCareshyHigh

TakeCareshyStandard


3030

$5 at FHP$40

$5 at FHP$40

$25$40

30

$100day for 5

$150day for 5

20

NA

$10

$15

$10

NA

$25$50

$40$80

30to$60050 to$1200

NA

Yes

Yes

Yes

687

687

669

669

686

686

904

904

792

792

786

786

571

571


HMSA InshyNetwork

4040

$15$15

40

$100

50+

$7

50+50+

$30$65

No




3030

$20$20

$30$30

30

$100

10

$7 + 20

$10

$15

$45$45

$50$50

$30 + 20$65 + 20 No

Yes

Yes

754

754

826

826

815

815

94

94

875

875

811

811

613

613

45


Idaho








Illinois
















Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



46


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

6

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Idaho


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649






SelectHealthshyHigh


Illinois


4040

$20$30

$20$40

$25$25

$25$35

$15$25

$20$30

$25$40

40

$200

None

$350

$500

$100

$100 after

20

50+

$7

$7

$20

$20

$5 $25$50

$5

$10

50+50+

$25$50

$35$60

$40$60

$40$60

$25$50$50

$25$50

30to$60050 to$1200

No

No

None

Yes

Yes

Yes

Yes

Yes

552

552

659

659

629

629

852

852

86

86

876

876

813

813

869

869

851

851

948

948

941

941

958

958

883

883

912

912

912

912

895

895

881

881

903

903

588

588

692

692

64

64




4040

$20$35

$25$35

40

Nothing

$500

50+

$10 copay

$5

50+50+

$40$60

$40$6025 $6025

No

Yes







30 after ded

$25$50

$25$50

$20$35

$25$40

$35$55

30 after ded

$200day x 5

20

$250day x 3

$500day x 3

20

NA

$7

$7

$10

$10

$10

NA

$35$70

$35$70

$40$60

$40$60

$40$60

NA

Yes

Yes

Yes

Yes

Yes

745 915 88 962 878 868 67



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No







5050

$20$35

$25$40

$15$15

$25$40

$25$50

50

$250day x 3

$500day x 3

None

$450

20

$10+

$10

$10

$10

$7

$10

$40+$60+

$40$60

$40$60

$35$60

$30$60

$35$50

No

Yes

Yes

Yes

Yes

Yes

647

647

665

577

822

822

919

896

788

788

902

86

943

943

957

956

859

859

892

914

834

834

898

918

66

66

732

623

47


Indiana












Iowa












Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



48


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Indiana


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649





4040

$25$50

$25$50

$35$55

40

$200day x 5

20

20

50+

$7

$7

$10

50+50+

$35$70

$35$70

$40$60

No

Yes

Yes

Yes

745 915 88 962 878 868 67









Iowa


5050

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$15

$25$40

50

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

20

20

$10+

$10

$10

$10

$10

$10

$10

$10

$10

$40+$60+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$25$50

30to$60050 to$1200

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

647

647

562

822

822

878

788

788

815

943

943

934

859

859

868

834

834

893

66

66

593









4040

$25$50

$25$50

$25$50

$25$50

$25$45

$0 for 3 then 20

$20$30

40

20

20

$200day x 5

20

Nothing

20 in40 out

$100day x 5

50+

$3 $10

$3 $10

$7

$7

$12

$9

$15

50+50+

$45$70$100

30$5000 Max

$35$70

$35$70

$45$90

$40$70

$30$50

No

Yes

No

Yes

Yes

Yes

Yes

NA

562

562

745

647

647

535

905

905

915

893

893

903

888

888

88

875

875

89

964

964

962

951

951

977

837

837

878

92

92

902

903

903

868

911

911

912

652

652

67

725

725



4040

$25$25

40

$100day x 5

40+

$15

40+40+

$30$50

NA



40+40+

$25$50

40+

20

40+

$10

40+40+

$35$50

NA

Yes 577 896 86 956 914 918 623

49





Kansas








Kentucky








Louisiana









50


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Kansas


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649






4040

$20$35

$30$60

$30$60

$35$55

40

$250day x 4

25

30

20

50+

$10

$3 $12

$3 $12

$10

50+50+

$35$100

$50$75

$5020

$40$60

No

Yes

Yes

Yes

Yes

639

602

602

862

906

906

862

88

88

94

96

96

838

894

894

901

884

884

538

663

663




Kentucky


5050

$20$35

$25$40

$25$40

50

$250day x 3

$500day x 3

20

$10+

$10

$10

$10

$40+$60+

$40$60

$40$60

30to$60050 to$1200

No

Yes

Yes

Yes

676

676

903

903

901

901

951

951

881

881

918

918

729

729








Louisiana


4040

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$25$40

40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

20

50+

$10

$10

$10

$10

$10

$10

$10

50+50+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

30to$60050 to$1200

No

Yes

Yes

Yes

Yes

Yes

Yes








4040

$25$45

$30$55

$20$35

$35$40

$20$35

$35$40

40

Ded+$100

Ded+30

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+

$5

$5

$10

$10

$10

$10

50+50+

$40$100

$40$100

$40$60

$40$60

$40$60

$40$60

No

Yes

Yes

Yes

Yes

Yes

Yes

573

573

874

874

823

823

968

968

831

831

827

827

625

625

51





Maine


Maryland











Massachusetts




52


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Maine


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649


Maryland


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No






4040

$15$30

$20$35

$25$35

Nothing$35

40

$150day x3

10 Plan Allow

$200

$200

50+

$5

$10

Nothing

Nothing

50+50+

$35$100

$35$100

$35$65

$35$65

No

Yes

Yes

Yes

Yes

69

69

648

648

844

844

86

86

872

872

833

833

942

942

925

925

865

865

846

846

914

914

902

902

567

567

54






MD IPAshyHigh

Massachusetts


$70$70

$20$40

$20$40

$10$20

$20$30

$25$40

$25$40

$500

$200day x 3

$200day x 3

$100

$250dayx3

$150day x 3

20

Nothing

$3$15

$3$15

$7$17 Net

$12$22Net

$7

$10

$35$65

$30$60

$30$60

$30$50$45$65

$35$55$50$70

$30$60

30to$60050 to$1200

Yes

Yes

Yes

Yes

Yes

Yes

Yes

563

563

83

83

583

864

864

867

867

846

864

864

831

831

876

969

969

927

927

937

892

892

813

813

867

871

871

836

836

841

606

606

702

702

677



4040

$25$35

40

$150 to $750max

50+

$10

50+50+

$30$60

No

Yes 627 851 882 929 883 801 649

53





Michigan










Minnesota






54


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Michigan


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649










Minnesota


4040

$15$25

$15$25

$10$10

$20$20

$10$20

$15$30

$10$20

$15$15

$25$40

40

Nothing

Nothing

Nothing

$500x3

Nothing

Nothing

None

None

20

50+

$10

$10

$5

$10

$5

$15

$0$8

$10

$10

50+50+

$30$60

$30$60

$15$15

NA$40

$50$50

$50$50

$40$60

$40$40

30to$60050 to$1200

No

Yes

Yes

No

No

Yes

Yes

Yes

Yes

Yes

651

651

742

742

793

793

793

899

899

90

90

888

888

919

875

875

912

912

862

862

92

933

933

952

952

943

943

951

884

884

883

883

899

899

946

937

937

836

836

902

902

919

672

672

795

795

656

656

658





4040

$25$45

$0 for 3 then 20

$25$40

40

Nothing

20 in40 out

20

50+

$12

$9

$10

50+50+

$45$90

$40$70

30to$60050 to$1200

No

Yes

Yes

Yes

647

647

893

893

875

875

951

951

92

92

911

911

725

725


55











Montana


Nebraska


Nevada




New Hampshire



Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



56


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649




4040

$20$35

$25$35

40

$250day x 4

$500

50+

$10

$5

50+50+

$35$100 $40$60

25$6025

No

Yes

Yes

639

647

862

891

862

861

94

961

838

84

901

864

538





30 after ded

$30$60

$30$60

$35$55

30 after ded

25

30

20

NA

$3 $12

$3 $12

$10

NA

$50$75

$5020

$40$60

NA

Yes

Yes

Yes

602

602

906

906

88

88

96

96

894

894

884

884

663

663





Montana


5050

$20$35

$25$40

$25$40

$25$40

50

$250day x 3

$500day x 3

$450

20

$10+

$10

$10

$7

$10

$40+$60+

$40$60

$40$60

$30$60

30to$60050 to$1200

No

Yes

Yes

Yes

Yes

676

676

665

903

903

919

901

901

902

951

951

957

881

881

892

918

918

898

729

729

732


Nebraska


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No


Nevada


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No




New Hampshire


4040

$20$35

$10$25

$25$40

40

$250day x 4

$300

20

50+

$10

$7

$10

50+50+

$35$100

$35$55$100

30to$60050 to$1200

No

Yes

Yes

Yes

602

516

838

696

861

66

923

892

849

892

918

912

636

529


57


New Jersey








New Mexico





Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code


Monthly Biweekly


58


Prescription Drugs


Mail lan

eeded

are

ll icate

r ng rm

ation




order discount

Ove

rall p

satisfaction

Gettin

g n

care

Gettin

g c

quickly

How

we

doctors

commun

Custome

service

Claim

sproce

ssi

Plan

Info

on

Costs

New Jersey


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649







$15$35

$20$20

20 Plan Allow

$150max$450

$5

$20

$35$100

$45$85

Yes

Yes

631

663

852

844

837

851

928

936

895

86

809

828

623



New Mexico


50 of sch

$30$30

$25$40

+50 of sch

$250day x 3

20

NA

$10

$10

NA

$45$85

30to$60050 to$1200

No

Yes

Yes

663 844 851 936 86 828 642




59


New York

























Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



60

North Dakota


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

New York



30to$60050 to$1200 Yes

l vera e 679 864 849 942 877 875 649









4040

$20$35

$15$35

$20$30

$25$40

$25$40

$25$40

$20$20

40

$250day x 4

20 Plan Allow

$100 x 5

$500+10

$500

$500

$150max$450

50+

$10

$5

25

30

$10

$10

$20

50+50+

$35$100

$35$100

2525

3030

$30$50

$30$50

$45$85

No

Yes

Yes

No

No

Yes

Yes

Yes

662

662

729

729

663

848

848

928

928

844

849

849

90

90

851

937

937

949

949

936

888

888

922

922

86

874

874

924

924

828

547

547

70

70






50 of sch

$30$30

$20$40

$30$50

$25$25

+50 of sch

$250day x 3

None

$1000

$250

NA

$10

$15

$15$100Ded

$10

NA

$45$85

$35$75

$30$75

$35$75 $75$100Ded

No

Yes

Yes

Yes

No

663

729

729

735

844

814

814

933

851

786

786

923

936

888

888

952

86

787

787

92

828

848

848

916

642

60

60



2525

$30$50

25

$750

NA

$10

NA

$5050

No












3030

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

30

$500

$750

$500

$750

$500

$750

$500

$750

$500

$750

NA

$5

$5

$5

$5

$5

$5

$5

$5

$5

$5

NA

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

739

739

739

739

739

739

739

739

739

739

934

934

934

934

934

934

934

934

934

934

89

89

89

89

89

89

89

89

89

89

962

962

962

962

962

962

962

962

962

962

896

896

896

896

896

896

896

896

896

896

92

92

92

92

92

92

92

92

92

92

768

768

768

768

768

768

768

768

768

768

61


North Carolina


North Dakota







Ohio








Oklahoma




Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



62


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

North Carolina


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649


North Dakota


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No





4040

$25$45

$0 for 3 then 20

$15$25

40

Nothing

20 in40 out

None

50+

$12

$9

50$600ded

50+50+

$45$90

$40$70

50$600 ded

No

Yes

Yes

None

647

647

893

893

875

875

951

951

92

92

911

911

725

725



2020

$20$30

20

$100day x 5

NA

$15

NA

$30$50

NA



4040

$25$25

40

$100day x 5

40+

$15

40+40+

$30$50

NA


Ohio


40+40+

$25$40

40+

20

40+

$10

40+40+

30to$60050 to$1200

NA


AultCare HMOshyHigh






Oklahoma


4040

$15$20

$20$35

$25$40

$20$20

$30$40

$10$20

$25$40

40

$150

$250day x 3

$500day x 3

$250

$500

$250

20

50+

$15

$10

$10

$10

$15

$15

$10

50+50+

$30$40$55

$40$60

$40$60

$30$30

$40$40

$30$50

30to$60050 to$1200

No

No

Yes

Yes

Yes

Yes

Yes

Yes

877

788

788

744

922

845

845

909

907

889

889

876

941

922

922

951

944

935

935

929

935

906

906

944

853

708

708

745



4040

$15$45

40

$250dymx1000

50+

$4$10

50+50+

$45$70

No

Yes 592 816 839 916 893 872 727

63


Oregon




Pennsylvania









Puerto Rico



Rhode Island


South Carolina



Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



64


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Information

on Costs

Oregon


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649




Pennsylvania


4040

$20$30

$30$40

$25$40

40

$200

$500

20

50+

$15

$20

$10

50+50+

$40$60

$40$60

30to$60050 to$1200

No

Yes

Yes

Yes

768

768

844

844

847

847

916

916

927

927

89

89

683

683









Puerto Rico


4040

$20$35

$15$35

$20$35

$20$35

$25$50

10 after Deduct

20 after Deduct

$5$5

40

$250day x 4

20 Plan Allow

$250day x 4

20aftrDeduct

15 after ded

10 after deduct

20after Deduct

None

50+

$10

$5

$10

30 $5$15

$5

$5 after ded

$5 after ded

$250

50+50+

$35$100

$35$100

$35$100

$35$60

$35$75

$35$75$100

$10$15

40 $40$120 50 $85$250

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

579

579

579

668

699

754

754

806

861

861

861

868

873

908

908

803

835

835

835

85

885

899

899

82

935

935

935

938

957

97

97

938

887

887

887

906

86

913

913

887

899

899

899

902

921

904

904

70

631

631

631

677

671

678

678




Rhode Island


$750$10

$25$40

$750 amp 10 +$10 amp 10 +

None 10 +

20

$5 or $12 NA

$10

NANA

2025 up to$100$175max

30to$60050 to$1200

Yes No

Yes

691 874 844 963 872 75 586


South Carolina


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No


65


South Dakota






Tennessee






Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



66


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

South Dakota



30to$60050 to$1200 Yes

679 864 849 942 877 875 649





4040

$25$45

$20$30

$0 for 3 then 20

40

Nothing

$100day x 5

20 in40 out

50+

$12

$9

$15

50+50+

$45$90

$40$70

$30$50

No

Yes

Yes

NA

647

647

535

893

893

903

875

875

89

951

951

977

92

92

902

911

911

912

725

725



4040

$25$25

40

$100day x 5

40+

$15

40+40+

$30$50

NA

NA

535


Tennessee


40+40+

$25$40

40+

20

40+

$10

40+40+

30to$60050 to$1200

NA





4040

$20$35

$20$35

$25$40

40

$250day x 4

$250day x 3

$500day x 3

50+

$10

$10

$10

50+50+

$35$100

$40$60

$40$60

No

Yes

Yes

Yes

66 875 868 959 889 914 69

67


Texas






















Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



68


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Texas


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649



4040

$5$25$35

40

15

50+

$5

50+50+

$35$60

No


FirstcareshyHigh

FirstcareshyHigh

FirstcareshyHigh

FirstcareshyHigh

FirstcareshyHigh


4040

$30$55

$30$55

$30$55

$30$55

$30$55

$35$55

40

$250day x 5

$250day x 5

$250day x 5

$250day x 5

$250day x 5

20

40

$10

$10

$10

$10

$10

$10

4040

$35$70

$35$70

$35$70

$35$70

$35$70

$40$60

No

Yes

Yes

Yes

Yes

Yes



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No












5050

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$45

$20$40

50

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

10

$250day x 5

$10+

$10

$10

$10

$10

$10

$10

$10

$10

$5

$10

$40+$60+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$45$100

$35$60

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

63

63

702

835

835

862

764

764

863

931

931

937

864

864

875

856

856

87

673

673

569

69



Enrollment Code

Monthly Biweekly


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family








Vermont

Virgin Islands

Utah


70


Prescription Drugs


Mail lan

eeded

are

ll icate

r ng rm

ation




order discount

Ove

rall p

satisfaction

Gettin

g n

care

Gettin

g c

quickly

How

we

doctors

commun

Custome

service

Claim

sproce

ssi

Plan

Info

on

Costs

Utah


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649






Vermont


$20$30

$25$40

$100 after

20

$5$25$50

$10

$25 $50$50

30to$60050 to$1200

Yes

Yes

629 876 851 958 912 903 64


Virgin Islands

4040 40 50+ 50+50+ No


$750$10 $750 amp 10 + $10 amp 10 +

None 10 +

$5 or $12 NA NANA

2025 up to$100$175max

Yes No

691 874 844 963 872 75 586

71


Virginia















Washington










Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



72


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Virginia








$25$40 4040

$15$30

$20$35

$25$35 4040

$5$25$35 4040

$25$35

Nothing$35

20 40

$150day x3

10 Plan Allow

15 40

15 40

$200

$200

$10 50+

$5

$10

$5 40

$5 40

Nothing

Nothing

HMOP

50+50+

$35$100

$35$100

$35$60 4040

$35$60 4040

$35$65

$35$65

30to$60050 to$1200

OS National

Yes No

Yes

Yes

Yes No

Yes No

Yes

Yes

Average

69

69

648

648

679

844

844

86

86

864

872

872

833

833

849

942

942

925

925

942

865

865

846

846

877

914

914

902

902

875

567

567

54

54

649





MD IPAshyHigh




Washington









$70$70

$10$20

$20$30

$25$40

$25$30

$35$35

$25$40 4040

$20$35

$25$25

$25$35

$154 or 2020

$30$30 $30+40+diff

$20$30

$30$40


$20$0childlt22$30


$500

$200 x3 days

$100

$250dayx3

$150day x 3

$150max$750

$20020

20

20 40

$250day x 4

$350

$500

Nothing Nothing

None None

$200

$500

Nothing

$0

$7$17 Net

$12$22Net

$7

$10

$10

$15

$10 50+

$10

$20

$20

$10 Not Covered

$5 Not Covered

$15

$20

$35$65

$30$50$50

$30$50$45$65

$35$55$50$70

$30$60

$40$55

50+50+

$35$100

$40$60

$40$60

Not Covered

NA

$40$60

$40$60

$353050up to $3000

$355050 up to $3000

$35$50 30day $100 90day

$25$50 30day$100 90day

30to$60050 to$1200

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes No

Yes

Yes

Yes

Yes No

Yes No

Yes

Yes

83

83

583

692

692

659

659

798

798

768

768

867

867

846

864

864

86

86

94

94

844

844

833

831

831

876

886

886

869

869

928

928

847

847

927

927

937

969

969

941

941

957

957

916

916

813

813

867

87

87

912

912

931

931

927

927

836

836

841

916

916

881

881

897

897

89

89

702

702

677

674

674

692

692

65

65

683

683

73


West Virginia



Wisconsin









Wyoming





Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



74


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

West Virginia


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649



Wisconsin


4040

$10$20

$25$40

40

$250

20

50+

$15

$10

50+50+

$30$50

30to$60050 to$1200

No

Yes

Yes

744 909 876 951 929 944 745



4040

$25$35

40

15

50+

$5

50+50+

$35$60

No








Wyoming


4040

$25$25

$10$10

$25$45

$0 for 3then 20

$10$10

$10$10

$25$40

40

None

None

Nothing

20 in40 out

Nothing

Nothing

20

40

$10

$5

$12

$9

$10

$10

$10

4040

$20$20

$45$90

$40$70

$20$50

3050

30$75max 50 wmin$50

30to$60050 to$1200

No

Yes

Yes

Yes

Yes

Yes

No

Yes

682

785

647

647

784

601

909

834

893

893

888

857

90

834

875

875

854

822

97

953

951

951

938

96

834

929

92

92

888

863

879

932

911

911

87

866

588

718

725

725

684

686




4040

$20$30

$20$40

40

$200

None

50+

$7

$7

50+50+

$25$50

$35$60

No

No

None

552

552

852

852

813

813

948

948

883

883

895

895

588

588

75











76



















insurance plans

77



ELIGIBILITY

FUNDING







CONTRIBUTIONS

DISTRIBUTIONS







ANNUAL ROLLOVER







78





79












Self only

Self amp family

Self only

Self amp family

Self only

Self amp family





800shy718shy1299

800shy821shy6136

800shy694shy9901

888shy636shy6252

474 475

341 342

481 482

324 325

9742

11021

13642

10454

21915

25172

30912

22700

4496 10115

5087 11618

6296 14267

4825 10477


80














81













Plan Code


Getting needed care


How well doctors


Claims processing






22

34

48

606

623

614

891

873

891

888

851

859

952

923

912

830

863

887

879

865

885

563

602

590


Plan Code


Getting needed care


How well doctors


Claims processing







22

47

TP TU TV

MW

606

664

566

478

891

909

849

875

888

907

864

801

952

925

932

948

830

871

843

856

879

845

853

812

563

680

542

555

82


83



Plan Name

Telephone Number


Self only

Self amp family

Self only

Self amp family

Self only

Self amp family



Alabama


Alaska


Arizona


Arkansas


California


Colorado


Plan Name

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

Telephone Number


F51

JS1

G51

F51

JS1

G51

Self only

F52

JS2

G52

F52

JS2

G52

Self amp family

16322

22787

21977

16322

22787

21977

Self only

39021

53701

51861

39021

53701

51861

Self amp family

7533

10517

10143

7533

10517

10143

Self only

18010

24785

23936

18010

24785

23936

Self amp family


84

Benefit Type


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs



Alabama


Alaska


Arizona


Arkansas


California


Colorado


Plan Name







Benefit Type

$8333$16666 $8333$16666

$8333$16666 $8333$16666

$8333$16666 $8333$16666

$8333$16666 $8333$16666

$8333$16666 $8333$16666

$8333$16666 $8333$16666


$1000$2000 $1000$2000

$1000$2000 $1000$2000

$1000$2000 $1000$2000

$1000$2000 $1000$2000

$1000$2000 $1000$2000

$1000$2000 $1000$2000

CY Ded SelfFamily

$4000$8000 $5000$10000

$4000$8000 $5000$10000

$4000$8000 $5000$10000

$4000$8000 $5000$10000

$4000$8000 $5000$10000

$4000$8000 $5000$10000


15 40

15 40

15 40

15 40

15 40

15 40

Office Visit

15 40

15 40

15 40

15 40

15 40

15 40

Inpatient Hospital

15 40

15 40

15 40

15 40

15 40

15 40

Outpatient Surgery

Nothing FundDed40

Nothing FundDed40

Nothing FundDed40

Nothing FundDed40

Nothing FundDed40

Nothing FundDed40

Preventive Services

$10$35$60 40+40+40+

$10$35$60 40+40+40+

$10$35$60 40+40+40+

$10$35$60 40+40+40+

$10$35$6 40+40+40+

$10$35$60 40+40+40+

Prescription Drugs

Levels I II III

85



Connecticut


Delaware





Florida





Georgia




Guam


Plan Name

877shy459shy6604

877shy459shy6604

877shy459shy6604

888shy789shy9065

877shy459shy6604

800shy441shy5501

888shy393shy6765

888shy393shy6765

877shy459shy6604

888shy393shy6765

888shy393shy6765

671shy647shy3526

Telephone Number


EP1

EP1

F51

B61

F51

J41

MJ1

QP1

F51

AD1

LM1

KX1

Self only

EP2

EP2

F52

B62

F52

J42

MJ2

QP2

F52

AD2

LM2

KX2

Self amp family

20174

20174

16322

14018

16322

13979

12818

10987

16322

11598

12208

6822

Self only

47770

47770

39021

31268

39021

43929

28521

24447

39021

25804

27163

17900

Self amp family

9311

9311

7533

6470

7533

6452

5916

5071

7533

5353

5634

3148

Self only

22048

22048

18010

14431

18010

20275

13163

11283

18010

11910

12537

8261

Self amp family


86

Connecticut


Delaware





Florida





Georgia




Guam


Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type


87




Idaho



Illinois




Indiana



Iowa



Kansas




Plan Name

877shy459shy6604

877shy459shy6604

800shy377shy4161

877shy459shy6604

888shy393shy6765

888shy393shy6765

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy257shy4692

877shy459shy6604

800shy969shy3343

888shy393shy6765

Telephone Number


JS1

H41

9K4

H41

GB1

MW1

JS1

MW1

H41

SV4

G51

9H1

PH1

Self only

JS2

H42

9K5

H42

GB2

MW2

JS2

MW2

H42

SV5

G52

9H2

PH2

Self amp family

22787

16237

8704

16237

12208

12208

22787

12208

16237

8970

21977

12747

10987

Self only

53701

38826

18033

38826

27163

27162

53701

27162

38826

21408

51861

29956

24447

Self amp family

10517

7494

4017

7494

5634

5634

10517

5634

7494

4140

10143

5883

5071

Self only

24785

17920

8323

17920

12537

12536

24785

12536

17920

9880

23936

13826

11283

Self amp family


88


Idaho



Illinois




Indiana



Iowa



Kansas




Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

89



Kentucky




Maine









Plan Name

877shy459shy6604

888shy393shy6765

877shy459shy6604

877shy459shy6604

877shy459shy6604

888shy789shy9065

800shy833shy7423

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

Telephone Number


H41

6N1

F51

EP1

F51

B61

GZ1

EP1

G51

H41

H41

Self only

H42

6N2

F52

EP2

F52

B62

GZ2

EP2

G52

H42

H42

Self amp family

16237

10987

16322

20174

16322

14018

11980

20174

21977

16237

16237

Self only

38826

24447

39021

47770

39021

31268

26835

47770

51861

38826

38826

Self amp family

7494

5071

7533

9311

7533

6470

5529

9311

10143

7494

7494

Self only

17920

11283

18010

22048

18010

14431

12385

22048

23936

17920

17920

Self amp family


90

Kentucky




Maine









Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

91






Nebraska


Nevada


New Hampshire


New Jersey


New Mexico




Plan Name


877shy459shy6604

800shy969shy3343

888shy393shy6765

77shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

800shy501shy3439

Telephone Number


G51

9H1

PH1

H41

H41

G51

EP1

EP1

G51

EP1

QA4

Self only

G52

9H2

PH2

H42

H42

G52

EP2

EP2

G52

EP2

QA5

Self amp family

21977

12747

10987

16237

16237

21977

20174

20174

21977

20174

9575

Self only

51861

29956

24447

38826

38826

51861

47770

47770

51861

47770

24919

Self amp family

10143

5883

5071

7494

7494

10143

9311

9311

10143

9311

4419

Self only

23936

13826

11283

17920

17920

23936

22048

22048

23936

22048

11501

Self amp family


92





Nebraska


Nevada


New Hampshire


New Jersey


New Mexico




Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

93



North Carolina


North Dakota






Pennsylvania




Rhode Island


South Carolina


Plan Name

877shy459shy6604

877shy459shy6604

877shy459shy6604

330shy363shy6360

877shy459shy6604

877shy459shy6604

877shy459shy6604

866shy351shy5946

888shy876shy2756

877shy459shy6604

877shy459shy6604

Telephone Number


F51

H41

JS1

3A4

JS1

H41

H41

Y61

8W4

EP1

JS1

Self only

F52

H42

JS2

3A5

JS2

H42

H42

Y62

8W5

EP2

JS2

Self amp family

16322

16237

22787

8669

22787

16237

16237

12298

12448

20174

22787

Self only

39021

38826

53701

17501

53701

38826

38826

28345

28053

47770

53701

Self amp family

7533

7494

10517

4001

10517

7494

7494

5676

5745

9311

10517

Self only

18010

17920

24785

8077

24785

17920

17920

13082

12948

22048

24785

Self amp family


94

North Carolina


North Dakota






Pennsylvania




Rhode Island


South Carolina


Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Benefit Type

Prescription Drugs

Levels I II III




30 after deduct

95



South Dakota


Tennessee








Vermont




Plan Name

877shy459shy6604

877shy459shy6604

877shy459shy6604

888shy393shy6765

888shy393shy6765

888shy393shy6765

877shy459shy6604

800shy377shy4161

877shy459shy6604

877shy459shy6604

888shy789shy9065

Telephone Number


G51

G51

JS1

TP1

TU1

TV1

G51

9K4

EP1

F51

B61

Self only

G52

G52

JS2

TP2

TU2

TV2

G52

9K5

EP2

F52

B62

Self amp family

21977

16322

22787

12208

12208

13429

21977

8704

20174

16322

14018

Self only

51861

39021

53701

27163

27162

29879

51861

18033

47770

39021

31268

Self amp family

10143

7533

10517

5634

5634

6198

10143

4017

9311

7533

6470

Self only

23936

18010

24785

12537

12536

13790

23936

8323

22048

18010

14431

Self amp family


96

South Dakota


Tennessee








Vermont




Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

97







Wyoming



Plan Name

877shy459shy6604

800shy552shy7114

877shy459shy6604

877shy459shy6604

877shy459shy6604

800shy377shy4161

Telephone Number


G51

L14

F51

JS1

H41

9K4

Self only

G52

L15

F52

JS2

H42

9K5

Self amp family

21977

10262

16322

22787

16237

8704

Self only

51861

22425

39021

53701

38826

18033

Self amp family

10143

4736

7533

10517

7494

4017

Self only

23936

10350

18010

24785

17920

8323

Self amp family


98





Wyoming



Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

$10$35$50 30day $100 90day

99


100

Appendix F


Waiting Periods





Contributions


Salary Deduction





101


















102










No Yes No No No




Yes Yes No No No


No No No No Yes


or spouse)

No No No Yes No



Yes No No No No


Yes Yes Yes No No


No No No Yes No







103



Reading the Chart


Dental Insurance









Vision Insurance



104



Plan Name

Telephone amp

Website


Class A

Class B

Class C

Class D

Deductible





0 40 60 50 $0




















105



Plan Name

Telephone amp

Website


Class A

Class B

Class C

Class D

Deductible


GEHA Standard






0 20 50 30 $0


0 20 50 30 $0












uccifedvipcom



20 40 60 50 $0


106



Plan Name

You pay

Telephone amp

Website

Class A

Class B

Class C

Class D Deductible













sssprcom


0

0

0

0

0

flat rate

Flat Rate

Approx 30

0

0

30

flat rate

flat rate

Flat Rate

Approx 50

0

0

60 30

flat rate

flat rate

Flat Rate

Approx 60

0

0

50

flat rate

flat rate

$0

$0


$0

$0

$0






107





Additional Features


Aetna Vision High


FEP BlueVision High
















$0

$0


Every24 months

Every 12 months

Every 24 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

108





Additional Features















Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

109



110


AL 356shy358 1 1 1 1 1 1 1 1 1 1 NA NA 3 NA NA



AZ 850shy853 3 5 5 2 2 2 2 1 1 1 NA NA 4 NA NA



CA 919shy921 3 5 5 5 5 4 4 4 4 4 NA NA 5 NA NA


CA 942 956shy958 4 5 5 5 5 4 4 4 4 4 NA NA 5 NA NA


CO 800shy806 3 4 4 3 3 4 4 4 4 3 NA NA 5 NA NA



CT 064shy069 3 5 5 5 5 5 5 5 5 5 NA NA NA 1 NA



FL 330shy334 2 4 4 3 3 3 3 3 3 3 NA NA 2 NA NA


GA 300shy303 305 311 399 3 2 2 2 2 3 3 2 2 1 NA NA 2 NA NA






IL 600shy608 2 2 2 3 3 3 3 4 4 3 NA NA 2 NA NA


IN 460shy462 472 2 1 1 1 1 2 2 1 1 1 NA NA 3 NA NA

IN 463shy464 2 2 2 3 3 3 3 4 4 3 NA NA 2 NA NA

IN 470 2 1 1 1 1 2 2 1 1 1 NA NA 1 NA NA



KY 410 452 459 2 1 1 1 1 2 2 1 1 1 NA NA 1 NA NA







111




MD 200202shy212 214 217 2 5 5 3 3 4 4 4 4 4 4 4 3 NA NA

MD 219 2 4 4 3 3 3 3 3 3 2 5 5 NA NA NA


ME 038 5 5 5 5 5 4 4 5 5 5 NA NA NA NA NA









NC 275shy277 283 4 2 2 2 2 2 2 1 1 2 NA NA 5 NA NA






NJ 3 5 5 5 5 5 5 5 5 5 NA NA NA 1 NA

NJ 080shy084 2 4 4 3 3 3 3 3 3 2 5 5 NA NA NA





NY 063 5 5 5 5 5 4 4 5 5 5 NA NA NA 1 NA

NY 140shy143 4 5 5 3 3 2 2 2 2 3 NA NA NA 1 NA


OH 430shy432 2 1 1 1 1 2 2 1 1 2 NA NA 2 NA NA

OH 440shy443 2 1 1 1 1 2 2 1 1 3 NA NA 2 NA NA

OH 450shy452 2 1 1 1 1 2 2 1 1 1 NA NA 1 NA NA

OH 453shy455 2 1 1 1 1 2 2 1 1 2 NA NA 1 NA NA




070072shy075077shy079085shy089



112




PA 153shy154 156 160shy162 1 2 2 1 1 1 1 1 1 1 1 1 NA NA NA

PA 173shy174 2 5 5 3 3 4 4 4 4 4 4 4 NA NA NA

PA 183 3 5 5 5 5 5 5 5 5 5 1 1 NA 1 NA

PA 189shy196 2 4 4 3 3 3 3 3 3 2 5 5 NA NA NA






TN 422 1 1 1 1 1 1 1 1 1 1 NA NA 1 NA NA


TX 739 2 3 3 1 1 2 2 1 1 1 NA NA 3 NA NA


TX 770 772shy775 2 2 2 1 1 2 2 1 1 1 NA NA 1 NA NA



VA 200shy205 220shy227 2 5 5 3 3 4 4 4 4 4 4 4 3 NA NA

VA 231shy232 238 3 3 3 2 2 2 2 1 1 2 3 3 3 NA NA





WA 986 4 5 5 3 3 3 3 4 4 5 NA NA NA NA NA



WI 540 2 4 4 4 4 3 3 4 4 3 NA NA NA NA NA


WV 254 2 5 5 3 3 4 4 4 4 4 NA NA 3 NA NA


WY 834 4 5 5 3 3 2 2 1 1 2 NA NA NA NA NA





Intershynational



113113

Aetna PPO

Delta Dental PPO

Delta Dental PPO

FEP BlueDental PPO

FEP BlueDental PPO

GEHA PPO

GEHA PPO

MetLife PPO

MetLife PPO












1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

$1288 $1418 $1510 $1666 $1809

$871 $949 $1024 $1080 $1234

$1669 $1831 $2008 $2136 $2485

$939 $1069 $1184 $1249 $1381

$1634 $1860 $2061 $2177 $2408

$900 $989 $1124 $1213 $1347

$1525 $1677 $1904 $2056 $2284

$868 $940 $1044 $1159 $1273

$1606 $1797 $1959 $2121 $2374

$1372 $1541 $1710 $1880 $2049

$2578 $2840 $3022 $3334 $3621

$1744 $1901 $2049 $2160 $2470

$3340 $3663 $4018 $4275 $4973

$1881 $2139 $2370 $2500 $2765

$3270 $3721 $4124 $4357 $4818

$1803 $1981 $2249 $2428 $2697

$3053 $3357 $3812 $4115 $4572

$1738 $1883 $2089 $2320 $2548

$3214 $3597 $3920 $4244 $4750

$2747 $3085 $3422 $3761 $4099

$3867 $4258 $4532 $5001 $5430

$2615 $2850 $3074 $3240 $3704

$5009 $5494 $6026 $6412 $7458

$2820 $3208 $3554 $3749 $4146

$4904 $5581 $6185 $6534 $7226

$2705 $2970 $3372 $3641 $4043

$4579 $5038 $5716 $6174 $6859

$2606 $2823 $3133 $3479 $3821

$4820 $5394 $5879 $6366 $7124

$4118 $4625 $5134 $5641 $6148

$2791 $3073 $3272 $3610 $3919

$1887 $2056 $2219 $2340 $2674

$3616 $3967 $4351 $4628 $5384

$2035 $2316 $2565 $2706 $2992

$3540 $4030 $4466 $4717 $5217

$1950 $2143 $2435 $2628 $2919

$3304 $3634 $4125 $4455 $4949

$1881 $2037 $2262 $2511 $2758

$3480 $3894 $4245 $4596 $5144

$2973 $3339 $3705 $4073 $4440

$5587 $6153 $6549 $7224 $7846

$3779 $4119 $4440 $4680 $5352

$7237 $7937 $8706 $9263 $10775

$4076 $4635 $5135 $5417 $5991

$7085 $8062 $8935 $9440 $10439

$3907 $4292 $4873 $5261 $5844

$6615 $7274 $8259 $8916 $9906

$3766 $4080 $4526 $5027 $5521

$6964 $7794 $8493 $9195 $10292

$5952 $6684 $7414 $8149 $8881

$8378 $9226 $9819 $10835 $11765

$5666 $6175 $6660 $7020 $8025

$10853 $11904 $13056 $13893 $16159

$6110 $6951 $7700 $8123 $8983

$10625 $12092 $13401 $14157 $15656

$5861 $6435 $7306 $7889 $8760

$9921 $10916 $12385 $13377 $14861

$5646 $6117 $6788 $7538 $8279

$10443 $11687 $12738 $13793 $15435

$8922 $10021 $11124 $12222 $13321





Self amp Family




Dominion Dental HMO

Dominion Dental HMO

EmblemHealth PPO

Humana

Triple S Salud PPO










1 2 3 4 5

1 2 3 4 5

1

1 2 3 4 5

1

$596 $622 $694 $829 $884

$1018 $1055 $1109 $1291 $1517

$1826

$990 $1048 $1136 $1378 $1475

$454

$1194 $1246 $1391 $1660 $1771

$2038 $2113 $2221 $2585 $3037

$3652

$1982 $2098 $2273 $2759 $2952

$910

$1790 $1868 $2085 $2489 $2655

$3056 $3168 $3330 $3876 $4554

$5478

$2971 $3146 $3409 $4136 $4428

$1191

$1291 $1348 $1504 $1796 $1915

$2206 $2286 $2403 $2797 $3287

$3956

$2145 $2271 $2461 $2986 $3196

$984

$2587 $2700 $3014 $3597 $3837

$4416 $4578 $4812 $5601 $6580

$7913

$4294 $4546 $4925 $5978 $6396

$1972

$3878 $4047 $4518 $5393 $5753

$6621 $6864 $7215 $8398 $9867

$11869

$6437 $6816 $7386 $8961 $9594

$2581





Self amp Family


114

Aetna


Delta Dental High


FEP BlueDental High

GEHA Standard

GEHA High

MetLife Standard

MetLife High

United Concordia

$1418

$1234

$2485

$1381

$2408

$900

$1525

$1273

$2374

$2049

$2840

$2470

$4973

$2765

$4818

$1803

$3053

$2548

$4750

$4099

$4258

$3704

$7458

$4146

$7226

$2705

$4579

$3821

$7124

$6148

$3073

$2674

$5384

$2992

$5217

$1950

$3304

$2758

$5144

$4440

$9226

$8025

$16159

$8983

$15656

$5861

$9921

$8279

$15435

$13321




Self amp Family

$6153

$5352

$10775

$5991

$10439

$3907

$6615

$5521

$10292

$8881


Premium Rate Charts


Aetna Vision

FEP BlueVision








$680 $1328

$800 $1012

$622 $884

$771 $1339

$1304 $2533

$1601 $2028

$1220 $1729

$1547 $2685

$1913 $3716

$2401 $3042

$1814 $2572

$2321 $4026

$314 $613

$369 $467

$287 $408

$356 $618

Standard High

Standard High

Standard High

Standard High

$602 $1169

$739 $936

$563 $798

$714 $1239

$883 $1715

$1108 $1404

$837 $1187

$1071 $1858







Aetna Vision

FEP BlueVision








$680 $1328

$800 $1012

$622 $884

$771 $1339

$1304 $2533

$1601 $2028

$1220 $1729

$1547 $2685

$1913 $3716

$2401 $3042

$1814 $2572

$2321 $4026

$314 $613

$369 $467

$287 $408

$356 $618

Standard High

Standard High

Standard High

Standard High

$602 $1169

$739 $936

$563 $798

$714 $1239

$883 $1715

$1108 $1404

$837 $1187

$1071 $1858






115

______________________________________________________________________________________________________________

























116
























117

Summary Information

























19121-c1-30 (70-10)_0

19121-pg31-36 (70-10)_0

19121-pg37-100 (70-10)_0

19121-pg101-118 (70-10)_0

















5







FSAFEDS




6



FEGLI












7






Key FEHB facts













8














9










10















11






Key FEDVIP facts













12

















13














14

















15





Key FSAFEDS facts










16













17















18


How do I enroll










19




Key FEGLI facts



















20











How do I enroll








21




Key FLTCIP facts












22





How do I apply








23


24


















25







donrsquot



















26












27


Definitions













28















Yes

Yes

Yes

Not Applicable

Yes

No

Yes

Not Applicable

Yes

Yes

Yes

No

Yes

Not Applicable

Yes

Yes

Yes

No

Yes1

Not Applicable

Yes

Not Applicable

Yes

Yes2



29













30










31













Telephone Number

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family






MHBP shystd

MHBP shyValue Plan

NALC shyhigh

NALC Value Option

SAMBA shyhigh

SAMBA shystd






800shy222shy2798

Local phone

Local phone

800shy821shy6136

800shy821shy6136

800shy410shy7778

800shy410shy7778

888shy636shy6252

888shy636shy6252

800shy638shy6589

800shy638shy6589

888shy438shy9135

202shy833shy4910

800shy424shy8196

800shy638shy8432

471

104

111

311

314

454

414

321

KM1

441

444

421

401

431

381

472

105

112

312

315

455

415

322

KM2

442

445

422

402

432

382

13670

19028

13209

20317

10418

20913

11302

16122

9001

27523

13171

15613

12535

11170

18913

30910

44412

30930

48310

23691

50565

26946

32727

19546

70356

30081

39039

30885

23316

30210

6309

8782

6096

9377

4808

9652

5216

7441

4154

12703

6079

7206

5785

5155

8729

14266

20498

14275

22297

10934

23338

12436

15105

9021

32472

13884

18018

14255

10761

13943


32




APWU shyhigh

BCBS shystd

BCBS shybasic

GEHA shyhigh

GEHA shystd

MHBP shystd

MHBP shyValue

NALC shyhigh

NALC Value

SAMBA shyhigh

SAMBA shystd

CRHP

FS

PCABP

Rural

Plan

PPO NonshyPPO

PPO NonshyPPO

PPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

NonshyPPO PPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

Benefit Type


$350 None $250 $350 None $350 + 35+


$350 None $100 $350 None $300


$400 None $200 $600 None $500


$300 None $200 $300 None $350

$4000 None 50 $2000 None 20

$300 None $200 $300 None $300


$350 None $200 $400 None $400



$350 $200 $100 $400 $200 $300

Deductible

Calendar Year

Prescription Drug

Hospital Inpatient

Per Person

$18 10 10 $8 2525 Yes 30+diff 30+diff 30 50 5050 Yes







$20 15 Nothing 20 3045 Yes 30 30 30 45+ 45+45+ Yes

50 50 50 50 5050+ No 20 20 20 $10 $40$60 No






$20 10 Nothing 30 3030 Yes 25 25 25 30 3030 Yes



RampB

Prescription Drugs



Office Visits


T2 $45 T3 50($55Min) T4 $50to$140 T5 $70to$195


33













Plan Code


Getting needed care


How well doctors


Claims processing





47

10 835 946 917 955 926 956 703



10

11

31

757

838

896

934

891

922

95

961

921

912

936

929

643

699


31

31 725 907 895 949 875 926 688

MHBP shystd

31

45 84 938 916 935 906 954 696

MHBP shyValue Plan

45

41 63 908 857 929 866 887 636

NALC shyhigh

41

32 856 936 922 959 934 965 771


32

KM

SAMBA shyhigh

KM

44 897 947 943 96 946 953 789

SAMBA shystd

44

44 816 93 905 956 911 946 757



44

42

roups

verage

837

805

941

927

945

917

962

951

94

911

927

934

747

716


42

40 798 898 909 935 892 889 721


40

43


43

38 865 946 947 967 928 966 773 38

34



Plan Name Location


Plan Code


Getting needed care


How well doctors


Claims processing




Arizona 10 11

851 747

905 898

919 884

933 923

938 914

969 928

724 680


California 10 11

809 705

915 873

897 840

954 943

881 910

937 912

677 616



768 691

935 893

930 874

951 940

882 881

898 922

657 622


Florida 10 11

864 806

942 916

922 894

952 947

934 916

954 937

733 660


Illinois 10 11

861 796

933 912

934 881

955 950

901 936

972 938

712 653


Maryland 10 11

857 770

931 897

917 898

954 940

897 921

956 967

713 666


Texas 10 11

887 825

934 898

931 883

950 955

936 910

957 967

721 617


Virginia 10 11

871 782

924 901

929 894

966 962

914 917

959 960

708 681

35


36















37



Enrollment Code

Monthly Biweekly


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Alabama


Alaska


Arizona









Arkansas





38


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Alabama




Alaska

4040 40 50+ 50+50+ No



Arizona

4040 40 50+ 50+50+ No










Arkansas

$25$40 $500day x 3 $10 $40$60 Yes





39



Enrollment Code

Monthly Biweekly


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

California
















Colorado




Connecticut


Delaware





40


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

California

HMOPOS National 679 864 849 942 877 875 649


to$1200 Yes

Average
















Colorado

$25$40 30 $10 $25$50 Yes 701 80 804 923 825 889 57





Connecticut

$20$40 10 $15 $40$80 Yes 722 884 873 936 876 879 622



Delaware

4040 40 50+ 50+50+ No





41











Florida


















Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



42


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs



HMOPOS Nationa

30to$60050 to$1200 Yes

l Average 679 864 849 942 877 875 649






4040

$15$30

$20$35

$25$35

Nothing$35

40

$150day x3

10 Plan Allow

$200

$200

50+

$5

$10

Nothing

Nothing

50+50+

$35$100

$35$100

$35$65

$35$65

No

Yes

Yes

Yes

Yes

69

69

648

648

844

844

86

86

872

872

833

833

942

942

925

925

865

865

846

846

914

914

902

902

567

567

54




MD IPAshyHigh

Florida


$70$70

$10$20

$20$30

$25$40

$25$40

$500

$100

$250dayx3

$150day x 3

20

Nothing

$7$17 Net

$12$22Net

$7

$10

$35$65

$30$50$45$65

$35$55$50$70

$30$60

30to$60050 to$1200

Yes

Yes

Yes

Yes

Yes

83

83

583

867

867

846

831

831

876

927

927

937

813

813

867

836

836

841

702

702

677








4040

$15$40

$25$45

$15$25

$15$30

$20$50

$35$55

40

$250dayx3

$300dayx3

$250

Ded + $150x3

Ded + $150x5

20

50+

$5

$10

$15 Tier 1

$3$20

$3$10

$10

50+50+

$30$5030

$40$6030


$40$6020

$50$7020

$40$60

No

No

No

No

No

No

Yes

746

746

855

514

514

877

877

905

808

808

847

847

905

764

764

957

957

953

921

921

919

919

938

827

827

87

87

946

783

783

68

68

755

535

535



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No










5050

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

50

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$10+

$10

$10

$10

$10

$10

$10

$10

$10

$40+$60+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

529

529

86

86

824

824

937

937

846

846

843

843

687

687

43


Georgia













Guam









Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



44


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Georgia


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649




4040

$20$35

$35$55

40

$250day x 4

20

50+

$10

$10

50+50+

$35$100

$40$60

No

Yes

Yes

59 90 878 941 86 857 62



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No










Guam


5050

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$30

$20$35

$15$40

50

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250dayx3

$250dayx3

$200

$10+

$10

$10

$10

$10

$10

$10

$10$20 Comm

$15$25 Comm

$10

$40+$60+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$50 Comm

$40$50 Comm

$2550 of AWP

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

514

794

794

883

845

845

837

85

85

941

935

935

859

884

884

849

839

839

556

625

625


TakeCareshyHigh

TakeCareshyStandard


3030

$5 at FHP$40

$5 at FHP$40

$25$40

30

$100day for 5

$150day for 5

20

NA

$10

$15

$10

NA

$25$50

$40$80

30to$60050 to$1200

NA

Yes

Yes

Yes

687

687

669

669

686

686

904

904

792

792

786

786

571

571


HMSA InshyNetwork

4040

$15$15

40

$100

50+

$7

50+50+

$30$65

No




3030

$20$20

$30$30

30

$100

10

$7 + 20

$10

$15

$45$45

$50$50

$30 + 20$65 + 20 No

Yes

Yes

754

754

826

826

815

815

94

94

875

875

811

811

613

613

45


Idaho








Illinois
















Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



46


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

6

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Idaho


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649






SelectHealthshyHigh


Illinois


4040

$20$30

$20$40

$25$25

$25$35

$15$25

$20$30

$25$40

40

$200

None

$350

$500

$100

$100 after

20

50+

$7

$7

$20

$20

$5 $25$50

$5

$10

50+50+

$25$50

$35$60

$40$60

$40$60

$25$50$50

$25$50

30to$60050 to$1200

No

No

None

Yes

Yes

Yes

Yes

Yes

552

552

659

659

629

629

852

852

86

86

876

876

813

813

869

869

851

851

948

948

941

941

958

958

883

883

912

912

912

912

895

895

881

881

903

903

588

588

692

692

64

64




4040

$20$35

$25$35

40

Nothing

$500

50+

$10 copay

$5

50+50+

$40$60

$40$6025 $6025

No

Yes







30 after ded

$25$50

$25$50

$20$35

$25$40

$35$55

30 after ded

$200day x 5

20

$250day x 3

$500day x 3

20

NA

$7

$7

$10

$10

$10

NA

$35$70

$35$70

$40$60

$40$60

$40$60

NA

Yes

Yes

Yes

Yes

Yes

745 915 88 962 878 868 67



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No







5050

$20$35

$25$40

$15$15

$25$40

$25$50

50

$250day x 3

$500day x 3

None

$450

20

$10+

$10

$10

$10

$7

$10

$40+$60+

$40$60

$40$60

$35$60

$30$60

$35$50

No

Yes

Yes

Yes

Yes

Yes

647

647

665

577

822

822

919

896

788

788

902

86

943

943

957

956

859

859

892

914

834

834

898

918

66

66

732

623

47


Indiana












Iowa












Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



48


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Indiana


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649





4040

$25$50

$25$50

$35$55

40

$200day x 5

20

20

50+

$7

$7

$10

50+50+

$35$70

$35$70

$40$60

No

Yes

Yes

Yes

745 915 88 962 878 868 67









Iowa


5050

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$15

$25$40

50

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

20

20

$10+

$10

$10

$10

$10

$10

$10

$10

$10

$40+$60+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$25$50

30to$60050 to$1200

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

647

647

562

822

822

878

788

788

815

943

943

934

859

859

868

834

834

893

66

66

593









4040

$25$50

$25$50

$25$50

$25$50

$25$45

$0 for 3 then 20

$20$30

40

20

20

$200day x 5

20

Nothing

20 in40 out

$100day x 5

50+

$3 $10

$3 $10

$7

$7

$12

$9

$15

50+50+

$45$70$100

30$5000 Max

$35$70

$35$70

$45$90

$40$70

$30$50

No

Yes

No

Yes

Yes

Yes

Yes

NA

562

562

745

647

647

535

905

905

915

893

893

903

888

888

88

875

875

89

964

964

962

951

951

977

837

837

878

92

92

902

903

903

868

911

911

912

652

652

67

725

725



4040

$25$25

40

$100day x 5

40+

$15

40+40+

$30$50

NA



40+40+

$25$50

40+

20

40+

$10

40+40+

$35$50

NA

Yes 577 896 86 956 914 918 623

49





Kansas








Kentucky








Louisiana









50


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Kansas


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649






4040

$20$35

$30$60

$30$60

$35$55

40

$250day x 4

25

30

20

50+

$10

$3 $12

$3 $12

$10

50+50+

$35$100

$50$75

$5020

$40$60

No

Yes

Yes

Yes

Yes

639

602

602

862

906

906

862

88

88

94

96

96

838

894

894

901

884

884

538

663

663




Kentucky


5050

$20$35

$25$40

$25$40

50

$250day x 3

$500day x 3

20

$10+

$10

$10

$10

$40+$60+

$40$60

$40$60

30to$60050 to$1200

No

Yes

Yes

Yes

676

676

903

903

901

901

951

951

881

881

918

918

729

729








Louisiana


4040

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$25$40

40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

20

50+

$10

$10

$10

$10

$10

$10

$10

50+50+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

30to$60050 to$1200

No

Yes

Yes

Yes

Yes

Yes

Yes








4040

$25$45

$30$55

$20$35

$35$40

$20$35

$35$40

40

Ded+$100

Ded+30

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+

$5

$5

$10

$10

$10

$10

50+50+

$40$100

$40$100

$40$60

$40$60

$40$60

$40$60

No

Yes

Yes

Yes

Yes

Yes

Yes

573

573

874

874

823

823

968

968

831

831

827

827

625

625

51





Maine


Maryland











Massachusetts




52


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Maine


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649


Maryland


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No






4040

$15$30

$20$35

$25$35

Nothing$35

40

$150day x3

10 Plan Allow

$200

$200

50+

$5

$10

Nothing

Nothing

50+50+

$35$100

$35$100

$35$65

$35$65

No

Yes

Yes

Yes

Yes

69

69

648

648

844

844

86

86

872

872

833

833

942

942

925

925

865

865

846

846

914

914

902

902

567

567

54






MD IPAshyHigh

Massachusetts


$70$70

$20$40

$20$40

$10$20

$20$30

$25$40

$25$40

$500

$200day x 3

$200day x 3

$100

$250dayx3

$150day x 3

20

Nothing

$3$15

$3$15

$7$17 Net

$12$22Net

$7

$10

$35$65

$30$60

$30$60

$30$50$45$65

$35$55$50$70

$30$60

30to$60050 to$1200

Yes

Yes

Yes

Yes

Yes

Yes

Yes

563

563

83

83

583

864

864

867

867

846

864

864

831

831

876

969

969

927

927

937

892

892

813

813

867

871

871

836

836

841

606

606

702

702

677



4040

$25$35

40

$150 to $750max

50+

$10

50+50+

$30$60

No

Yes 627 851 882 929 883 801 649

53





Michigan










Minnesota






54


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Michigan


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649










Minnesota


4040

$15$25

$15$25

$10$10

$20$20

$10$20

$15$30

$10$20

$15$15

$25$40

40

Nothing

Nothing

Nothing

$500x3

Nothing

Nothing

None

None

20

50+

$10

$10

$5

$10

$5

$15

$0$8

$10

$10

50+50+

$30$60

$30$60

$15$15

NA$40

$50$50

$50$50

$40$60

$40$40

30to$60050 to$1200

No

Yes

Yes

No

No

Yes

Yes

Yes

Yes

Yes

651

651

742

742

793

793

793

899

899

90

90

888

888

919

875

875

912

912

862

862

92

933

933

952

952

943

943

951

884

884

883

883

899

899

946

937

937

836

836

902

902

919

672

672

795

795

656

656

658





4040

$25$45

$0 for 3 then 20

$25$40

40

Nothing

20 in40 out

20

50+

$12

$9

$10

50+50+

$45$90

$40$70

30to$60050 to$1200

No

Yes

Yes

Yes

647

647

893

893

875

875

951

951

92

92

911

911

725

725


55











Montana


Nebraska


Nevada




New Hampshire



Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



56


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649




4040

$20$35

$25$35

40

$250day x 4

$500

50+

$10

$5

50+50+

$35$100 $40$60

25$6025

No

Yes

Yes

639

647

862

891

862

861

94

961

838

84

901

864

538





30 after ded

$30$60

$30$60

$35$55

30 after ded

25

30

20

NA

$3 $12

$3 $12

$10

NA

$50$75

$5020

$40$60

NA

Yes

Yes

Yes

602

602

906

906

88

88

96

96

894

894

884

884

663

663





Montana


5050

$20$35

$25$40

$25$40

$25$40

50

$250day x 3

$500day x 3

$450

20

$10+

$10

$10

$7

$10

$40+$60+

$40$60

$40$60

$30$60

30to$60050 to$1200

No

Yes

Yes

Yes

Yes

676

676

665

903

903

919

901

901

902

951

951

957

881

881

892

918

918

898

729

729

732


Nebraska


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No


Nevada


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No




New Hampshire


4040

$20$35

$10$25

$25$40

40

$250day x 4

$300

20

50+

$10

$7

$10

50+50+

$35$100

$35$55$100

30to$60050 to$1200

No

Yes

Yes

Yes

602

516

838

696

861

66

923

892

849

892

918

912

636

529


57


New Jersey








New Mexico





Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code


Monthly Biweekly


58


Prescription Drugs


Mail lan

eeded

are

ll icate

r ng rm

ation




order discount

Ove

rall p

satisfaction

Gettin

g n

care

Gettin

g c

quickly

How

we

doctors

commun

Custome

service

Claim

sproce

ssi

Plan

Info

on

Costs

New Jersey


HMO

30to$60050 to$1200

POS National

Yes

Average 679 864 849 942 877 875 649







$15$35

$20$20

20 Plan Allow

$150max$450

$5

$20

$35$100

$45$85

Yes

Yes

631

663

852

844

837

851

928

936

895

86

809

828

623



New Mexico


50 of sch

$30$30

$25$40

+50 of sch

$250day x 3

20

NA

$10

$10

NA

$45$85

30to$60050 to$1200

No

Yes

Yes

663 844 851 936 86 828 642




59


New York

























Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



60

North Dakota


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

New York



30to$60050 to$1200 Yes

l vera e 679 864 849 942 877 875 649









4040

$20$35

$15$35

$20$30

$25$40

$25$40

$25$40

$20$20

40

$250day x 4

20 Plan Allow

$100 x 5

$500+10

$500

$500

$150max$450

50+

$10

$5

25

30

$10

$10

$20

50+50+

$35$100

$35$100

2525

3030

$30$50

$30$50

$45$85

No

Yes

Yes

No

No

Yes

Yes

Yes

662

662

729

729

663

848

848

928

928

844

849

849

90

90

851

937

937

949

949

936

888

888

922

922

86

874

874

924

924

828

547

547

70

70






50 of sch

$30$30

$20$40

$30$50

$25$25

+50 of sch

$250day x 3

None

$1000

$250

NA

$10

$15

$15$100Ded

$10

NA

$45$85

$35$75

$30$75

$35$75 $75$100Ded

No

Yes

Yes

Yes

No

663

729

729

735

844

814

814

933

851

786

786

923

936

888

888

952

86

787

787

92

828

848

848

916

642

60

60



2525

$30$50

25

$750

NA

$10

NA

$5050

No












3030

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

30

$500

$750

$500

$750

$500

$750

$500

$750

$500

$750

NA

$5

$5

$5

$5

$5

$5

$5

$5

$5

$5

NA

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

739

739

739

739

739

739

739

739

739

739

934

934

934

934

934

934

934

934

934

934

89

89

89

89

89

89

89

89

89

89

962

962

962

962

962

962

962

962

962

962

896

896

896

896

896

896

896

896

896

896

92

92

92

92

92

92

92

92

92

92

768

768

768

768

768

768

768

768

768

768

61


North Carolina


North Dakota







Ohio








Oklahoma




Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



62


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

North Carolina


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649


North Dakota


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No





4040

$25$45

$0 for 3 then 20

$15$25

40

Nothing

20 in40 out

None

50+

$12

$9

50$600ded

50+50+

$45$90

$40$70

50$600 ded

No

Yes

Yes

None

647

647

893

893

875

875

951

951

92

92

911

911

725

725



2020

$20$30

20

$100day x 5

NA

$15

NA

$30$50

NA



4040

$25$25

40

$100day x 5

40+

$15

40+40+

$30$50

NA


Ohio


40+40+

$25$40

40+

20

40+

$10

40+40+

30to$60050 to$1200

NA


AultCare HMOshyHigh






Oklahoma


4040

$15$20

$20$35

$25$40

$20$20

$30$40

$10$20

$25$40

40

$150

$250day x 3

$500day x 3

$250

$500

$250

20

50+

$15

$10

$10

$10

$15

$15

$10

50+50+

$30$40$55

$40$60

$40$60

$30$30

$40$40

$30$50

30to$60050 to$1200

No

No

Yes

Yes

Yes

Yes

Yes

Yes

877

788

788

744

922

845

845

909

907

889

889

876

941

922

922

951

944

935

935

929

935

906

906

944

853

708

708

745



4040

$15$45

40

$250dymx1000

50+

$4$10

50+50+

$45$70

No

Yes 592 816 839 916 893 872 727

63


Oregon




Pennsylvania









Puerto Rico



Rhode Island


South Carolina



Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



64


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Information

on Costs

Oregon


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649




Pennsylvania


4040

$20$30

$30$40

$25$40

40

$200

$500

20

50+

$15

$20

$10

50+50+

$40$60

$40$60

30to$60050 to$1200

No

Yes

Yes

Yes

768

768

844

844

847

847

916

916

927

927

89

89

683

683









Puerto Rico


4040

$20$35

$15$35

$20$35

$20$35

$25$50

10 after Deduct

20 after Deduct

$5$5

40

$250day x 4

20 Plan Allow

$250day x 4

20aftrDeduct

15 after ded

10 after deduct

20after Deduct

None

50+

$10

$5

$10

30 $5$15

$5

$5 after ded

$5 after ded

$250

50+50+

$35$100

$35$100

$35$100

$35$60

$35$75

$35$75$100

$10$15

40 $40$120 50 $85$250

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

579

579

579

668

699

754

754

806

861

861

861

868

873

908

908

803

835

835

835

85

885

899

899

82

935

935

935

938

957

97

97

938

887

887

887

906

86

913

913

887

899

899

899

902

921

904

904

70

631

631

631

677

671

678

678




Rhode Island


$750$10

$25$40

$750 amp 10 +$10 amp 10 +

None 10 +

20

$5 or $12 NA

$10

NANA

2025 up to$100$175max

30to$60050 to$1200

Yes No

Yes

691 874 844 963 872 75 586


South Carolina


4040

$25$40

40

20

50+

$10

50+50+

30to$60050 to$1200

No


65


South Dakota






Tennessee






Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



66


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

South Dakota



30to$60050 to$1200 Yes

679 864 849 942 877 875 649





4040

$25$45

$20$30

$0 for 3 then 20

40

Nothing

$100day x 5

20 in40 out

50+

$12

$9

$15

50+50+

$45$90

$40$70

$30$50

No

Yes

Yes

NA

647

647

535

893

893

903

875

875

89

951

951

977

92

92

902

911

911

912

725

725



4040

$25$25

40

$100day x 5

40+

$15

40+40+

$30$50

NA

NA

535


Tennessee


40+40+

$25$40

40+

20

40+

$10

40+40+

30to$60050 to$1200

NA





4040

$20$35

$20$35

$25$40

40

$250day x 4

$250day x 3

$500day x 3

50+

$10

$10

$10

50+50+

$35$100

$40$60

$40$60

No

Yes

Yes

Yes

66 875 868 959 889 914 69

67


Texas






















Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



68


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Texas


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649



4040

$5$25$35

40

15

50+

$5

50+50+

$35$60

No


FirstcareshyHigh

FirstcareshyHigh

FirstcareshyHigh

FirstcareshyHigh

FirstcareshyHigh


4040

$30$55

$30$55

$30$55

$30$55

$30$55

$35$55

40

$250day x 5

$250day x 5

$250day x 5

$250day x 5

$250day x 5

20

40

$10

$10

$10

$10

$10

$10

4040

$35$70

$35$70

$35$70

$35$70

$35$70

$40$60

No

Yes

Yes

Yes

Yes

Yes



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No



5050

$35$55

50

20

$10+

$10

$40+$60+

$40$60

No












5050

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$45

$20$40

50

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

10

$250day x 5

$10+

$10

$10

$10

$10

$10

$10

$10

$10

$5

$10

$40+$60+

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$40$60

$45$100

$35$60

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

63

63

702

835

835

862

764

764

863

931

931

937

864

864

875

856

856

87

673

673

569

69



Enrollment Code

Monthly Biweekly


Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family








Vermont

Virgin Islands

Utah


70


Prescription Drugs


Mail lan

eeded

are

ll icate

r ng rm

ation




order discount

Ove

rall p

satisfaction

Gettin

g n

care

Gettin

g c

quickly

How

we

doctors

commun

Custome

service

Claim

sproce

ssi

Plan

Info

on

Costs

Utah


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649






Vermont


$20$30

$25$40

$100 after

20

$5$25$50

$10

$25 $50$50

30to$60050 to$1200

Yes

Yes

629 876 851 958 912 903 64


Virgin Islands

4040 40 50+ 50+50+ No


$750$10 $750 amp 10 + $10 amp 10 +

None 10 +

$5 or $12 NA NANA

2025 up to$100$175max

Yes No

691 874 844 963 872 75 586

71


Virginia















Washington










Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



72


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

Virginia








$25$40 4040

$15$30

$20$35

$25$35 4040

$5$25$35 4040

$25$35

Nothing$35

20 40

$150day x3

10 Plan Allow

15 40

15 40

$200

$200

$10 50+

$5

$10

$5 40

$5 40

Nothing

Nothing

HMOP

50+50+

$35$100

$35$100

$35$60 4040

$35$60 4040

$35$65

$35$65

30to$60050 to$1200

OS National

Yes No

Yes

Yes

Yes No

Yes No

Yes

Yes

Average

69

69

648

648

679

844

844

86

86

864

872

872

833

833

849

942

942

925

925

942

865

865

846

846

877

914

914

902

902

875

567

567

54

54

649





MD IPAshyHigh




Washington









$70$70

$10$20

$20$30

$25$40

$25$30

$35$35

$25$40 4040

$20$35

$25$25

$25$35

$154 or 2020

$30$30 $30+40+diff

$20$30

$30$40


$20$0childlt22$30


$500

$200 x3 days

$100

$250dayx3

$150day x 3

$150max$750

$20020

20

20 40

$250day x 4

$350

$500

Nothing Nothing

None None

$200

$500

Nothing

$0

$7$17 Net

$12$22Net

$7

$10

$10

$15

$10 50+

$10

$20

$20

$10 Not Covered

$5 Not Covered

$15

$20

$35$65

$30$50$50

$30$50$45$65

$35$55$50$70

$30$60

$40$55

50+50+

$35$100

$40$60

$40$60

Not Covered

NA

$40$60

$40$60

$353050up to $3000

$355050 up to $3000

$35$50 30day $100 90day

$25$50 30day$100 90day

30to$60050 to$1200

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes No

Yes

Yes

Yes

Yes No

Yes No

Yes

Yes

83

83

583

692

692

659

659

798

798

768

768

867

867

846

864

864

86

86

94

94

844

844

833

831

831

876

886

886

869

869

928

928

847

847

927

927

937

969

969

941

941

957

957

916

916

813

813

867

87

87

912

912

931

931

927

927

836

836

841

916

916

881

881

897

897

89

89

702

702

677

674

674

692

692

65

65

683

683

73


West Virginia



Wisconsin









Wyoming





Number Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Enrollment Code

Monthly Biweekly



74


Primary care


Hospital per stay

deductible

Prescription Drugs



Mail order

discount

Ove

rall plan

satisfaction

Gettin

g nee

ded

care

Gettin

g care

quickly

How

well

doctors

communicate

Customer

service

Claim

sproce

ssing

Plan

Inform

ation

on

Costs

West Virginia


HMOP

30to$60050 to$1200

OS National

Yes

Average 679 864 849 942 877 875 649



Wisconsin


4040

$10$20

$25$40

40

$250

20

50+

$15

$10

50+50+

$30$50

30to$60050 to$1200

No

Yes

Yes

744 909 876 951 929 944 745



4040

$25$35

40

15

50+

$5

50+50+

$35$60

No








Wyoming


4040

$25$25

$10$10

$25$45

$0 for 3then 20

$10$10

$10$10

$25$40

40

None

None

Nothing

20 in40 out

Nothing

Nothing

20

40

$10

$5

$12

$9

$10

$10

$10

4040

$20$20

$45$90

$40$70

$20$50

3050

30$75max 50 wmin$50

30to$60050 to$1200

No

Yes

Yes

Yes

Yes

Yes

No

Yes

682

785

647

647

784

601

909

834

893

893

888

857

90

834

875

875

854

822

97

953

951

951

938

96

834

929

92

92

888

863

879

932

911

911

87

866

588

718

725

725

684

686




4040

$20$30

$20$40

40

$200

None

50+

$7

$7

50+50+

$25$50

$35$60

No

No

None

552

552

852

852

813

813

948

948

883

883

895

895

588

588

75











76



















insurance plans

77



ELIGIBILITY

FUNDING







CONTRIBUTIONS

DISTRIBUTIONS







ANNUAL ROLLOVER







78





79












Self only

Self amp family

Self only

Self amp family

Self only

Self amp family





800shy718shy1299

800shy821shy6136

800shy694shy9901

888shy636shy6252

474 475

341 342

481 482

324 325

9742

11021

13642

10454

21915

25172

30912

22700

4496 10115

5087 11618

6296 14267

4825 10477


80














81













Plan Code


Getting needed care


How well doctors


Claims processing






22

34

48

606

623

614

891

873

891

888

851

859

952

923

912

830

863

887

879

865

885

563

602

590


Plan Code


Getting needed care


How well doctors


Claims processing







22

47

TP TU TV

MW

606

664

566

478

891

909

849

875

888

907

864

801

952

925

932

948

830

871

843

856

879

845

853

812

563

680

542

555

82


83



Plan Name

Telephone Number


Self only

Self amp family

Self only

Self amp family

Self only

Self amp family



Alabama


Alaska


Arizona


Arkansas


California


Colorado


Plan Name

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

Telephone Number


F51

JS1

G51

F51

JS1

G51

Self only

F52

JS2

G52

F52

JS2

G52

Self amp family

16322

22787

21977

16322

22787

21977

Self only

39021

53701

51861

39021

53701

51861

Self amp family

7533

10517

10143

7533

10517

10143

Self only

18010

24785

23936

18010

24785

23936

Self amp family


84

Benefit Type


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs



Alabama


Alaska


Arizona


Arkansas


California


Colorado


Plan Name







Benefit Type

$8333$16666 $8333$16666

$8333$16666 $8333$16666

$8333$16666 $8333$16666

$8333$16666 $8333$16666

$8333$16666 $8333$16666

$8333$16666 $8333$16666


$1000$2000 $1000$2000

$1000$2000 $1000$2000

$1000$2000 $1000$2000

$1000$2000 $1000$2000

$1000$2000 $1000$2000

$1000$2000 $1000$2000

CY Ded SelfFamily

$4000$8000 $5000$10000

$4000$8000 $5000$10000

$4000$8000 $5000$10000

$4000$8000 $5000$10000

$4000$8000 $5000$10000

$4000$8000 $5000$10000


15 40

15 40

15 40

15 40

15 40

15 40

Office Visit

15 40

15 40

15 40

15 40

15 40

15 40

Inpatient Hospital

15 40

15 40

15 40

15 40

15 40

15 40

Outpatient Surgery

Nothing FundDed40

Nothing FundDed40

Nothing FundDed40

Nothing FundDed40

Nothing FundDed40

Nothing FundDed40

Preventive Services

$10$35$60 40+40+40+

$10$35$60 40+40+40+

$10$35$60 40+40+40+

$10$35$60 40+40+40+

$10$35$6 40+40+40+

$10$35$60 40+40+40+

Prescription Drugs

Levels I II III

85



Connecticut


Delaware





Florida





Georgia




Guam


Plan Name

877shy459shy6604

877shy459shy6604

877shy459shy6604

888shy789shy9065

877shy459shy6604

800shy441shy5501

888shy393shy6765

888shy393shy6765

877shy459shy6604

888shy393shy6765

888shy393shy6765

671shy647shy3526

Telephone Number


EP1

EP1

F51

B61

F51

J41

MJ1

QP1

F51

AD1

LM1

KX1

Self only

EP2

EP2

F52

B62

F52

J42

MJ2

QP2

F52

AD2

LM2

KX2

Self amp family

20174

20174

16322

14018

16322

13979

12818

10987

16322

11598

12208

6822

Self only

47770

47770

39021

31268

39021

43929

28521

24447

39021

25804

27163

17900

Self amp family

9311

9311

7533

6470

7533

6452

5916

5071

7533

5353

5634

3148

Self only

22048

22048

18010

14431

18010

20275

13163

11283

18010

11910

12537

8261

Self amp family


86

Connecticut


Delaware





Florida





Georgia




Guam


Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type


87




Idaho



Illinois




Indiana



Iowa



Kansas




Plan Name

877shy459shy6604

877shy459shy6604

800shy377shy4161

877shy459shy6604

888shy393shy6765

888shy393shy6765

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy257shy4692

877shy459shy6604

800shy969shy3343

888shy393shy6765

Telephone Number


JS1

H41

9K4

H41

GB1

MW1

JS1

MW1

H41

SV4

G51

9H1

PH1

Self only

JS2

H42

9K5

H42

GB2

MW2

JS2

MW2

H42

SV5

G52

9H2

PH2

Self amp family

22787

16237

8704

16237

12208

12208

22787

12208

16237

8970

21977

12747

10987

Self only

53701

38826

18033

38826

27163

27162

53701

27162

38826

21408

51861

29956

24447

Self amp family

10517

7494

4017

7494

5634

5634

10517

5634

7494

4140

10143

5883

5071

Self only

24785

17920

8323

17920

12537

12536

24785

12536

17920

9880

23936

13826

11283

Self amp family


88


Idaho



Illinois




Indiana



Iowa



Kansas




Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

89



Kentucky




Maine









Plan Name

877shy459shy6604

888shy393shy6765

877shy459shy6604

877shy459shy6604

877shy459shy6604

888shy789shy9065

800shy833shy7423

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

Telephone Number


H41

6N1

F51

EP1

F51

B61

GZ1

EP1

G51

H41

H41

Self only

H42

6N2

F52

EP2

F52

B62

GZ2

EP2

G52

H42

H42

Self amp family

16237

10987

16322

20174

16322

14018

11980

20174

21977

16237

16237

Self only

38826

24447

39021

47770

39021

31268

26835

47770

51861

38826

38826

Self amp family

7494

5071

7533

9311

7533

6470

5529

9311

10143

7494

7494

Self only

17920

11283

18010

22048

18010

14431

12385

22048

23936

17920

17920

Self amp family


90

Kentucky




Maine









Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

91






Nebraska


Nevada


New Hampshire


New Jersey


New Mexico




Plan Name


877shy459shy6604

800shy969shy3343

888shy393shy6765

77shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

877shy459shy6604

800shy501shy3439

Telephone Number


G51

9H1

PH1

H41

H41

G51

EP1

EP1

G51

EP1

QA4

Self only

G52

9H2

PH2

H42

H42

G52

EP2

EP2

G52

EP2

QA5

Self amp family

21977

12747

10987

16237

16237

21977

20174

20174

21977

20174

9575

Self only

51861

29956

24447

38826

38826

51861

47770

47770

51861

47770

24919

Self amp family

10143

5883

5071

7494

7494

10143

9311

9311

10143

9311

4419

Self only

23936

13826

11283

17920

17920

23936

22048

22048

23936

22048

11501

Self amp family


92





Nebraska


Nevada


New Hampshire


New Jersey


New Mexico




Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

93



North Carolina


North Dakota






Pennsylvania




Rhode Island


South Carolina


Plan Name

877shy459shy6604

877shy459shy6604

877shy459shy6604

330shy363shy6360

877shy459shy6604

877shy459shy6604

877shy459shy6604

866shy351shy5946

888shy876shy2756

877shy459shy6604

877shy459shy6604

Telephone Number


F51

H41

JS1

3A4

JS1

H41

H41

Y61

8W4

EP1

JS1

Self only

F52

H42

JS2

3A5

JS2

H42

H42

Y62

8W5

EP2

JS2

Self amp family

16322

16237

22787

8669

22787

16237

16237

12298

12448

20174

22787

Self only

39021

38826

53701

17501

53701

38826

38826

28345

28053

47770

53701

Self amp family

7533

7494

10517

4001

10517

7494

7494

5676

5745

9311

10517

Self only

18010

17920

24785

8077

24785

17920

17920

13082

12948

22048

24785

Self amp family


94

North Carolina


North Dakota






Pennsylvania




Rhode Island


South Carolina


Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Benefit Type

Prescription Drugs

Levels I II III




30 after deduct

95



South Dakota


Tennessee








Vermont




Plan Name

877shy459shy6604

877shy459shy6604

877shy459shy6604

888shy393shy6765

888shy393shy6765

888shy393shy6765

877shy459shy6604

800shy377shy4161

877shy459shy6604

877shy459shy6604

888shy789shy9065

Telephone Number


G51

G51

JS1

TP1

TU1

TV1

G51

9K4

EP1

F51

B61

Self only

G52

G52

JS2

TP2

TU2

TV2

G52

9K5

EP2

F52

B62

Self amp family

21977

16322

22787

12208

12208

13429

21977

8704

20174

16322

14018

Self only

51861

39021

53701

27163

27162

29879

51861

18033

47770

39021

31268

Self amp family

10143

7533

10517

5634

5634

6198

10143

4017

9311

7533

6470

Self only

23936

18010

24785

12537

12536

13790

23936

8323

22048

18010

14431

Self amp family


96

South Dakota


Tennessee








Vermont




Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

97







Wyoming



Plan Name

877shy459shy6604

800shy552shy7114

877shy459shy6604

877shy459shy6604

877shy459shy6604

800shy377shy4161

Telephone Number


G51

L14

F51

JS1

H41

9K4

Self only

G52

L15

F52

JS2

H42

9K5

Self amp family

21977

10262

16322

22787

16237

8704

Self only

51861

22425

39021

53701

38826

18033

Self amp family

10143

4736

7533

10517

7494

4017

Self only

23936

10350

18010

24785

17920

8323

Self amp family


98





Wyoming



Plan Name


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

$10$35$50 30day $100 90day

99


100

Appendix F


Waiting Periods





Contributions


Salary Deduction





101


















102










No Yes No No No




Yes Yes No No No


No No No No Yes


or spouse)

No No No Yes No



Yes No No No No


Yes Yes Yes No No


No No No Yes No







103



Reading the Chart


Dental Insurance









Vision Insurance



104



Plan Name

Telephone amp

Website


Class A

Class B

Class C

Class D

Deductible





0 40 60 50 $0




















105



Plan Name

Telephone amp

Website


Class A

Class B

Class C

Class D

Deductible


GEHA Standard






0 20 50 30 $0


0 20 50 30 $0












uccifedvipcom



20 40 60 50 $0


106



Plan Name

You pay

Telephone amp

Website

Class A

Class B

Class C

Class D Deductible













sssprcom


0

0

0

0

0

flat rate

Flat Rate

Approx 30

0

0

30

flat rate

flat rate

Flat Rate

Approx 50

0

0

60 30

flat rate

flat rate

Flat Rate

Approx 60

0

0

50

flat rate

flat rate

$0

$0


$0

$0

$0






107





Additional Features


Aetna Vision High


FEP BlueVision High
















$0

$0


Every24 months

Every 12 months

Every 24 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

108





Additional Features















Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

109



110


AL 356shy358 1 1 1 1 1 1 1 1 1 1 NA NA 3 NA NA



AZ 850shy853 3 5 5 2 2 2 2 1 1 1 NA NA 4 NA NA



CA 919shy921 3 5 5 5 5 4 4 4 4 4 NA NA 5 NA NA


CA 942 956shy958 4 5 5 5 5 4 4 4 4 4 NA NA 5 NA NA


CO 800shy806 3 4 4 3 3 4 4 4 4 3 NA NA 5 NA NA



CT 064shy069 3 5 5 5 5 5 5 5 5 5 NA NA NA 1 NA



FL 330shy334 2 4 4 3 3 3 3 3 3 3 NA NA 2 NA NA


GA 300shy303 305 311 399 3 2 2 2 2 3 3 2 2 1 NA NA 2 NA NA






IL 600shy608 2 2 2 3 3 3 3 4 4 3 NA NA 2 NA NA


IN 460shy462 472 2 1 1 1 1 2 2 1 1 1 NA NA 3 NA NA

IN 463shy464 2 2 2 3 3 3 3 4 4 3 NA NA 2 NA NA

IN 470 2 1 1 1 1 2 2 1 1 1 NA NA 1 NA NA



KY 410 452 459 2 1 1 1 1 2 2 1 1 1 NA NA 1 NA NA







111




MD 200202shy212 214 217 2 5 5 3 3 4 4 4 4 4 4 4 3 NA NA

MD 219 2 4 4 3 3 3 3 3 3 2 5 5 NA NA NA


ME 038 5 5 5 5 5 4 4 5 5 5 NA NA NA NA NA









NC 275shy277 283 4 2 2 2 2 2 2 1 1 2 NA NA 5 NA NA






NJ 3 5 5 5 5 5 5 5 5 5 NA NA NA 1 NA

NJ 080shy084 2 4 4 3 3 3 3 3 3 2 5 5 NA NA NA





NY 063 5 5 5 5 5 4 4 5 5 5 NA NA NA 1 NA

NY 140shy143 4 5 5 3 3 2 2 2 2 3 NA NA NA 1 NA


OH 430shy432 2 1 1 1 1 2 2 1 1 2 NA NA 2 NA NA

OH 440shy443 2 1 1 1 1 2 2 1 1 3 NA NA 2 NA NA

OH 450shy452 2 1 1 1 1 2 2 1 1 1 NA NA 1 NA NA

OH 453shy455 2 1 1 1 1 2 2 1 1 2 NA NA 1 NA NA




070072shy075077shy079085shy089



112




PA 153shy154 156 160shy162 1 2 2 1 1 1 1 1 1 1 1 1 NA NA NA

PA 173shy174 2 5 5 3 3 4 4 4 4 4 4 4 NA NA NA

PA 183 3 5 5 5 5 5 5 5 5 5 1 1 NA 1 NA

PA 189shy196 2 4 4 3 3 3 3 3 3 2 5 5 NA NA NA






TN 422 1 1 1 1 1 1 1 1 1 1 NA NA 1 NA NA


TX 739 2 3 3 1 1 2 2 1 1 1 NA NA 3 NA NA


TX 770 772shy775 2 2 2 1 1 2 2 1 1 1 NA NA 1 NA NA



VA 200shy205 220shy227 2 5 5 3 3 4 4 4 4 4 4 4 3 NA NA

VA 231shy232 238 3 3 3 2 2 2 2 1 1 2 3 3 3 NA NA





WA 986 4 5 5 3 3 3 3 4 4 5 NA NA NA NA NA



WI 540 2 4 4 4 4 3 3 4 4 3 NA NA NA NA NA


WV 254 2 5 5 3 3 4 4 4 4 4 NA NA 3 NA NA


WY 834 4 5 5 3 3 2 2 1 1 2 NA NA NA NA NA





Intershynational



113113

Aetna PPO

Delta Dental PPO

Delta Dental PPO

FEP BlueDental PPO

FEP BlueDental PPO

GEHA PPO

GEHA PPO

MetLife PPO

MetLife PPO












1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

$1288 $1418 $1510 $1666 $1809

$871 $949 $1024 $1080 $1234

$1669 $1831 $2008 $2136 $2485

$939 $1069 $1184 $1249 $1381

$1634 $1860 $2061 $2177 $2408

$900 $989 $1124 $1213 $1347

$1525 $1677 $1904 $2056 $2284

$868 $940 $1044 $1159 $1273

$1606 $1797 $1959 $2121 $2374

$1372 $1541 $1710 $1880 $2049

$2578 $2840 $3022 $3334 $3621

$1744 $1901 $2049 $2160 $2470

$3340 $3663 $4018 $4275 $4973

$1881 $2139 $2370 $2500 $2765

$3270 $3721 $4124 $4357 $4818

$1803 $1981 $2249 $2428 $2697

$3053 $3357 $3812 $4115 $4572

$1738 $1883 $2089 $2320 $2548

$3214 $3597 $3920 $4244 $4750

$2747 $3085 $3422 $3761 $4099

$3867 $4258 $4532 $5001 $5430

$2615 $2850 $3074 $3240 $3704

$5009 $5494 $6026 $6412 $7458

$2820 $3208 $3554 $3749 $4146

$4904 $5581 $6185 $6534 $7226

$2705 $2970 $3372 $3641 $4043

$4579 $5038 $5716 $6174 $6859

$2606 $2823 $3133 $3479 $3821

$4820 $5394 $5879 $6366 $7124

$4118 $4625 $5134 $5641 $6148

$2791 $3073 $3272 $3610 $3919

$1887 $2056 $2219 $2340 $2674

$3616 $3967 $4351 $4628 $5384

$2035 $2316 $2565 $2706 $2992

$3540 $4030 $4466 $4717 $5217

$1950 $2143 $2435 $2628 $2919

$3304 $3634 $4125 $4455 $4949

$1881 $2037 $2262 $2511 $2758

$3480 $3894 $4245 $4596 $5144

$2973 $3339 $3705 $4073 $4440

$5587 $6153 $6549 $7224 $7846

$3779 $4119 $4440 $4680 $5352

$7237 $7937 $8706 $9263 $10775

$4076 $4635 $5135 $5417 $5991

$7085 $8062 $8935 $9440 $10439

$3907 $4292 $4873 $5261 $5844

$6615 $7274 $8259 $8916 $9906

$3766 $4080 $4526 $5027 $5521

$6964 $7794 $8493 $9195 $10292

$5952 $6684 $7414 $8149 $8881

$8378 $9226 $9819 $10835 $11765

$5666 $6175 $6660 $7020 $8025

$10853 $11904 $13056 $13893 $16159

$6110 $6951 $7700 $8123 $8983

$10625 $12092 $13401 $14157 $15656

$5861 $6435 $7306 $7889 $8760

$9921 $10916 $12385 $13377 $14861

$5646 $6117 $6788 $7538 $8279

$10443 $11687 $12738 $13793 $15435

$8922 $10021 $11124 $12222 $13321





Self amp Family




Dominion Dental HMO

Dominion Dental HMO

EmblemHealth PPO

Humana

Triple S Salud PPO










1 2 3 4 5

1 2 3 4 5

1

1 2 3 4 5

1

$596 $622 $694 $829 $884

$1018 $1055 $1109 $1291 $1517

$1826

$990 $1048 $1136 $1378 $1475

$454

$1194 $1246 $1391 $1660 $1771

$2038 $2113 $2221 $2585 $3037

$3652

$1982 $2098 $2273 $2759 $2952

$910

$1790 $1868 $2085 $2489 $2655

$3056 $3168 $3330 $3876 $4554

$5478

$2971 $3146 $3409 $4136 $4428

$1191

$1291 $1348 $1504 $1796 $1915

$2206 $2286 $2403 $2797 $3287

$3956

$2145 $2271 $2461 $2986 $3196

$984

$2587 $2700 $3014 $3597 $3837

$4416 $4578 $4812 $5601 $6580

$7913

$4294 $4546 $4925 $5978 $6396

$1972

$3878 $4047 $4518 $5393 $5753

$6621 $6864 $7215 $8398 $9867

$11869

$6437 $6816 $7386 $8961 $9594

$2581





Self amp Family


114

Aetna


Delta Dental High


FEP BlueDental High

GEHA Standard

GEHA High

MetLife Standard

MetLife High

United Concordia

$1418

$1234

$2485

$1381

$2408

$900

$1525

$1273

$2374

$2049

$2840

$2470

$4973

$2765

$4818

$1803

$3053

$2548

$4750

$4099

$4258

$3704

$7458

$4146

$7226

$2705

$4579

$3821

$7124

$6148

$3073

$2674

$5384

$2992

$5217

$1950

$3304

$2758

$5144

$4440

$9226

$8025

$16159

$8983

$15656

$5861

$9921

$8279

$15435

$13321




Self amp Family

$6153

$5352

$10775

$5991

$10439

$3907

$6615

$5521

$10292

$8881


Premium Rate Charts


Aetna Vision

FEP BlueVision








$680 $1328

$800 $1012

$622 $884

$771 $1339

$1304 $2533

$1601 $2028

$1220 $1729

$1547 $2685

$1913 $3716

$2401 $3042

$1814 $2572

$2321 $4026

$314 $613

$369 $467

$287 $408

$356 $618

Standard High

Standard High

Standard High

Standard High

$602 $1169

$739 $936

$563 $798

$714 $1239

$883 $1715

$1108 $1404

$837 $1187

$1071 $1858







Aetna Vision

FEP BlueVision








$680 $1328

$800 $1012

$622 $884

$771 $1339

$1304 $2533

$1601 $2028

$1220 $1729

$1547 $2685

$1913 $3716

$2401 $3042

$1814 $2572

$2321 $4026

$314 $613

$369 $467

$287 $408

$356 $618

Standard High

Standard High

Standard High

Standard High

$602 $1169

$739 $936

$563 $798

$714 $1239

$883 $1715

$1108 $1404

$837 $1187

$1071 $1858






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117

Summary Information

























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