Guide To Federal Benefits

Guide To Federal Benefits

The 2012

Healthcare and Insurance RI 70-1Revised November 2011

bull Federal Employees Health Benefits (FEHB) Program p 10

bull Federal Employees Dental and Vision Insurance Program

(FEDVIP) p14

bull Federal Flexible Spending Account Program (FSAFEDS) p18

bull Federal Employeesrsquo Group Life Insurance (FEGLI) Program p 22

bull Federal Long Term Care Insurance Program (FLTCIP) p 24

For Federal Civilian Employees

Visit us at wwwopmgovinsure

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 14 to December 12 2011

Varies by agency automated enrollment or via SF 2809

wwwopmgovinsurehealth

FEDVIP Within 60 days from new hire date


Go to wwwBENEFEDScom or call 1shy877shy888shy3337

wwwopmgovinsuredental wwwopmgovinsurevision

FSAFEDS Within 60 days from new hire date


Go to wwwFSAFEDScom or call 1shy877shy372shy3337

wwwopmgovinsureflexible

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

wwwopmgovinsurelife

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


Go to wwwLTCFEDScom or call 1shy800shy582shy3337 wwwopmgovinsureltc

Table of Contents

Page

Introduction to Federal Benefits and This Guide 3

PreshyExisting Insurance Program 4

Federal Benefits Snapshot 5

Federal Benefits Open Season Snapshot 6

Thinking About Retiring 7

Federal Employees Health Benefits (FEHB) Program 10

FEHB Program Health Information Technology and PriceCost Transparency 13

Federal Employees Dental and Vision Insurance Program (FEDVIP) 14

Federal Flexible Spending Account Program (FSAFEDS) 18

Federal Employeesrsquo Group Life Insurance (FEGLI) Program 22

Federal Long Term Care Insurance Program (FLTCIP) 24

Appendix A FEHB Program Features 27

Appendix B Choosing an FEHB Plan 28

Appendix C Qualifying Life Events that May Permit a Change in Your FEHB Enrollment 31

Appendix D FEHB Member Survey Results 32

Appendix E FEHB Plan Comparison Charts 33

bull FeeshyforshyService 34

bull Health Maintenance Organization Plans and Plans Offering a PointshyofshyService Product 39

bull High Deductible and ConsumershyDriven Health Plans 64

Appendix F FEDVIP Program Features 81

Appendix G FEDVIP Definitions 82

Appendix H FEDVIP Qualifying Life Events for Enrollment Changes 83

Appendix I FEDVIP Plan Comparison Charts 84

bull Nationwide and International Dental Plans Open to All 85

bull Regional Dental Plans 86

bull Nationwide and International Vision Plans Open to All 87

Appendix J FEDVIP Dental Rating Regional Chart 88

Appendix K FEDVIP Premium Rate Charts 91

Medicaid and the Childrenrsquos Health Insurance Program (CHIP) 94

1

This page intentionally left blank

2

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 bull Federal Employees Dental and Vision Insurance Program bull Federal Flexible Spending Account Program bull Federal Employeesrsquo Group Life Insurance Program bull Federal Long Term Care Insurance Program

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 it 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

3

Preshyexisting Condition Insurance Program (PCIP)

Do you know someone who needs health insurance but canrsquot get it The PreshyExisting Condition Insurance Plan (PCIP) may help

An individual is eligible to buy coverage in PCIP if

bull He or she has a preshyexisting medical condition or has been denied coverage because of the health condition

bull He or she has been without health coverage for at least the last six months (If the individual currently has insurance coverage that does not cover the preshyexisting condition or is enrolled in a state high risk pool then that person is not eligible for PCIP)

bull He or she is a citizen or national of the United States or resides in the US legally

The Federal government administers PCIP in the following states Alabama Arizona District of Columbia Delaware Florida Georgia Hawaii Idaho Indiana Kentucky Louisiana Massachusetts Minnesota Mississippi North Dakota Nebraska Nevada South Carolina Tennessee Texas Vermont Virginia West Virginia and Wyoming To find out about eligibility visit wwwpcipgov andor wwwhealthcaregov or call 1shy866shy717shy5826 (TTY 1shy866shy561shy1604)

4

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 10 for general information on FEHB (including eligibility) and for guidance on choosing a plan

2 If you decide to enroll examine the 2012 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 14 for general information on FEDVIP (including eligibility) and guidance on choosing a FEDVIP dental plan andor vision plan


3 See page 16 for information on how to enroll

FSAFEDS 1 See page 18 for general information on FSAFEDS (including eligibility) and for guidance on making a decision whether to participate


FEGLI 1 See page 22 for general information on FEGLI (including eligibility) and for guidance on making a decision whether to select optional insurance (Basic FEGLI is automatic)


1 See page 24 for general information on FLTCIP (including eligibility) and for guidance FLTCIP on making a decision whether to apply

2 See page 25 for information on how to apply for coverage

5

Federal Benefits Open Season Snapshot

Current Employees

During Open Season you have the opportunity to 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 2012 premiums and satisfaction survey results in Appendix E

2 Examine your planrsquos 2012 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 2012 do nothing ndash your enrollment will continue automatically

5 If not satisfied with your current plan for 2012 see Appendix B for guidance on choosing another plan

6 See page 7 for information on FEHB and retirement

1 See page 10 for general information on FEHB (including eligibility) and Appendix B for guidance on choosing a plan



FEDVIP 1 Check your planrsquos 2012 premiums in Appendix K and examine your planrsquos 2012 brochure for benefit and enrollmentservice area changes

2 If also enrolled in FEHB check your 2012 FEHB brochure for any changes in dental andor vision benefits

3 If satisfied with your planrsquos rates and benefits for 2012 do nothing ndash your enrollment will continue automatically

4 If not satisfied with your current plan for 2012 see page 14 for guidance on choosing another plan and for information on how to change your enrollment

5 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

6 See page 7 for information on FEDVIP and retirement

1 See page 14 for general information on FEDVIP (including eligibility) and for guidance on choosing a FEDVIP plan

2 If you decide to enroll examine the 2012 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 2012 FEHB brochure for any changes in dental andor vision benefits


FSAFEDS 1 If you want to participate in 2012 you must make a new election Keep in mind your election and enrollment do not carry over from year to year see page 21 for information on how to enroll

2 Check your 2012 FEHB and 2012 FEDVIP plan brochures to see how any benefit changes may affect your outshyofshypocket health care expenses

3 See page 18 for any updated information about the Program

1 See page 18 for general information on FSAFEDS (including eligibility) and for guidance on making a decision whether to participate


6

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 the date your annuity starts 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 signshyup for Medicare when you become eligible

7


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 one to three 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

8



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 via Standard Form (SF) 2818 how you wish your coverage(s) to continue during your retirement

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

9

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 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 and do not want to change plans or enrollment type 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 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 savingsreimbursable 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

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

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

10


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 legally adopted children recognized natural (born out of wedlock) children and stepchildren

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

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 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 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 the date your annuity starts 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

11


When can I enroll

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

How do I enroll

You may be able to enroll 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 wwwopmgovinsurehealth 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

12


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 wwwopmgovinsurehealthphrtoolsasp 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 wwwopmgovinsurehealthreferencehittransparencyasp 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

13

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 seven dental plans and three 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 2012 provided you remain eligible for the program Enrollment continues year to year automatically Please Note your premiums and benefits may change for 2012

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 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 (FSA) with FEDVIP You can submit your FEDVIP copayments and deductibles as eligible expenses against your FSA account

bull Cancellation of coverage can only be made during Open Season upon deployment to active military duty or upon transferring to an eligible position

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)

14



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

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

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

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 one regional dental plan 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 wwwopmgovinsuredental and wwwopmgovinsurevision for premium and rating region information


In general Federal employees eligible for FEHB coverage (whether or not actually enrolled) and retirees (regardless of FEHB status) are eligible to enroll in a dental andor vision plan 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

15


When can I enroll

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

How do I enroll

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

16


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 wwwopmgovinsuredental and wwwopmgovinsurevision for information including

bull How to enroll bull Dental premium rates bull FEDVIP plan websites brochures and provider searches bull Vision premium rates

17

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

Recent changes to FSAFEDS

bull Coverage for OvershytheshyCounter Medicines or Drugs shy Overshytheshycounter (OTC) products that are medicines or drugs are not eligible for reimbursement from your Health Care FSA ndash unless ndash you have a prescription for that item written by your physician The only exception is insulin ndash you will not need a prescription Other currently eligible OTC items that are not medicines or drugs will not require a prescription

bull Expanded Coverage for Your Childrsquos Eligible Health Care Expenses shy An employee enrolled in FSAFEDS may request reimbursement for eligible health care expenses incurred by a natural child stepchild adopted child eligible foster child or a child who is placed with the employee for legal adoption The child does not need to reside with the employee or qualify as the employeersquos tax dependent

18



There are three types of FSAs Each type has a minimum annual election of $250 and a maximum of $5000

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 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 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

19



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

When can I enroll

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)

20


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

21

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 may be able to continue their FEGLI coverage into retirement 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

22



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

When can I enroll

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 Seasons were held in 2004 and in 1999

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 wwwopmgovinsurelife contains more details

How does my beneficiary file a claim

He or she must use a specific form (FEshy6) to claim FEGLI benefits available from your human resources office or retirement system or at wwwopmgovinsurelife


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

23

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 eligible for the FEHB Program you are eligible to apply for coverage under the FLTCIP even if you are not enrolled in the FEHB Program Retirees are eligible to apply

24



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 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

25


26

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

Annual 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 Other events 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

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)

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

for your family if you die or

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

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

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

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

27

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

Choice of doctors Specialty care Outshyofshypocket costs Paperwork hospitals pharmacies and other providers

FeeshyforshyService wPPO (Preferred Provider Organization)

You must use the planrsquos network to reduce your outshyofshypocket costs For BCBS Basic Option you

Referral not required to get benefits

You pay fewer costs if you use a PPO provider than if you donrsquot

Some if you donrsquot use network providers

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

Health Maintenance You generally must Referral generally Your outshyofshypocket Little if any Organization use the planrsquos network required from primary costs are generally

to reduce your outshyofshy care doctor to get limited to copayments pocket costs benefits

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

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

pay more

ConsumershyDriven Plans

You may use network and nonshynetwork

Referral not required to get maximum

You will pay an annual deductible and


providers You will pay benefits from PPOs costshysharing You pay more by not using the less if you use the network network

High Deductible Some plans are Referral not required You will pay an If you have an HSA or Health Plans wHealth network only others to get maximum annual deductible and HRA account you may Savings Account (HSA) pay something even if benefits from PPOs costshysharing You pay have to file a claim to or Health you do not use a less if you use the obtain reimbursement Reimbursement network provider network Arrangement (HRA)

28


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 wwwopmgovinsurehealthsearchplansearchaspx You can also find help in selecting a plan using tools provided by PlanSmartChoice and Consumerrsquos Checkbook at wwwopmgovinsurehealthplaninfoindexasp

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 out of pocket 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

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

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 wwwopmgovinsurehealthplaninfoqualityhedisaspx

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

29


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 health insurance premiums to the Federal Employees Health Benefits (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 participants 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

30

Appendix C Qualifying Life Events (QLEs)

that May Permit a Change in 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 qualifying life event changes to the employeersquos FEHB enrollment may be permitted Individuals who donrsquot participate in Premium Conversion (retirees and employees who waived participation) 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

31

Appendix D FEHB Member Survey Results

Each year Federal Employees Health Benefits 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)

32

Appendix E FEHB Plan Comparison Charts

Nationwide FeeshyforshyService Plans (Pages 34 through 37)

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 resource office first

The Health Maintenance Organization (HMO) and PointshyofshyService (POS) section begins on page 39

The High Deductible Health Plan (HDHP) and ConsumershyDriven Health Plan (CDHP) section begins on page 64

33

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 Telephone Number

Enrollment Code

Your Share of Premium

Monthly Biweekly

Self Self amp only family

Self Self amp Self Self amp only family only family

APWU Health Plan (APWU) shyhigh 800shy222shy2798 471 472 12762 28856 5890 13318

Blue Cross and Blue Shield Service Benefit Plan (BCBS) shystd Local phone 104 105 18542 43004 8558 19848

Blue Cross and Blue Shield Service Benefit Plan (BCBS) shybasic Local phone 111 112 12188 28542 5625 13173

GEHA Benefit Plan (GEHA) shyhigh 800shy821shy6136 311 312 18503 43838 8540 20233

GEHA Benefit Plan (GEHA) shystd 800shy821shy6136 314 315 9272 21086 4279 9732

MHBP shystd 800shy410shy7778 454 455 20874 50100 9634 23123

MHBP shy Value Plan 800shy410shy7778 414 415 8577 20449 3959 9438

NALC shyhigh 888shy636shy6252 321 322 16178 32760 7467 15120

SAMBA shyhigh 800shy638shy6589 441 442 25922 66049 11964 30484

SAMBA shystd 800shy638shy6589 444 445 13171 30550 6079 14100

Compass Rose Health Plan (CRHP) shyhigh 800shy769shy6953

Plan Name Open Only to Specific Groups

421 422 13272 32275 6126 14896

Foreign Service Benefit Plan (FSBP) shyhigh 202shy833shy4910 401 402 12349 30734 5699 14185

Panama Canal Area Benefit Plan (PCABP) shyhigh 800shy424shy8196 431 432 10538 21996 4864 10152

Rural Carrier Benefit Plan (Rural) shyhigh 800shy638shy8432 381 382 18319 29905 8455 13802

34

Prescription Drug Payment Levels Plans use a variety of terms to define what you pay for prescription drugs such as generic brand name Tier I Tier II Level I etc The 2 to 3 payment levels that plans use follow Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs Many plans are basing how much you pay for prescription drugs on what they are charged

Mail Order Discounts If your plan has a Mail Order progrram and that program is superior to the purchase of medications at the pharmacy (eg you get a greater quantity or pay less through Mail Order) your planrsquos response is ldquoyesrdquo If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit the planrsquos response is 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

Plan

Benefit Type

MedicalshySurgical ndash You Pay

Deductible Copay ($)Coinsurance ()

Per Person Hospital Inpatient

Doctors Hospital Inpatient

RampB

Prescription Drugs

Level I Level II Level III Mail Order Discounts

Office Visits

Inpatient Surgical Services

Calendar Year

Prescription Drug

APWU shyhigh

BCBS shystd

BCBS shybasic

GEHA shyhigh

GEHA shystd

MHBP shystd

MHBP shyValue

NALC shyhigh

SAMBA shyhigh

SAMBA shystd

CRHP

FSBP

PCABP

Rural

PPO NonshyPPO

PPO NonshyPPO

PPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

POS FFS

PPO NonshyPPO

$275 None $500 None

$350 None $350 None

None None

$350 None $350 None

$350 None $350 None

$400 None $600 None

$600 None $900 Not Covered

$300 None $300 None

$300 None $300 None

$350 None $350 None

$300 None $350 None

$300 None $300 None

None None None None

$350 $200 $400 $200

FFS National Average

None $300

$250 $350

$150day x 5

$100 $300

None None

$200 $500

None None

$200 $350

$200 $300

$150 up to $450 $200 up to $600

$150 $350

Nothing $200

$100 $25

$100 $300

$18 10 30+diff 30+diff

$20 15 35 35

$25 $150

$20 10 25 25

$10 15 35 35

$20 10 30 30

$30 20 40 40

$20 15 30 30

$20 10 30 30

$20 15 35 35

$10 Nothing 30 30

10 10 30 30

50 50 $5 Nothing

$20 10 25 25

10 30

Nothing 35

Nothing

Nothing Nothing

15 35

Nothing 30

20 40

Nothing 30

Nothing 30

Nothing 35

Nothing 30

Nothing 20

50 Nothing

Nothing 20

$8 2525 Yes 50 5050 Yes

20 (15MCare B) 3030 Yes 45 + 45+45+ Yes

$10 $50$150 NA

$5 25 Max $150NA Yes $5 25 Max $150 +NA Yes


$10 30($200 max)50($200 max) Yes 50 5050 Yes

$10 4575 Yes Not Covered Not CoveredNot Covered Yes

20 3030 Yes 45 45+ 45+45+ Yes

$10 15($55 max)30($90 max) Yes $10 15($55 max)30($90 max) Yes


$5 $3030 or $45 Yes $5 $3030 or $45 Yes

$10 25$50 minNA Yes $10 25$50 minNA Yes

20 2020 No 20 2020 No

30 3030 Yes 30 3030 Yes

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

35


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

Plan Name Open to All

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

APWU Health Plan shyhigh

FFS National A

47

verage 774

78

916

898

91

921

948

938

897

837

929

898

725

737 47

Blue Cross and Blue Shield Service Benefit Plan shystd 10 788 924 884 944 888 945 719 10

Blue Cross and Blue Shield Service Benefit Plan shybasic 11 717 907 876 939 885 932 725

GEHA Benefit Plan shyhigh 31 855 928 911 943 928 966 74 31

GEHA Benefit Plan shystd 31 773 894 88 934 901 939 73 31

MHBP shystd 45 706 916 917 943 898 927 713 45

MHBP shy Value Plan 41 564 879 877 955 857 849 638 41

NALC shyhigh 32 811 934 914 951 923 951 766 32

SAMBA shyhigh 44 893 946 937 968 901 973 791 44

SAMBA shystd 44 745 923 933 952 903 925 74

Compass Rose Health Plan

Plan Name Open Only to Specific GFFS National

44

42

roups Average 774 916 91 948 897 929 725

42

Foreign Service Benefit Plan 40 788 90 928 951 902 883 698 40

Panama Canal Area Benefit Plan 43 43

Rural Carrier Benefit Plan 38 845 945 944 96 934 964 77 38

36

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

Location Plan Name


Plan Code


Getting needed care


How well doctors


Claims processing


FFS National Average 774 916 91 948 897 929 725

Blue Cross and Blue Shield Service shy Standard Arizona 10 819 93 898 947 914 962 743 Benefit Plan shy Basic 11 752 895 895 929 883 939 642

Blue Cross and Blue Shield Service shy Standard California 10 771 93 94 947 899 955 673 Benefit Plan shy Basic 11 656 885 818 927 871 894 659

Blue Cross and Blue Shield Service shy Standard District of Columbia 10 794 914 897 931 883 912 708 Benefit Plan shy Basic 11 646 843 838 902 862 933 626

Blue Cross and Blue Shield Service shy Standard Florida 10 864 936 943 934 888 957 763 Benefit Plan shy Basic 11 764 922 895 92 883 935 671

Blue Cross and Blue Shield Service shy Standard Illinois 10 829 928 904 945 928 963 70 Benefit Plan shy Basic 11 759 913 89 94 823 933 672

Blue Cross and Blue Shield Service shy Standard Maryland 10 832 941 914 941 864 937 743 Benefit Plan shy Basic 11 713 883 911 928 878 924 667

Blue Cross and Blue Shield Service shy Standard Texas 10 835 933 908 94 89 959 726 Benefit Plan shy Basic 11 803 921 872 924 91 969 686

Blue Cross and Blue Shield Service shy Standard Virginia 10 863 943 928 956 906 965 745 Benefit Plan shy Basic 11 758 903 919 935 877 955 679

37


38


Health Maintenance Organization Plans and Plans Offering a PointshyofshyService Product

(Pages 40 through 63)

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 drugs ndash Plans use a variety of terms to define what you pay for prescription drugs such as generic brand Level I Level II Tier I Tier II etc In capturing these differences we use the following Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs The level in which a medication is placed and what you pay for prescription drugs is often based on what the plan is charged

Mail Order Discount ndash If your plan has a mail order program and that program is superior to the purchase of medications at the pharmacy (eg you get a greater quantity or pay less through mail order) your planrsquos response is ldquoyesrdquo If the plan does not have a mail order program or it is not superior to its pharmacy benefit the planrsquos response is ldquonordquo

Member Survey Results ndash See Appendix D for a description

39

Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages


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

Arizona

Aetna Open Access shyhighshy Phoenix and Tucson Areas 877shy459shy6604 WQ1 WQ2 23237 63735 10725 29416

Health Net of Arizona Inc shyhighshy MaricopaPimaOther AZ counties 800shy289shy2818 A71 A72 15119 50381 6978 23253

Health Net of Arizona Inc shystdshy MaricopaPimaOther AZ counties 800shy289shy2818 A74 A75 12370 35483 5709 16377

Arkansas

QualChoice shy high shy All of Arkansas 800shy235shy7111 DH1 DH2 16857 43946 7780 20283

QualChoice shy std shy All of Arkansas 800shy235shy7111 DH4 DH5 11134 26073 5139 12034

California

Aetna Open Access shyhighshy Los Angeles and San Diego Areas 877shy459shy6604 2X1 2X2 12307 31486 5680 14532

Blue Shield of CA Access+HMO shyhighshy Southern Region 800shy880shy8086 SI1 SI2 13414 31488 6191 14533

Health Net of California shyhighshy Northern Region 800shy522shy0088 LB1 LB2 52715 125157 24330 57765

Health Net of California shystdshy Northern Region 800shy522shy0088 LB4 LB5 48447 115288 22360 53210

Health Net of California shyhighshy Southern Region 800shy522shy0088 LP1 LP2 19277 47844 8897 22082

Health Net of California shystdshy Southern Region 800shy522shy0088 LP4 LP5 15661 39487 7228 18225

Kaiser Foundation Health Plan of California shyhighshy Northern California 800shy464shy4000 591 592 25944 68220 11974 31486

Kaiser Foundation Health Plan of California shystdshy Northern California 800shy464shy4000 594 595 15195 39953 7013 18440

Kaiser Foundation Health Plan of California shyhighshy Southern California 800shy464shy4000 621 622 12608 29139 5819 13449

Kaiser Foundation Health Plan of California shystdshy Southern California 800shy464shy4000 624 625 8076 18665 3727 8614

United Healthcare of California shyhighshy Most of California 866shy546shy0510 CY1 CY2 12810 29285 5912 13516

Colorado

Kaiser Foundation Health Plan of Colorado shyhighshy DenverBoulderSouthern Colorado areas 800shy632shy9700 651 652 17398 40506 8030 18695

Kaiser Foundation Health Plan of Colorado shystdshy DenverBoulderSouthern Colorado areas 800shy632shy9700 654 655 8185 18498 3778 8537

Delaware Aetna Open Access shyhighshy KentNew CastleSussex areas 877shy459shy6604 P31 P32 62387 157861 28794 72859

Aetna Open Access shybasicshy KentNew CastleSussex areas 877shy459shy6604 P34 P35 33995 81655 15690 37687

40

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

Arizona

Aetna Open AccessshyHigh $20$35 $250day x 4 $10

HMOP

$35$65

OS Nationa

Yes

l Average 659

583

855

842

855

864

935

883

839

858

876

884

664

636

Health Net of Arizona IncshyHigh $15$30 $200day x 3 $10 $30$50 Yes 702 878 868 921 863 946 675

Health Net of Arizona IncshyStd

Arkansas

QualChoiceshy InshyNetwork

$15$40

$20$30

$250day x 3

$100max$500

$10

$0

$40$70

$40$60

Yes

Yes

702

61

878

845

868

873

921

935

863

877

946

887

675

652 QualChoiceshy OutshyNetwork 4040 40 NA NA NA NA 61 845 873 935 877 887 652


California

Aetna Open AccessshyHigh

$20$40

$20$35

$200max$1000

$250day x 4

$5

$10

$40$60

$35$65

Yes

Yes

61

612

845

808

873

822

935

922

877

813

887

882

652

608

Blue Shield of CA Access+HMOshyHigh $20$30 $150 day x 3 $10 $35$50 Yes 709 874 876 938 824 878 665

Health Net of CaliforniashyHigh $15$30 $100day x 5 $10 $35$60 Yes 662 833 819 90 794 885 591

Health Net of CaliforniashyStd $30$50 $500 $15 $35$60 Yes 662 833 819 90 794 885 591



Kaiser Foundation HP of California shyHigh $15$25 $250 $10 $30$30 Yes 764 846 83 91 826 754 597

Kaiser Foundation HP of California shyStd $30$40 $500 $15 $35$35 Yes 764 846 83 91 826 754 597



United Healthcare of California shyHigh

Colorado

Kaiser Foundation HP of Colorado shyHigh

$20$35

$20$40

$150day x 4

$250

$10

$10

$35$60

$35$60

Yes

Yes

692

716

787

833

824

862

935

918

761

77

88

876

588

684

Kaiser Foundation HP of Colorado shyStd

Delaware Aetna Open AccessshyHigh

$25$45

$20$35

$250day x 3

$150day x 5

$15

$10

$40$80

$35$65

Yes

Yes

716

616

833

884

862

88

918

943

77

857

876

932

684

631

Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 616 884 88 943 857 932 631

41




Plan Name ndash Location Telephone Self Number only

Self amp Self family only


Self amp family

District of Columbia Aetna Open Access shyhighshy Washington DC Area 877shy459shy6604 JN1 JN2 33796 76072 15598 35110

Aetna Open Access shybasicshy Washington DC Area 877shy459shy6604 JN4 JN5 12446 29128 5744 13444

CareFirst BlueChoice shyhighshy Washington DC Metro Area 888shy789shy9065 2G1 2G2 13999 32255 6461 14887

CareFirst BlueChoice Healthy Blue Option shystdshy Washington DC Metro Area 888shy789shy9065 2G4 2G5 12883 28982 5946 13376

Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy Washington DC area 877shy574shy3337 E31 E32 14800 36835 6831 17001

Kaiser Foundation Health Plan MidshyAtlantic States shystdshy Washington DC area 877shy574shy3337 E34 E35 8969 20629 4139 9521

MD IPA shyhighshy Washington DC area 877shy835shy9861 JP1 JP2 16579 41260 7652 19043

Florida AvshyMed Health Plan shyhighshy Broward Dade and Palm Beach 800shy882shy8633 ML1 ML2 18274 50680 8434 23391

AvshyMed Health Plan shystdshy Broward Dade and Palm Beach 800shy882shy8633 ML4 ML5 12265 29438 5661 13587

Capital Health Plan shyhighshy Tallahassee area 850shy383shy3311 EA1 EA2 10227 27101 4720 12508

Coventry Health Plan of Florida shyhighshy Southern Florida 800shy441shy5501 5E1 5E2 12185 36227 5624 16720

Coventry Health Plan of Florida shystdshy Southern Florida 800shy441shy5501 5E4 5E5 11028 28494 5090 13151

Humana Medical Plan Inc shyhighshy South Florida 888shy393shy6765 EE1 EE2 16490 37882 7611 17484

Humana Medical Plan Inc shystdshy South Florida 888shy393shy6765 EE4 EE5 12083 27187 5577 12548

Humana Medical Plan Inc shyhighshy Tampa 888shy393shy6765 LL1 LL2 34027 77341 15705 35696

Humana Medical Plan Inc shystdshy Tampa 888shy393shy6765 LL4 LL5 13457 31059 6211 14335

Georgia Aetna Open Access shyhighshy Atlanta and Athens Areas 877shy459shy6604 2U1 2U2 28232 67349 13030 31084

Humana Employers Health of Georgia Inc shyhighshy Columbus 888shy393shy6765 CB1 CB2 13459 31061 6212 14336

Humana Employers Health of Georgia Inc shystdshy Columbus 888shy393shy6765 CB4 CB5 12755 28698 5887 13245

Humana Employers Health of Georgia Inc shyhighshy Atlanta 888shy393shy6765 DG1 DG2 12915 29058 5961 13411

Humana Employers Health of Georgia Inc shystdshy Atlanta 888shy393shy6765 DG4 DG5 12419 27942 5732 12896

Humana Employers Health of Georgia Inc shyhighshy Macon 888shy393shy6765 DN1 DN2 13459 31061 6212 14336

Humana Employers Health of Georgia Inc shystdshy Macon 888shy393shy6765 DN4 DN5 12755 28698 5887 13245

Kaiser Foundation Health Plan of Georgia shyhighshy Atlanta Athens Columbus Macon Savananah 888shy865shy5813 F81 F82 16038 38835 7402 17924

Kaiser Foundation Health Plan of Georgia shystdshy Atlanta Athens Columbus Macon Savananah 888shy865shy5813 F84 F85 9746 22270 4498 10278

42


Primary care



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

District of Columbia Aetna Open AccessshyHigh $15$30 $150day x 3 $5

HMO

$35$65

POS National

Yes

Average 659

659

855

871

855

87

935

918

839

901

876

874

664

667


CareFirst BlueChoiceshyHigh $25$35 $200 Nothing $30$50 Yes 618 862 846 917 722 846 532

CareFirst BlueChoice InshyNetwork Nothing$35 $200 Nothing $30$50 Yes

CareFirst BlueChoice OutshyNetwork $70$70 $500 Nothing $30$50 Yes

Kaiser Foundation HP MidshyAtlantic States shyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716

Kaiser Foundation HP MidshyAtlantic States shyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716

MD IPAshyHigh

Florida AvshyMed Health PlanshyHigh

$25$40

$15$40

$150day x 3

$150day x 5

$7

$5

$30$150$250

$30$5030

Yes

No

632

724

838

869

871

855

925

913

841

894

90

853

65

648

AvshyMed Health PlanshyStd $25$45 $175day x 5 $10 $40$6030 No 724 869 855 913 894 853 648

Capital Health PlanshyHigh $15$25 $250 $15 $30$50 No 862 862 896 942 909 978 778

Coventry Health Plan of FloridashyHigh $15$30 Ded+$150x3 $3$20 $40$6020 No 502 812 822 899 787 873 647

Coventry Health Plan of FloridashyStandard $20$50 Ded+$100x5 $10 $50$7020 No 502 812 822 899 787 873 647

Humana Medical Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 524 828 866 926 828 849 628

Humana Medical Plan IncshyStandard $25$40 $500day x 3 $10 $40$60 Yes 524 828 866 926 828 849 628

Humana Medical Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes

Humana Medical Plan Inc shyStandard

Georgia Aetna Open AccessshyHigh

$25$40

$20$35

$500day x 3

$250day x 4

$10

$10

$40$60

$35$65

Yes

Yes 569 888 835 927 882 873 589

Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes

Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes

Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 504 824 83 956 806 812 642

Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 504 824 83 956 806 812 642



Kaiser Foundation HP of Georgia shyHigh $10$25 $350 $10$20 Comm $30$40 Comm $30$40 Comm Yes 768 845 84 922 818 822 614

Kaiser Foundation HP of Georgia shyStd $20$30 $250day x 3 $15$25 Comm $30$40 Comm $30$40 Comm Yes 768 845 84 922 818 822 614

43





Guam

TakeCare shyhighshy GuamNMariana IslandsBelau(Palau) 671shy647shy3526 JK1 JK2 12447 41060 5745 18951

TakeCare shystdshy GuamNMariana IslandsBelau(Palau) 671shy647shy3526 JK4 JK5 11043 29162 5097 13459

Hawaii HMSA shyhighshy All of Hawaii 808shy948shy6499 871 872 11847 26372 5468 12172

Kaiser Foundation Health Plan of Hawaii shyhighshy HawaiiKauaiLanaiMauiMolokaiOahu 808shy432shy5955 631 632 13685 28987 6316 13378

Kaiser Foundation Health Plan of Hawaii shystdshy HawaiiKauaiLanaiMauiMolokaiOahu 808shy432shy5955 634 635 6162 13250 2844 6115

Idaho

Altius Health Plans shyhighshy Southern Region 800shy377shy4161 9K1 9K2 19786 42302 9132 19524

Altius Health Plans shystdshy Southern Region 800shy377shy4161 DK4 DK5 10651 23431 4916 10814

Group Health Cooperative shyhighshy Kootenai and Latah 888shy901shy4636 541 542 19699 39110 9092 18051

Group Health Cooperative shystdshy Kootenai and Latah 888shy901shy4636 544 545 9559 21579 4412 9959

Illinois

Aetna Open Access shyhighshy Chicago Area 877shy459shy6604 IK1 IK2 34233 89563 15800 41337

Blue Preferred Plus POS shyhighshy Madison and St Clair counties 888shy811shy2092 9G1 9G2 26208 54102 12096 24970

Health Alliance HMO shyhighshy CentralECentralN CentSouthWest 800shy851shy3379 FX1 FX2 21846 54966 10083 25369

Humana Benefit Plan of Illinois Inc shyhighshy Central and Northwestern 888shy393shy6765 9F1 9F2 39583 89839 18269 41464

Humana Benefit Plan of Illinois Inc shystdshy Central and Northwestern 888shy393shy6765 AB4 AB5 13459 31061 6212 14336

Humana Health Plan Inc shyhighshy Chicago 888shy393shy6765 751 752 29971 68215 13833 31484

Humana Health Plan Inc shystdshy Chicago 888shy393shy6765 754 755 13457 31059 6211 14335

Union Health Service shyhighshy Chicago area 312shy829shy4224 761 762 12827 29794 5920 13751

United Healthcare of the Midwest shyhighshy Southwest llinois 877shy835shy9861 B91 B92 19353 43374 8932 20019

United Healthcare Plan of the River Valley Inc shyhighshy West Central Illinois 800shy747shy1446 YH1 YH2 13276 37085 6127 17116

44


Primary care



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

Guam

TakeCareshyHigh $20$40 $100day for 5 days $10

HMOP

$15$25$50

OS Nationa

No

l Average 659

642

855

726

855

626

935

895

839

694

876

664

664

563

TakeCareshyStd

Hawaii HMSAshy InshyNetwork

$25$40

$15$15

$150day for 5 days

$100

$15

$7

$20$40$80

$30$65

No

Yes

642

833

726

924

626

91

895

959

694

837

664

941

563

666 HMSAshy OutshyNetwork 3030 30 $7 + 20 $30+20

$65+20 No 833 924 91 959 837 941 666

Kaiser Foundation HP of Hawaii shyHigh $20$20 $100 $15 $15$15 Yes 751 821 797 935 792 853 707

Kaiser Foundation HP of Hawaii shyStd

Idaho

Altius Health PlansshyHigh

$30$30

$20$30

10

$200

$20

$7

$20$20

$25$50

Yes

Yes

751

556

821

86

797

88

935

948

792

817

853

853

707

625

Altius Health PlansshyStd $20$35 None $7 $35$60 Yes 556 86 88 948 817 853 625

Group Health CooperativeshyHigh $25$25 $350day x 3 $20 $40$60 Yes 691 839 844 926 867 896 711

Group Health CooperativeshyStd

Illinois


$25+20$25+20

$20$35

$500day x 3

$250day x 4

$20

$10

$40$60

$35$65

Yes

Yes

691

615

839

826

844

82

926

909

867

866

896

823

711

642

Blue Preferred Plus POS InshyNetwork $25$35 $500 $10 $30$5025 $5025 Yes 718 897 85 915 857 913 659

Blue Preferred Plus POS OutshyNetwork 30 after ded 30 after ded NA NA NA 718 897 85 915 857 913 659

Health Alliance HMOshyHigh $20$30 $2005 days $15 $30$50 Yes 849 897 884 96 927 902 726

Humana BP of Illinois Inc shyHigh $20$35 $250 x 3 $10 $40$60 Yes 606 879 861 954 774 735 719

Humana BP of Illinois Inc shyStd $25$40 $400 X 3 $10 $40$60 Yes 606 879 861 954 774 735 719

Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702

Humana Health Plan Inc shyStd $25$40 $500day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702

Union Health Service shyHigh $15$15 None $15 $30$35 No

UHC of the Midwest Inc shyHigh $25$40 $450 $7 $30$60 Yes 569 863 866 949 815 894 617

UHC Plan of the River Valley Inc shyHigh $20$45 Nothing $10 $35$50 Yes 524 873 853 956 798 886 622

45







Self amp family

Indiana

Aetna Open Access shyhighshy Northern Indiana Area 877shy459shy6604 IK1 IK2 34233 89563 15800 41337

Health Alliance HMO shyhighshy Western Indiana 800shy851shy3379 FX1 FX2 21846 54966 10083 25369

Humana Health Plan Inc shyhighshy LakePorterLaPorte Counties 888shy393shy6765 751 752 29971 68215 13833 31484

Humana Health Plan Inc shystdshy LakePorterLaPorte Counties 888shy393shy6765 754 755 13457 31059 6211 14335

Humana Health Plan Inc shyhighshy Southern Indiana 888shy393shy6765 MH1 MH2 17459 40062 8058 18490

Humana Health Plan Inc shystdshy Southern Indiana 888shy393shy6765 MH4 MH5 13459 31061 6212 14336

Physicians Health Plan of Northern Indiana shyhighshy Northeast Indiana 260shy432shy6690 DQ1 DQ2 19103 42326 8817 19535

Iowa

Coventry Health Care of Iowa shyhighshy CentralEasternWestern Iowa 800shy257shy4692 SV1 SV2 11864 31973 5476 14757

Coventry Health Care of Iowa shystdshy CentralEasternWestern Iowa 800shy257shy4692 SY4 SY5 9243 21722 4266 10026

Health Alliance HMO shyhighshy Central Iowa 800shy851shy3379 FX1 FX2 21846 54966 10083 25369

HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197

HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540

Sanford Health Plan shyhighshy Northwestern Iowa 800shy752shy5863 AU1 AU2 25421 61310 11733 28297

Sanford Health Plan shystdshy Northwestern Iowa 800shy752shy5863 AU4 AU5 22906 55477 10572 25605

UnitedHealthcare Plan of the River Valley Inc shyhighshy Eastern Iowa W Central Illinois 800shy747shy1446 YH1 YH2 13276 37085 6127 17116

Kansas

Aetna Open Access shyhighshy Kansas City Area 877shy459shy6604 HY1 HY2 11817 36274 5454 16742

Coventry Health Care of Kansas shyhighshy Kansas City Metro Area (KS and MO) 800shy969shy3343 HA1 HA2 12196 32723 5629 15103

Coventry Health Care of Kansas shystdshy Kansas City Metro Area (KS and MO) 800shy969shy3343 HA4 HA5 10096 23722 4660 10948

Humana Health Plan Inc shyhighshy Kansas City area 888shy393shy6765 MS1 MS2 45714 103636 21099 47832

Humana Health Plan Inc shystdshy Kansas City area 888shy393shy6765 MS4 MS5 13457 31059 6211 14335

46


Primary care



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

$35$65

OS Nationa

Yes

l Average 659

615

855

826

855

82

935

909

839

866

876

823

664

642


Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702

Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702



Physicians Health Plan of Northern IndianashyHigh

Iowa

Coventry Health Care of IowashyHigh

$15$15

$20$45

20

15

$10

$3$10

$25$50

$40$65

Yes

Yes

583

567

879

857

88

867

952

966

905

824

944

907

603

675

Coventry Health Care of IowashyStd $20$45 20 $3$10 305000Max 305000Max No 567 857 867 966 824 907 675


HealthPartnersshyHigh $25$45 Nothing $12 $45$90 Yes 641 873 897 951 888 912 66

HealthPartnersshyStd $0 for 3 then 20 $0 for 3 then 20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66

Sanford Health Planshy InshyNetwork $20$30 $100day x 5 $15 $30$50 NA 53 831 861 963 905 907 703

Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA NA 53 831 861 963 905 907 703

Sanford Health Planshy InshyNetwork $25$25 $100day x 5 $15 $30$50 No 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA No 53 831 861 963 905 907 703

UHC Plan of the River Valley IncshyHigh

Kansas


$25$45

$20$35

Nothing

$250day x 4

$10

$10

$35$50

$35$65

Yes

Yes

524 873 853 956 798 886 622

Coventry Health Care of KansasshyHigh $20$60 None $3$12 $40$65 Yes 501 871 88 95 853 868 624

Coventry Health Care of KansasshyStd $30$60 None $3$12 $50$75 Yes 501 871 88 95 853 868 624



47





Kentucky

Humana Health Plan Inc shyhighshy Louisville Area 888shy393shy6765 MH1 MH2 17459 40062 8058 18490

Humana Health Plan Inc shystdshy Louisville Area 888shy393shy6765 MH4 MH5 13459 31061 6212 14336

Humana Health Plan Inc shyhighshy Lexington Area 888shy393shy6765 MI1 MI2 13398 30812 6184 14221

Humana Health Plan Inc shystdshy Lexington Area 888shy393shy6765 MI4 MI5 11412 25677 5267 11851

Louisiana

Coventry Health Care of Louisiana shyhighshy New Orleans area 800shy341shy6613 BJ1 BJ2 19017 47855 8777 22087

Coventry Health Care of Louisiana shystdshy New Orleans area 800shy341shy6613 BJ4 BJ5 13035 31308 6016 14450

Maryland

Aetna Open Access shyhighshy NorthernCentralSouthern Maryland Areas 877shy459shy6604 JN1 JN2 33796 76072 15598 35110

Aetna Open Access shybasicshy NorthernCentralSouthern Maryland Areas 877shy459shy6604 JN4 JN5 12446 29128 5744 13444

CareFirst BlueChoice shyhighshy All of Maryland 866shy296shy7363 2G1 2G2 13999 32255 6461 14887

CareFirst BlueChoice Healthy Blue Optionshystdshy All of Maryland 866shy296shy7363 2G4 2G5 12883 28982 5946 13376

Coventry Health Care shyhighshy All of Maryland 800shy833shy7423 IG1 IG2 10806 27119 4987 12516

Coventry Health Care shystdshy All of Maryland 800shy833shy7423 IG4 IG5 10049 25121 4638 11594

Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy BaltimoreWashington DC areas 877shy574shy3337 E31 E32 14800 36835 6831 17001

Kaiser Foundation Health Plan MidshyAtlantic States shystdshy BaltimoreWashington DC areas 877shy574shy3337 E34 E35 8969 20629 4139 9521

MD IPA shyhighshy All of Maryland 877shy835shy9861 JP1 JP2 16579 41260 7652 19043

Massachusetts

Fallon Community Health Plan shybasicshy CentralEastern Massachusetts 800shy868shy5200 JG1 JG2 21173 59490 9772 27457

48


Primary care



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

Kentucky

Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10

HMO

$40$60

POS National

Yes

Average 659 855 855 935 839 876 664

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

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

Humana Health Plan Inc shyStd

Louisiana

Coventry Health Care of LouisianashyHigh

$25$40

$25$45

$500day x 3

$100

$10

$5

$40$60

$40$75

Yes

Yes 579 866 853 964 793 843 677

Coventry Health Care of LouisianashyStd

Maryland


$30$55

$15$30

30

$150day x3

$5

$5

$40$75

$35$65

Yes

Yes

579

659

866

871

853

87

964

918

793

901

843

874

677

667





Coventry Health CareshyHigh $20$40 $200day x 3 $3$15 $30$60 Yes 477 81 811 935 708 818 553

Coventry Health CareshyStd $20$40 $200day x 3 $3$15 $30$60 Yes 477 81 811 935 708 818 553



MD IPAshyHigh

Massachusetts

Fallon Community Health PlanshyBasic

$25$40

$25$35

$150day x 3

$150 to $750max

$7

$10

$30$150$250

$30$60

Yes

Yes

632

61

838

862

871

883

925

95

841

828

90

799

65

627

49




Bluecare Network of MI shyhighshy Traverse City

Bluecare Network of MI shyhighshy Grand Rapids

Bluecare Network of MI shyhighshy East Region

Bluecare Network of MI shyhighshy Southeast Region

Grand Valley Health Plan shyhighshy Grand Rapids area

Grand Valley Health Plan shystdshy Grand Rapids area

Health Alliance Plan shyhighshy Southeastern MichiganFlint area

Health Alliance Plan shystdshy Southeastern MichiganFlint area

HealthPlus MI shyhighshy East Michigan

Physicians Health Plan shystdshy MidshyMichigan

HealthPartners shyhighshy

HealthPartners shystdshy

Aetna Open Access shyhighshy Kansas City Area

Blue Preferred Plus POS shyhighshy St LouisCentralSW areas

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

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

Humana Health Plan Inc shyhighshy Kansas City area

Humana Health Plan Inc shystdshy Kansas City area

United Healthcare of the Midwest shyhighshy St Louis Area

Enrollment Code


Michigan

H61 H62

J31 J32

K51 K52

LX1 LX2

RL1 RL2

RL4 RL5

521 522

GY4 GY5

X51 X52

9U4 9U5

Minnesota

V31 V32

V34 V35

Missouri HY1 HY2

9G1 9G2

HA1 HA2

HA4 HA5

MS1 MS2

MS4 MS5

B91 B92

Telephone Number

800shy662shy6667

800shy662shy6667

800shy662shy6667

800shy662shy6667

616shy949shy2410

616shy949shy2410

800shy556shy9765

800shy556shy9765

800shy332shy9161

866shy539shy3342

952shy883shy5000

952shy883shy5000

877shy459shy6604

888shy811shy2092

800shy969shy3343

800shy969shy3343

888shy393shy6765

888shy393shy6765

877shy835shy9861

50

Monthly


17455 60199

20874 69088

15762 37947

12930 44648

19006 64274

12973 45145

15511 44042

12822 33321

12002 34959

20141 55759

32886 78427

8987 20671

11817 36274

26208 54102

12196 32723

10096 23722

45714 103636

13457 31059

19353 43374

Biweekly


8056 27784

9634 31887

7275 17514

5968 20607

8772 29665

5987 20836

7159 20327

5918 15379

5539 16135

9296 25735

15178 36197

4148 9540

5454 16742

12096 24970

5629 15103

4660 10948

21099 47832

6211 14335

8932 20019


Primary care



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

Bluecare Network of MIshyHigh $15$25 Nothing $5

HMO

$50NA

POS National

Yes

Average 659 855 855 935 839 876 664

Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes

Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes 61 844 87 911 852 887 613


Grand Valley Health PlanshyHigh $10$10 Nothing $5 $15$15 No 796 869 919 939 89 864 778

Grand Valley Health PlanshyStd $20$20 $500 x 3 $10 $40$40 No 796 869 919 939 89 864 778

Health Alliance PlanshyHigh $10$20 Nothing $5 $25$25 Yes 748 876 842 957 849 869 653

Health Alliance PlanshyStd $15$30 Nothing $10 $40$40 Yes

HealthPlus MIshyHigh $10$20 None $8 $40$60 Yes 763 902 904 953 873 90 724

Physicians Health PlanshyStd

Minnesota

HealthPartnersshyHigh

$20Nothing

$25$45

20

Nothing

$15

$12

$25$50

$45$90

Yes

Yes

774

641

906

873

886

897

964

951

893

888

887

912

69

66

HealthPartnersshyStd

Missouri Aetna Open AccessshyHigh $20$35

$0 for 3 then 20 $0 for 3 then 20 20 in40 out

$250day x 4

$9

$10

$40$70

$35$65

Yes

Yes

641 873 897 951 888 912 66


Blue Preferred Plus POS OutshyNetwork 30 after ded 30 after ded 30 after ded NA NA NA NA 718 897 85 915 857 913 659

Coventry Health Care of KansasshyHigh $20$60 20 $3$12 $40$65 Yes 501 871 88 95 853 868 624

Coventry Health Care of KansasshyStd $30$60 20 $3$12 $50$75 Yes 501 871 88 95 853 868 624



United Healthcare of the Midwest IncshyHigh $25$40 $450 $7 $30$60 Yes 569 863 866 949 815 894 617

51


Aetna Open Access shyhighshy Clark County and Las Vegas areas

Health Plan of Nevada shyhighshy Las Vegas area




Self Self amp Self Self amp Self Self amp only family only family only family

Nevada

HF1 HF2 10582 33646 4884 15529

NM1 NM2 10448 24635 4822 11370

Telephone Number

877shy459shy6604

800shy777shy1840

New Jersey

Aetna Open Access shyhighshy Northern New Jersey 877shy459shy6604 JR1 JR2 41628 98562 19213 45490

Aetna Open Access shybasicshy Northern New Jersey 877shy459shy6604 JR4 JR5 24416 59488 11269 27456

Aetna Open Access shyhighshy Southern NJ 877shy459shy6604 P31 P32 62387 157861 28794 72859

Aetna Open Access shybasicshy Southern NJ 877shy459shy6604 P34 P35 33995 81655 15690 37687

GHI Health Plan shyhighshy Northern New Jersey 212shy501shy4444 801 802 25441 74455 11742 34364

GHI Health Plan shystdshy Northern New Jersey 212shy501shy4444 804 805 11681 27270 5391 12586

New Mexico

Lovelace Health Plan shyhighshy All of New Mexico 800shy808shy7363

Presbyterian Health Plan shyhighshy All counties in New Mexico 800shy356shy2219

52

Q11 Q12 22873 58561 10557 27028

P21 P22 17370 41076 8017 18958


Primary care



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

Nevada


HMO

$35$65

POS National

Yes

Average 659 855 855 935 839 876 664

Health Plan of NevadashyHigh

New Jersey


$10$20

$20$35

$150

$150day x 5

$5

$10

$35$55

$35$65

Yes

Yes

567

617

709

855

706

886

898

937

78

852

845

861

561

605


Aetna Open AccessshyHigh $20$35 $150day x 5 $10 $35$65 Yes 729 89 91 948 902 902 741


GHI Health Planshy InshyNetwork $15$15 $100 $15 $25$50 Yes 604 856 861 926 763 772 572 GHI Health Planshy OutshyNetwork +50 of sch +50 of sch NA NA NA No 604 856 861 926 763 772 572

GHI Health PlanshyStd

New Mexico

Lovelace Health PlanshyHigh

$25$25

$20$35

$250day x 3

$250 after ded

$5

$5

$25$50

$35$6050

Yes

Yes

604

623

856

807

861

786

926

896

763

807

772

862

572

746

Presbyterian Health PlanshyHigh $25$35 $100 x 5 days $10 $40$7525 Yes 653 831 814 918 823 876 673

53





New York Aetna Open Access shyhighshy NYC AreaUpstate NY 877shy459shy6604 JC1 JC2 32251 88675 14885 40927

Aetna Open Access shybasicshy NYC AreaUpstate NY 877shy459shy6604 JC4 JC5 18521 53023 8548 24472

Blue Choice shyhighshy Rochester area 800shy462shy0108 MK1 MK2 22050 54639 10177 25218

Blue Choice shystdshy Rochester area 800shy462shy0108 MK4 MK5 13332 43643 6153 20143

CDPHP Universal Benefits shyhighshy Upstate Hudson Valley Central New York 877shy269shy2134 SG1 SG2 17270 55893 7971 25797

CDPHP Universal Benefits shystdshy Upstate Hudson Valley Central New York 877shy269shy2134 SG4 SG5 10761 27761 4966 12813

GHI HMO shyhighshy BrnxBrklynManhatQueenRichmonWestche 877shy244shy4466 6V1 6V2 37834 109100 17462 50354

GHI HMO shyhighshy CapitalHudson Valley Regions 877shy244shy4466 X41 X42 27148 80953 12530 37363

GHI Health Plan shyhighshy All of New York 212shy501shy4444 801 802 25441 74455 11742 34364

GHI Health Plan shystdshy Most of New York City 212shy501shy4444 804 805 11681 27270 5391 12586

HIP of Greater New York shyhighshy New York City area 800shyHIPshyTALK 511 512 20414 70973 9422 32757

HIP of Greater New York shystdshy New York City area 800shyHIPshyTALK 514 515 13724 53244 6334 24574

Independent Health Assoc shyhighshy Western New York 800shy501shy3439 QA1 QA2 14928 48169 6890 22232

MVP Health Care shyhighshy Eastern Region 888shy687shy6277 GA1 GA2 13362 43962 6167 20290

MVP Health Care shystdshy Eastern Region 888shy687shy6277 GA4 GA5 11930 29849 5506 13776

MVP Health Care shyhighshy Western Region 888shy687shy6277 GV1 GV2 13096 41303 6044 19063

MVP Health Care shystdshy Western Region 888shy687shy6277 GV4 GV5 11424 28584 5273 13192

MVP Health Care shyhighshy Central Region 888shy687shy6277 M91 M92 16048 51079 7407 23575

MVP Health Care shystdshy Central Region 888shy687shy6277 M94 M95 12526 35596 5781 16429

MVP Health Care shyhighshy Northern Region 888shy687shy6277 MF1 MF2 23939 70828 11049 32690

MVP Health Care shystdshy Northern Region 888shy687shy6277 MF4 MF5 16701 52700 7708 24323

MVP Health Care shyhighshy MidshyHudson Region 888shy687shy6277 MX1 MX2 16902 53174 7801 24542

MVP Health Care shystdshy MidshyHudson Region 888shy687shy6277 MX4 MX5 12638 36569 5833 16878

54


Primary care



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 Aetna Open AccessshyHigh $20$35 $150day x 5 $10

HMO

$35$65

POS National

Yes

Average 659

651

855

828

855

853

935

927

839

873

876

875

664

60


Blue ChoiceshyHigh $20$20 $240 $10 $30$100 No 724 921 924 947 86 931 71

Blue ChoiceshyStd $25$40 $500 $7 $50$100 No 724 921 924 947 86 931 71

CDPHP Universal Benefits IncshyHigh $20$30 $100 x 5 25 2525 No 71 911 882 957 909 903 739

CDPHP Universal Benefits IncshyStd $25$40 $500+10 30 3030 No 71 911 882 957 909 903 739

GHI HMO SelectshyHigh $25$40 $500 $10 $30$50 Yes 513 806 859 945 814 817 65



GHI Health PlanshyStd $25$25 $250day x 3 $5 $25$50 Yes 604 856 861 926 763 772 572

HIP of Greater New YorkshyHigh $10$20 None $15 $30$50 Yes 701 843 813 898 79 844 561

HIP of Greater New YorkshyStd $20$40 $500 $15 $30$50 Yes 701 843 813 898 79 844 561

Independent Health Assocshy InshyNetwork $20$20 $250 $10 $20$35 No 741 905 915 953 892 935 784 Independent Health Assocshy OutshyNetwork 2525 25 NA NA NA No 741 905 915 953 892 935 784

MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786

MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786









55





North Dakota



Heart of America Health Plan shyhighshy Northcentral North Dakota 800shy525shy5661 RU1 RU2 11236 28876 5186 13327

Ohio

AultCare HMO shyhighshy StarkCarrollHolmesTuscarawasWayne Co 330shy363shy6360 3A1 3A2 17728 52557 8182 24257

HMO Health Ohio shyhighshy Northeast Ohio 800shy522shy2066 L41 L42 36224 89930 16719 41506

Kaiser Foundation Health Plan of Ohio shyhighshy ClevelandAkron areas 800shy686shy7100 641 642 25023 60344 11549 27851

Kaiser Foundation Health Plan of Ohio shystdshy ClevelandAkron areas 800shy686shy7100 644 645 10804 24849 4986 11469

The Health Plan of the Upper Ohio Valley shyhighshyEastern Ohio 800shy624shy6961 U41 U42 15195 35529 7013 16398

Oklahoma

Globalhealth Inc shyhighshy Oklahoma 877shy280shy2990 IM1 IM2 9779 23566 4513 10877

Oregon

Kaiser Foundation Health Plan of Northwest shyhighshy PortlandSalem areas 800shy813shy2000 571 572 20921 48379 9656 22329

Kaiser Foundation Health Plan of Northwest shystdshy PortlandSalem areas 800shy813shy2000 574 575 11677 26824 5389 12380

56


Primary care



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 Dakota

HealthPartnersshyHigh $25$45 Nothing $12

HMO

$45$90

POS National

Yes

Average 659

641

855

873

855

897

935

951

839

888

876

912

664

66

HealthPartnersshyStd $0 for 3 then20 $0 for 3 then20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66

Heart of America Health PlanshyHigh InshyNetwork $15$25 None 50 5050 None Heart of America Health PlanshyHigh OutshyNetwork

Ohio

AultCare HMOshyHigh

2020

$15$20

20

$150

NA

$15

NA

$30$45

NA

No 865 935 926 946 946 958 863

HMO Health OhioshyHigh $20$20 $250 $20 $30$40 Yes 679 871 875 961 84 912 701

Kaiser Foundation HP of OhioshyHigh $20$20 $250 $10 $30$30 Yes 736 857 85 907 835 858 724

Kaiser Foundation HP of OhioshyStd $30$40 $500 $15 $40$40 Yes 736 857 85 907 835 858 724

The Health Plan of the Upper Ohio ValleyshyHigh

Oklahoma

Globalhealth IncshyHigh

Oregon

Kaiser Foundation HP of NorthwestshyHigh

$10$20

$15$35

$15$25

$250

$150day x 3

$200

$15

$10

$15

$30$50

$30$40

$40$40

Yes

Yes

Yes

739

56

677

905

731

769

89

812

778

963

941

893

927

715

864

957

883

848

758

626

679

Kaiser Foundation HP of NorthwestshyStd $25$35 $500 $20 $40$40 Yes 677 769 778 893 864 848 679

57





Pennsylvania

Aetna Open Access shyhighshy Philadelphia 800shy392shy9137 P31 P32 62387 157861 28794 72859

Aetna Open Access shybasicshy Philadelphia 800shy392shy9137 P34 P35 33995 81655 15690 37687

Aetna Open Access shyhighshy Pittsburgh and Western PA Areas 877shy459shy6604 YE1 YE2 12215 37849 5638 17469

Geisinger Health Plan shystdshy NortheasternCentralSouth Central areas 800shy447shy4000 GG4 GG5 24219 58498 11178 26999

HealthAmerica Pennsylvania shyhighshy Greater Pittsburgh area 866shy351shy5946 261 262 16956 44653 7826 20609

HealthAmerica Pennsylvania shystdshy Central Pennsylvania 866shy351shy5946 SW4 SW5 15645 35977 7221 16605

UPMC Health Plan shyhighshy Western Pennsylvania 888shy876shy2756 8W1 8W2 19435 47493 8970 21920

UPMC Health Plan shystdshy Western Pennsylvania 888shy876shy2756 UW4 UW5 15251 37871 7039 17479

Puerto Rico Humana Health Plans of Puerto Rico Inc shyhighshy Puerto Rico 800shy314shy3121 ZJ1 ZJ2 8177 18399 3774 8492

TripleshyS Salud Inc shyhighshy All of Puerto Rico 787shy774shy6060 891 892 8389 18875 3872 8712

South Dakota



Sanford Health Plan shyhighshy EasternCentralRapid City Areas 800shy752shy5863 AU1 AU2 25421 61310 11733 28297

Sanford Health Plan shystdshy EasternCentralRapid City Areas 800shy752shy5863 AU4 AU5 22906 55477 10572 25605

Tennessee

Aetna Open Access shyhighshy Memphis Area 877shy459shy6604 UB1 UB2 15845 53244 7313 24574

Humana Health Plan Inc shyhighshy Knoxville 888shy393shy6765 GJ1 GJ2 13459 31061 6212 14336

Humana Health Plan Inc shystdshy Knoxville 888shy393shy6765 GJ4 GJ5 11479 25828 5298 11921

58


Primary care



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

Pennsylvania


HMO

$35$65

POS National

Yes

Average 659

567

855

873

855

885

935

946

839

752

876

886

664

682



Geisinger Health PlanshyStd $20$35 20aftrDeduct 30 $5$15 40 $40$12050 $60$180 Yes 704 889 899 959 841 896 713

HealthAmerica PennsylvaniashyHigh $25$50 15 $5 $35$60 Yes 695 864 888 946 836 919 709

HealthAmerica PennsylvaniashyStd $25$50 15 $5 $35$60 Yes 695 864 888 946 836 919 709

UPMC Health PlanshyHigh $20$35 None $5 $35$70 Yes 764 903 871 959 87 885 716

UPMC Health PlanshyStd

Puerto Rico Humana HP of Puerto Rico shy InshyNetwork

$20$35

$5$5

None

None

$5

$250

$35$70

$10$15

Yes

Yes

764

753

903

807

871

815

959

936

87

834

885

811

716

591 Humana HP of Puerto Rico shy OutshyNetwork $10$10 $50 NA NA NA No 753 807 815 936 834 811 591

TripleshyS Salud Incshy InshyNetwork $750$10 None $5 or $12 Greater of $15 or 20

25 up to $100$175 max Yes 716 857 796 968 683 695 514 TripleshyS Salud Incshy OutshyNetwork

South Dakota


$750+10$10+10

$25$45

10 +

Nothing

NA

$12

NA NA

$45$90

No

Yes

716

641

857

873

796

897

968

951

683

888

695

912

514

66

HealthPartnersshyStd $0 for 3 then20 $0 for 3 then 20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66

Sanford Health Planshy InshyNetwork $20$30 $100day x 5 $15 $30$50 NA 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA NA 53 831 861 963 905 907 703

Sanford Health Planshy InshyNetwork $25$25 $100day x 5 $15 $30$50 No 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork

Tennessee


4040

$20$35

40

$250day x 4

NA

$10

NA NA

$35$65

No

Yes

53

639

831

877

861

842

963

936

905

85

907

919

703

708

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

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

59





Texas

Aetna Open Access shyhighshy Austin and San Antonio Areas 877shy459shy6604 P11 P12 34790 99255 16057 45810

Firstcare shyhighshy West Texas 800shy884shy4901 CK1 CK2 12270 57475 5663 26527

Humana Health Plan of Texas shyhighshy Corpus Christi 888shy393shy6765 UC1 UC2 18345 42055 8467 19410

Humana Health Plan of Texas shystdshy Corpus Christi 888shy393shy6765 UC4 UC5 13459 31059 6212 14335

Humana Health Plan of Texas shyhighshy San Antonio 888shy393shy6765 UR1 UR2 44696 101346 20629 46775

Humana Health Plan of Texas shystdshy San Antonio 888shy393shy6765 UR4 UR5 13457 31059 6211 14335

Humana Health Plan of Texas shyhighshy Austin 888shy393shy6765 UU1 UU2 19558 44783 9027 20669

Humana Health Plan of Texas shystdshy Austin 888shy393shy6765 UU4 UU5 13459 31061 6212 14336

UnitedHealthcare Benefits of Texas Inc shyhighshy San Antonio 866shy546shy0510 GF1 GF2 19474 47638 8988 21987

Utah

Altius Health Plans shyhighshy Wasatch Front 800shy377shy4161 9K1 9K2 19786 42302 9132 19524

Altius Health Plans shystdshy Wasatch Front 800shy377shy4161 DK4 DK5 10651 23431 4916 10814

SelectHealth shyhighshy Urban and Suburban Utah 800shy538shy5038 SF1 SF2 21966 47129 10138 21752

Virgin Islands

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

Virginia Aetna Open Access shyhighshy NorthernCentralRichmond Virginia Areas 877shy459shy6604 JN1 JN2 33796 76072 15598 35110

Aetna Open Access shybasicshy NorthernCentralRichmond Virginia Areas 877shy459shy6604 JN4 JN5 12446 29128 5744 13444

CareFirst BlueChoice shyhighshy Northern Virginia 866shy296shy7363 2G1 2G2 13999 32255 6461 14887

CareFirst BlueChoice Healthy Blue Optionshystdshy Northern Virginia 866shy296shy7363 2G4 2G5 12883 28982 5946 13376

Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy Northern VirginiaFredericksburg area 877shy574shy3337 E31 E32 14800 36835 6831 17001

Kaiser Foundation Health Plan MidshyAtlantic States shystdshy Northern VirginiaFredericksburg area 877shy574shy3337 E34 E35 8969 20629 4139 9521

MD IPA shyhighshy NVACntrl VARichmond 877shy835shy9861 JP1 JP2 16579 41260 7652 19043

Optima Health Plan shyhighshy Hampton Roads and Richmond areas 800shy206shy1060 9R1 9R2 16681 44919 7699 20732

Optima Health Plan shystdshy Hampton Roads and Richmond areas 800shy206shy1060 9R4 9R5 9333 22083 4307 10192

Piedmont Community Healthcare shyhighshy Lynchburg area 888shy674shy3368 2C1 2C2 12771 29243 5894 13497

60


Primary care



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

$35$65

OS Nationa

Yes

l Average 659

698

855

833

855

793

935

896

839

829

876

886

664

652

FirstcareshyHigh $20$55 $200day x 5 $15 $35$65 No 597 846 875 946 781 865 637

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

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

Humana Health Plan of TexasshyHigh $20$35 $250day x 3 $10 $40$60 Yes 587 86 795 91 805 87 621

Humana Health Plan of TexasshyStd $25$40 $500day x 3 $10 $40$60 Yes 587 86 795 91 805 87 621



UnitedHealthcare Benefits of TexasshyHigh

Utah


$20$40

$20$30

$250day x 5

$200

$10

$7

$35$60

$25$50

Yes

Yes

654

556

864

86

842

88

936

948

797

817

905

853

646

625


SelectHealthshyHigh

Virgin Islands

TripleshyS Salud Incshy InshyNetwork

$15$25

$750$10

$100

None

$5

$5 or $12

$2550

Greater of $15 or 20 25 up to $100$175 ma

NA

Yes x

553 834 823 93 935 92 712

TripleshyS Salud Incshy OutshyNetwork $750 amp 10+ 10+ NA NANA No

Virginia Aetna Open AccessshyHigh $15$30

$10 amp 10+

$150day x3 $5 $35$65 Yes 659 871 87 918 901 874 667



CareFirst BlueChoiceshyHigh InshyNetwork Nothing$35 $200 Nothing $30$50 Yes

CareFirst BlueChoiceshyHigh OutshyNetwork $70$70 $500 Nothing $30$50 Yes

Kaiser Foundation HPshyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716

Kaiser Foundation HPshyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716

MD IPAshyHigh $25$35 $150day x 3 $7 $25$150$250 Yes 632 838 871 925 841 90 65

Optima Health PlanshyHigh $15$0 childlt13$30 $200 $10 $25$50$75 Yes 689 90 849 934 917 933 719

Optima Health PlanshyStd $20$30 None $5 $2550up to $3000 No 689 90 849 934 917 933 719

Piedmont Community HCshyHigh $35$35 20 $15 $30$55 Yes

61





Washington

Group Health Cooperative shyhighshyWestern WACentral WASpokanePullman 888shy901shy4636 541 542 19699 39110 9092 18051

Group Health Cooperative shystdshy Western WACentral WASpokanePullman 888shy901shy4636 544 545 9559 21579 4412 9959

KPS Health Plans shystdshy All of Washington 800shy552shy7114 L11 L12 10650 22988 4915 10610

KPS Health Plans shyhighshy All of Washington 800shy552shy7114 VT1 VT2 26338 55718 12156 25716

Kaiser Foundation Health Plan of Northwest shyhighshy VancouverLongview 800shy813shy2000 571 572 20921 48379 9656 22329

Kaiser Foundation Health Plan of Northwest shystdshy VancouverLongview 800shy813shy2000 574 575 11677 26824 5389 12380

West Virginia

The Health Plan of the Upper Ohio Valley shyhighshy NorthernCentral West Virginia 800shy624shy6961 U41 U42 15195 35529 7013 16398

Wisconsin

Dean Health Plan shyhighshy South Central Wisconsin 800shy279shy1301 WD1 WD2 15028 48410 6936 22343

Group Health Cooperative shyhighshy South Central Wisconsin 608shy828shy4827 WJ1 WJ2 12504 35304 5771 16294



MercyCare HMO shyhighshy South Central Wisconsin 800shy895shy2421 EY1 EY2 12765 37875 5891 17481

Physicians Plus shyhighshy Dane County 800shy545shy5015 LW1 LW2 12539 38142 5787 17604

Wyoming

Altius Health Plans shyhighshy Uinta County 800shy377shy4161 9K1 9K2 19786 42302 9132 19524

Altius Health Plans shystdshy Uinta County 800shy377shy4161 DK4 DK5 10651 23431 4916 10814

62


Primary care



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

Washington

Group Health CooperativeshyHigh $25$25 $350day x 3 $20

HMOP

$40$60

OS National

Yes

Average 659

691

855

839

855

844

935

926

839

867

876

896

664

711

Group Health CooperativeshyStd $25+20 $25+20 $500day x 3 $20 $40$60 Yes 691 839 844 926 867 896 711

KPS Health Plansshy InshyNetwork $153 or 2020 Nothing $10 $3550

$40 max $100 Yes 775 934 929 948 91 937 718 KPS Health Plansshy OutshyNetwork $153 +40+diff

40+diff Nothing Not Covered Not Covered No 775 934 929 948 91 937 718

KPS Health Plansshy InshyNetwork $30$30 None $5 $2550 or $100 Yes 775 934 929 948 91 937 718 KPS Health Plansshy OutshyNetwork $30+40+diff

$30+40+diff None Not covered NA NA No 775 934 929 948 91 937 718

Kaiser Foundation HP of NorthwestshyHigh $15$25 $200 $15 $40$40 Yes 677 769 778 893 864 848 679

Kaiser Foundation HP of NorthwestshyStd

West Virginia

The HP of the Upper Ohio ValleyshyHigh

Wisconsin

Dean Health PlanshyHigh

$25$35

$10$20

$10$10

$500

$250

None

$20

$15

$10

$40$40

$30$50

30$75max30

Yes

Yes

No

677

739

77

769

905

871

778

89

883

893

963

962

864

927

854

848

957

921

679

758

689

Group Health CooperativeshyHigh $10 $10 None $5 $20$20 Yes 796 788 847 961 893 916 756



MercyCare HMOshyHigh $10$10 Nothing $10 $20$50 Yes

Physicians PlusshyHigh

Wyoming


$10$10

$20$30

Nothing

$200

$10

$7

3050

$25$50

No

Yes

766

556

86

86

889

88

95

948

901

817

912

853

723

625


63


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 often covered in full usually with no or only a small deductible or copayment Preventive care expenses may also be payable up to an annual maximum dollar amount (up to $300 for instance) 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 $1200 for Self and $2400 for Family coverage) and annual outshyofshypocket limits (not to exceed $6050 for Self and $12100 for 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 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 HSArsquos are subject to a number of rules and limitations established by the Department of the Treasury

Visit wwwustreasgovofficespublicshyaffairshsa for more information The 2012 maximum contribution limits are $3100 for Self Only coverage and $6250 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

64



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

65



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

66



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

67



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 shyCDHP shy Nationwide

GEHA High Deductible Health Plan shyHDHP shy Nationwide

MHBP Consumer Option shyHDHPshy Nationwide

866shy833shy3463

800shy821shy6136

800shy694shy9901

474 475

341 342

481 482

8923 20072

9996 22832

11557 26186

4118 9264

4614 10538

5334 12086

68



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 Drugs are catagorized using a variety of terms to define what you pay such as generic brand Level I Level II Tier I Tier II etc In capturing these differences we use the following Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs The level in which a medication is placed and what you pay for prescription drugs is often based on what the plan is charged

High Deductible Health Plans and Consumer Driven 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 Planshy InshyNetwork $1200$2400 $600$1200 $3000$4500 15 None 15 Nothing 252525 APWU Health Planshy OutshyNetwork $1200$2400 $600$1200 $9000$9000 40+diff None 40+diff Nothing up to $1200 Not Covered

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

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

69

High Deductible Health Plans and ConsumershyDriven Health Plan Member Survey Results




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





High Deductible Health Plans Plan Name


Plan Code


Getting needed care


How well doctors


Claims processing


HDHP National Average 592 863 885 931 85 889 577

Aetna Health Fund shy Nationwide

GEHA High Deductible Health Plan shy Nationwide

MHBP Consumer Option shy Nationwide

22

34

48

60

637

54

856

864

868

893

885

877

935

923

936

859

852

839

90

876

892

592

593

547

ConsumershyDriven Health Plans Plan Name

Plan Code


Getting needed care


How well doctors


Claims processing


CDHP National Average 577 849 868 929 833 867 619


APWU Health Fund shy Nationwide

Humana Coverage First shyTX

22

47

TU TV

60

643

489

856

884

806

893

868

841

935

924

929

859

803

839

90

809

891

592

657

609

70


71

A Aetna HealthFundshy

High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages

The Aetna Healthfund is available in all or part of the following states AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS


Plan Name

Telephone Number


Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Aetna HealthFund shyCDHP

Aetna HealthFund shyHDHP

877shy459shy6604

877shy459shy6604

221 222

224 225

15604 37056

9412 20613

7202 17103

4344 9514


Florida

Coventry Health Care of Flordia shyHDHPshySouthern Florida

Humana CoverageFirst shyCDHPshy Tampa Area

Humana CoverageFirst shyCDHPshy South Florida Area

Georgia Humana CoverageFirst shyCDHPshy Atlanta Area

Humana CoverageFirst shyCDHPshy Macon Area

Guam TakeCare shyHDHPshy GuamN Mariana IslandsBelau (Palau)

Idaho

Altius Health Plans shyHDHPshy Southern Region

Plan Name

800shy441shy5501

888shy393shy6765

888shy393shy6765

888shy393shy6765

888shy393shy6765

671shy647shy3526

800shy377shy4161

Telephone Number


J41

MJ1

QP1

AD1

LM1

KX1

9K4

Self only

J42

MJ2

QP2

AD2

LM2

KX2

9K5

Self amp family

11570

12685

10873

11477

11840

8138

8704

Self only

28710

28542

24465

25824

26639

21442

18033

Self amp family

5340

5855

5018

5297

5464

3756

4017

Self only

13251

13173

11291

11919

12295

9896

8323

Self amp family

72

OutshyNetwork $833316666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+

MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV and WY

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 HealthFundshy InshyNetwork $833316666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFundshy OutshyNetwork $833316666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+

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

Benefit Type


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Florida

Coventry Health Care of Florida

Plan Name

$8334$16667 $2500$5000 $5000$10000 $10 20 20 Nothing $5$35$5020

Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60

Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+


Humana CoverageFirstshy

Georgia Humana CoverageFirstshy

OutshyNetwork

InshyNetwork

NA

$8333

$3000$6000

$1000$2000

$4000$8000

$3000$6000

30

$25

30

$300day x 5

30

$150

30

Nothing

$10+$40+$60+

$10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+

Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy

Guam TakeCareshy

OutshyNetwork

InshyNetwork

NA

$8666$22208

$3000$6000

$3000$6000

$4000$8000

$5000$10000

30

20afterDed

30

20 after Ded

30

20 after Ded

30

Nothing

$10+$40+$60+

$20$40$150 TakeCareshy

Idaho

Altius Health Plans

OutshyNetwork $8666$22208

$4583$9166

$3000$6000

$1200$2400

$10000$20000

$5000$10000 $20

30 afterDed

10

30 after Ded 30 after Ded

10

1st $300ded

Nothing

30 after Ded

$7$25$50

73



Illinois Humana CoverageFirst shyCDHPshy CentralNorthwestern Illinois

Humana CoverageFirst shyCDHPshy Chicago Area

Indiana Humana CoverageFirst shyCDHPshy LakePorterLaPorte Counties

Iowa Coventry Health Care of Iowa shyHDHPshy CentralEasternWestern Iowa

Kansas Coventry Health Care of Kansas (Kansas City)shyHDHPshy

Kansas City Metro Area (KS and MO)

Humana CoverageFirst shyCDHPshy Kansas City Area

Kentucky Humana CoverageFirst shyCDHPshy Lexington Area

Maryland Coventry Health Care shyHDHPshy All of Maryland

Plan Name

888shy393shy6765

888shy393shy6765

888shy393shy6765

800shy257shy4692

800shy969shy3343

888shy393shy6765

888shy393shy6765

800shy833shy7423

Telephone Number


GB1

MW1

MW1

SV4

9H1

PH1

6N1

GZ1

Self only

GB2

MW2

MW2

SV5

9H2

PH2

6N2

GZ2

Self amp family

12685

12081

12081

8608

9721

10873

10064

9834

Self only

28542

27182

27182

20544

22845

24464

22644

22508

Self amp family

5855

5576

5576

3973

4486

5018

4645

4539

Self only

13173

12546

12546

9482

10544

11291

10451

10388

Self amp family

74

Premium Benefit CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Contribution Type SelfFamily SelfFamily Visit Hospital Surgery Services Drugs to HSAHRA Levels I II III Plan Name

Illinois Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+

Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+

Indiana Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+

Iowa Coventry Health Care of Iowa $6667$13334 $2000$4000 $5000$10000 $20 15 15 Nothing $3$10$40$65

Kansas Coventry Health Care of Kansas (Kansas City)shyHDHP $6666$13333 $2500$5000 $3500$7000 20 20 20 Nothing Nothing


Kentucky Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+

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

75

A



Missouri Coventry Health Care of Kansas (Kansas City)shyHDHPshy



New York Independent Health Assoc shyHDHPshy Western New York

Ohio AultCare HMO shyHDHPshy StarkCarrollHolmesTuscarawasWayne Co

Pennsylvania

HealthAmerica PennsylvaniashyHDHPshy Greater Pittsburgh Area

HealthAmerica PennsylvaniashyHDHPshy Central Pennsylvania

UPMC Health Plan shyHDHPshy Western Pennsylvania

Texas Humana CoverageFirst shyCDHPshy Corpus Christi Area

Humana CoverageFirst shyCDHPshy San Antonio Area

Humana CoverageFirst shyCDHPshy Austin Area

Plan Name

800shy969shy3343

888shy393shy6765

800shy501shy3439

330shy363shy6360

866shy351shy5946

866shy351shy5946

888shy876shy2756

888shy393shy6765

888shy393shy6765

888shy393shy6765

Telephone Number


9H1

PH1

QA4

3A4

Y61

YW1

8W4

TP1

TU1

TV1

Self only

9H2

PH2

QA5

3A5

Y62

YW2

8W5

TP2

TU2

TV2

Self amp family

9721

10873

9633

7760

11914

14046

11884

11840

12081

12284

Self only

22845

24464

24717

15548

27430

30756

26620

26640

27182

27639

Self amp family

4486

5018

4446

3581

5499

6483

5485

5464

5576

5669

Self only

10544

11291

11408

7176

12660

14195

12286

12295

12546

12756

Self amp family

76


Missouri Coventry Health Care of Kansas (Kansas City)shyHDHP $6666$13333 $2500$5000 $3500$7000 20 20 20 $20$350 Nothing


New York Independent Health Assocshy InshyNetwork $6641$16667 $2000$4000 $5000$10000 $15 Nothing 20 $15 $7$25$40 Independent Health Assocshy OutshyNetwork $6641$16667 $2000$4000 $5000$10000 40 40 40 Ded40 NA

Ohio AultCare HMOshy InshyNetwork $7458$14958 $2000$4000 $4000$8000 20 20 20 Nothing 202020 AultCare HMOshy OutshyNetwork $7458$14958 $4000$8000 $8000$16000 40 UCR 40 UCR 40 UCR 50 UCR 404040

Pennsylvania

HealthAmerica PennsylvaniashyHDHP $5209$10417 $1500$3000 $4000$8000 $15 None Nothing $15$25 $5$35$50

HealthAmerica PennsylvaniashyHDHP $5209$10417 $1500$3000 $4000$8000 $15 None Nothing Nothing $5$35$50

UPMC Health Planshy InshyNetwork $10417$20834 $2500$5000 $4000$8000 Nothingafter ded None Nothingafterded Nothing $5$35$70

UPMC Health Planshy OutshyNetwork $10417$20834 $2500$5000 $5500$11000 20afterded 20afterded 20afterded 20 NA

Texas Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+



77



Utah Altius Health Plans shyHDHPshy Wasatch Front

Washington KPS Health Plans shyHDHPshy All of Washington

Wyoming

Altius Health Plans shyHDHPshy Uinta County

Plan Name

800shy377shy4161

800shy552shy7114

800shy377shy4161

Telephone Number


9K4

L14

9K4

Self only

9K5

L15

9K5

Self amp family

8704

9545

8704

Self only

18033

20857

18033

Self amp family

4017

4405

4017

Self only

8323

9626

8323

Self amp family

78


Utah Altius Health Plans $4583$9166 $1200$2400 $5000$10000 $20 10 10 Nothing $7$25$50

Washington $10$3550

KPS Health Plansshy InshyNetwork $6250$125 $1500$3000 $5000$10000 20 None 20 Nothingup to $400 $40 max $100 KPS Health Plansshy OutshyNetwork $6250$125 $1500$3000 $5000$10000 40 None 40 Not Covered Not Covered

Wyoming

Altius Health Plans $4583$9166 $1200$2400 $5000$10000 $20 10 10 Nothing $7$25$50

79


80

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

81

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 will 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 24 month waiting period for orthodontic benefits This means that you must be covered continuously by the same plan and option for 24 months before your child is eligible for orthodontic coverage

82

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

83

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 wwwopmgovinsuredentalrates 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 wwwopmgovinsurevisionrates 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 24shymonth waiting period for children up to age 19

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

84

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 wwwaetnafedscom

0 40 60 70 $0 $3000 per year per person shy inshynetwork $2000 per year per person shy outshyofshynetwork $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services

Aetna High (OutshyofshyNetwork Benefits)

0 40 60 70 $0

GEHA Standard (InshyNetwork Benefits)

1shy877shy434shy2336 wwwgehadentalcom

0 45 65 50 $0 $5000 per year per person (high option) or $1200 per year per person (standard option) per person $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services

GEHA Standard (OutshyofshyNetwork Benefits)

0 45 65 50 $0

GEHA High (InshyNetwork Benefits)

0 20 50 50 $0

GEHA High (OutshyofshyNetwork Benefits)

0 20 50 50 $0

MetLife Standard (InshyNetwork Benefits)

1shy888shy865shy6854 wwwfederaldentalmetlifecom

0 45 65 50 $0 $1200 standard option inshynetwork annual nonshyorthodontic maximum per person $1500 standard option inshynetwork lifetime max per person for orthodontics $600 standard option outshynetwork annual nonshyorthodontic maximum

MetLife Standard (OutshyofshyNetwork Benefits)

40 60 80 50 $100person per person $1000 standard option outshyofshynetwork lifetime max per person for orthodontics $10000 high option inshynetwork annual nonshyorthodontic maximum

MetLife High (InshyNetwork Benefits)

0 30 50 50 $0 per person $3500 high option inshynetwork lifetime max per person for orthodontics $10000 high option outshyofshynetwork annual nonshyorthodontic maximum per person

MetLife High (OutshyofshyNetwork Benefits)

10 40 60 50 $50person $3500 high option outshyofshynetwork lifetime max per person for orthodontics There is no calendar year deductible for Class D services 24shymonth waiting period for orthodontia services

United Concordia High (InshyNetwork Benefits)

1shy877shy438shy8224 (Open Season) 1shy877shy394shy8224 (General)

wwwuccifedvipcom

0 20 50 50 $0 $3500 per year per person $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services

United Concordia High (OutshyofshyNetwork Benefits)

20 (0 for Dental Accident Services)

40 60 50 $0

Please Note OutshyofshyNetwork Benefits ndash members are responsible for paying the difference between the planrsquos payment and the nonshynetwork providerrsquos billed charges

85


Regional Dental Plans Only Open to Persons Living in Specific Geographic Areas


Plan Name

Telephone amp

Website

Class A

Class B

Class C

Class D Deductible

Humana High 1shy877shy692shy2468 0 Flat Flat Flat $0 $10000 per year per person (Open to residents of wwwfedshumanacom Rate Rate Rate Unlimited lifetime orthodontic coverage the Southeastern Outshyofshynetwork benefits NOT provided Midwestern and Approx Approx Approx No waiting period for orthodontic services MidshyAtlantic states) 25 35 50

GHI High 212shy501shy4444 0 0 0 0 $0 $2500 per year per person (Inshynetwork benefits) wwwghicom $2000 lifetime max per person

(orthodontic services only) (Open to NY and Northern Outshyofshynetwork benefits available ndash NJ residents and parts of paid at the same inshynetwork rate CT and PA) 12shymonth waiting period for

orthodontia services GHI High 0 0 0 0 $50 self$150 self amp (Outshyofshynetwork benefits) familyself plus one

Class B and Class C

TripleshyS Salud High (Open to Puerto Rico

787shy774shy6060 787shy749shy4777

0 30 60 30

50 $0 No maximum $1500 lifetime max per person

residents) 1shy800shy981shy3241 TTY 787shy792shy1370 TTY 1shy866shy215shy1999

(orthodontic services only) Outshyofshynetwork benefits NOT provided 24shymonth waiting period for

wwwsssprcom orthodontia services


86


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

Plan Name Frames Lenses Exams Coshy

payments Covered Lens

Options Additional Features

FEP BlueVision Standard

FEP BlueVision High

UnitedHealthcare Vision Plan Standard

UnitedHealthcare Vision Plan High

VSP (Vision Service Plan) Standard

VSP (Vision Service Plan) High

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

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

$0

$0

$10 exam $25 material



$10 (including exam and glasses)

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

Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating Tinted Lenses UV Coating


Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating Antishyreflective Coating Lenses that transition to light UV Coating Select tints

Breakage warranty Laser vision correction discount low vision coverage $130 plus 20 of remaining cost frame allowance Additional lens options covered with a coshypay 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 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 prosthetic eye vision therapy Laser vision correction discount $130 frame allowance Additional lens option discounts Outshyofshynetwork benefits availablendash paid at a lower rate Flat rate reimbursement for international outshyofshynetwork and limited access services


Laser vision correction discount $120 frame allowance 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

Laser vision correction discount $150 frame allowance 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

87

Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)

Dental Rating Regional Chart

Rating Areas State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS

Salud

AK entire state 5 5 5 5 5 5 NA NA NA

AL 356shy358 1 1 1 1 1 1 1 NA NA AL rest of state 2 1 1 1 1 1 1 NA NA

AR entire state 2 1 1 1 1 1 5 NA NA

AZ entire state 3 3 3 1 1 1 2 NA NA

CA 900shy918 922shy935 3 4 4 5 5 3 4 NA NA CA 919shy921 3 4 4 4 4 4 4 NA NA CA 939shy941 943shy954 4 5 5 5 5 5 4 NA NA CA 942 956shy958 4 4 4 4 4 4 4 NA NA CA rest of state 4 4 4 5 5 4 4 NA NA

CO entire state 3 4 4 4 4 3 4 NA NA

CT 060shy063 5 4 4 5 5 5 NA NA NA CT 064shy069 3 5 5 5 5 5 NA 1 NA

DC entire state 2 4 4 4 4 4 2 NA NA

DE entire state 2 3 3 3 3 2 NA NA NA

FL 327shy328 337 2 2 2 1 1 1 2 NA NA FL 330shy334 2 4 4 3 3 3 2 NA NA FL rest of state 3 2 2 1 1 1 2 NA NA

GA 300shy303 311 3 3 3 2 2 1 3 NA NA GA rest of state 4 2 2 1 1 1 5 NA NA

GU entire state 5 1 1 5 5 5 NA NA NA

HI entire state 4 3 3 4 4 5 NA NA NA

IA entire state 3 1 1 1 1 2 NA NA NA

ID entire state 4 2 2 1 1 2 NA NA NA

IL 600shy608 2 3 3 4 4 3 1 NA NA IL 620shy622 2 2 2 1 1 1 1 NA NA IL rest of state 3 1 1 1 1 1 1 NA NA

IN 460shy462 2 2 2 1 1 1 1 NA NA IN 463shy464 2 3 3 4 4 3 1 NA NA IN rest of state 3 1 1 1 1 2 1 NA NA

KS 660shy662 1 2 2 1 1 2 1 NA NA KS rest of state 3 1 1 1 1 2 1 NA NA

KY 410 2 2 2 1 1 1 1 NA NA KY rest of state 1 1 1 1 1 1 1 NA NA

88



Rating Areas

State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS Salud

LA entire state 2 2 2 1 1 1 5 NA NA

MA entire state 5 4 4 5 5 5 NA NA NA

MD 206shy218 2 4 4 4 4 4 2 NA NA MD 219 2 3 3 3 3 2 NA NA NA MD rest of state 2 2 2 2 2 4 NA NA NA

ME entire state 5 3 3 2 2 3 NA NA NA

MI 480shy485 3 3 3 3 3 2 NA NA NA MI rest of state 3 2 2 2 2 3 NA NA NA

MN 550shy555 2 3 3 4 4 3 NA NA NA MN rest of state 3 2 2 2 2 2 NA NA NA

MO 630shy633 2 2 2 1 1 1 1 NA NA MO 640shy641 1 2 2 1 1 2 1 NA NA MO rest of state 3 1 1 1 1 1 1 NA NA

MS entire state 2 1 1 1 1 1 5 NA NA

MT entire state 4 2 2 1 1 1 NA NA NA

NC entire state 4 2 2 1 1 1 5 NA NA

ND entire state 3 1 1 1 1 2 NA NA NA

NE entire state 1 1 1 1 1 2 NA NA NA

NH entire state 5 4 4 5 5 5 NA NA NA

NJ 080shy084 2 3 3 3 3 2 NA NA NA NJ rest of state 3 5 5 5 5 5 NA 1 NA

NM entire state 3 3 3 1 1 1 NA NA NA

NV 897 4 4 4 4 4 4 NA NA NA NV rest of state 2 3 3 2 2 2 NA NA NA

NY 004 005 3 5 5 5 5 5 NA 1 NA NY 100shy119 124shy126 3 5 5 5 5 5 NA 1 NA NY rest of state 4 2 2 2 2 3 NA 1 NA

OH 430shy432 2 2 2 1 1 2 3 NA NA OH 440shy443 2 2 2 1 1 3 1 NA NA OH 450shy452 2 2 2 1 1 1 1 NA NA

OH 453shy455 2 2 2 1 1 2 1 NA NA

OH rest of state 3 1 1 1 1 1 1 NA NA

OK entire state 2 2 2 1 1 1 3 NA NA

OR 970shy973 4 3 3 4 4 5 NA NA NA OR rest of state 5 3 3 3 3 4 NA NA NA

89




Salud

PA 150shy154 156 160 1 1 1 1 1 1 NA NA NA PA 183 3 5 5 5 5 5 NA 1 NA PA 189shy194 2 3 3 3 3 2 NA NA NA PA rest of state 3 1 1 1 1 1 NA NA NA

PR entire state 3 1 1 1 1 1 NA NA 1

RI entire state 5 4 4 5 5 5 NA NA NA

SC entire state 4 2 2 1 1 1 5 NA NA

SD entire state 3 1 1 1 1 2 NA NA NA

TN entire state 1 2 2 1 1 1 1 NA NA

TX 750shy753 760shy762 2 3 3 1 1 1 3 NA NA TX 770shy775 2 3 3 1 1 1 3 NA NA TX rest of state 2 2 2 1 1 1 3 NA NA

UT entire state 2 1 1 1 1 2 1 NA NA

VA 201 220shy226 2 4 4 4 4 4 2 NA NA VA 230shy232 238 3 2 2 1 1 2 5 NA NA VA rest of state 3 2 2 1 1 1 4 NA NA

VI entire state overseas 1 1 5 5 5 NA NA NA

VT entire state 5 2 2 2 2 3 NA NA NA

WA 980shy985 5 5 5 5 5 5 NA NA NA WA 986 4 3 3 4 4 5 NA NA NA WA rest of state 5 4 4 4 4 4 NA NA NA

WI 530shy534 3 2 2 2 2 3 NA NA NA WI 540 2 3 3 4 4 3 NA NA NA WI rest of state 3 2 2 2 2 2 NA NA NA

WV entire state 4 2 2 1 1 1 3 NA NA WY entire state 4 1 1 1 1 2 NA NA NA

90

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 K to determine your specific region

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

Aetna PPO High 1 $1256 $2511 $3767 $2721 $5441 $8162 (In and OutshyofshyNetwork benefits) 2 $1382 $2764 $4146 $2994 $5989 $8983

3 $1471 $2941 $4411 $3187 $6372 $9557 4 $1622 $3243 $4865 $3514 $7027 $10541 5 $1760 $3521 $5281 $3813 $7629 $11442

GEHA PPO Standard 1 $908 $1816 $2726 $1967 $3935 $5906 (In and OutshyofshyNetwork benefits) 2 $997 $1994 $2991 $2160 $4320 $6481

3 $1132 $2262 $3393 $2453 $4901 $7352 4 $1221 $2441 $3662 $2646 $5289 $7934 5 $1355 $2710 $4064 $2936 $5872 $8805

GEHA PPO High 1 $1489 $2977 $4469 $3226 $6450 $9683 (In and OutshyofshyNetwork benefits) 2 $1637 $3274 $4914 $3547 $7094 $10647

3 $1857 $3715 $5573 $4024 $8049 $12075 4 $2005 $4010 $6017 $4344 $8688 $13037 5 $2225 $4453 $6681 $4821 $9648 $14476

MetLife PPO Standard 1 $853 $1708 $2563 $1848 $3701 $5553 (In and OutshyofshyNetwork benefits) 2 $923 $1845 $2770 $2000 $3998 $6002

3 $1022 $2042 $3064 $2214 $4424 $6639 4 $1135 $2270 $3404 $2459 $4918 $7375 5 $1246 $2492 $3739 $2700 $5399 $8101

MetLife PPO High 1 $1567 $3133 $4696 $3395 $6788 $10175 (In and OutshyofshyNetwork benefits) 2 $1752 $3507 $5259 $3796 $7599 $11395

3 $1910 $3815 $5725 $4138 $8266 $12404 4 $2066 $4129 $6194 $4476 $8946 $13420 5 $2313 $4625 $6937 $5012 $10021 $15030

United Concordia PPO High 1 $1418 $2833 $4251 $3072 $6138 $9211 (In and OutshyofshyNetwork benefits) 2 $1627 $3250 $4877 $3525 $7042 $10567

3 $1767 $3529 $5295 $3829 $7646 $11473 4 $1906 $3806 $5713 $4130 $8246 $12378 5 $2054 $4107 $6160 $4450 $8899 $13347

9911


Premium Rate Charts Regional Dental Rates

Please note Rating areas for each carrier are not the same for all plans Please refer to Appendix K to determine your specific region

Plan Name Option Rating Region


Self Only Self Plus One

Self amp Family Self Only Self Plus One

Self amp Family

Humana High 1 $965 $1928 $2893 $2091 $4177 $6268 (InshyNetwork Benefits only 2 $1038 $2075 $3113 $2249 $4496 $6745

except for emergency services) 3 $1045 $2089 $3134 $2264 $4526 $6790 4 $1426 $2852 $4278 $3090 $6179 $9269 5 $1433 $2865 $4298 $3105 $6208 $9312

GHI PPO High (Inshyand OutshyofshyNetwork Benefits)

1 $1618 $3234 $4852 $3506 $7007 $10513

TripleshyS Salud PPO High (InshyNetwork Benefits only

except for services rendered by orthodontists)

1 $435 $869 $1141 $943 $1883 $2472

International Dental Rates Please note International premium rates are not regionally based

Plan Name




Self amp Family

Aetna

GEHA Standard

GEHA High

MetLife Standard

MetLife High

United Concordia

$1882

$908

$1489

$1246

$2313

$2054

$3762

$1816

$2977

$2492

$4625

$4107

$5644

$2726

$4469

$3739

$6937

$6160

$4078

$1967

$3226

$2700

$5012

$4450

$8151

$3935

$6450

$5399

$10021

$8899

$12229

$5906

$9683

$8101

$15030

$13347

92


Premium Rate Charts

Nationwide Vision Rates

Plan Name Telephone amp Website

Plan Option




Self amp Family

FEP BlueVision

UnitedHealthcare Vision Plan

VSP (Vision Service Plan)

1shy888shy550shy2583 wwwfepblueorg

1shy866shy249shy1999 TTY 800shy524shy3157

wwwmyuhcvisioncomfedvip

1shy800shy807shy0764 wwwchoosevspcom

Standard High

Standard High

Standard High

$377 $475

$300 $423

$413 $617

$752 $949

$585 $824

$825 $1233

$1129 $1425

$871 $1228

$1238 $1850

$817 $1029

$650 $916

$895 $1337

$1629 $2056

$1269 $1786

$1788 $2672

$2446 $3088

$1887 $2660

$2682 $4008

International Vision Rates


Plan Option




Self amp Family

FEP BlueVision







Standard High

Standard High

Standard High

$377 $475

$300 $423

$413 $617

$752 $949

$585 $824

$825 $1233

$1129 $1425

$871 $1228

$1238 $1850

$817 $1029

$650 $916

$895 $1337

$1629 $2056

$1269 $1786

$1788 $2672

$2446 $3088

$1887 $2660

$2682 $4008

93

Medicaid and the Childrenrsquos Health Insurance Program (CHIP) Offer Free or LowshyCost Health Coverage to Children and Families

bull If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employershysponsored health coverage but need assistance in paying their health premiums

bull 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

bull 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

bull Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance

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 2011 You should contact your State for further information on eligibility ndash

ALABAMA ndash Medicaid IOWA ndash Medicaid Website httpwwwmedicaidalabamagov Website wwwdhsstateiaushipp Phone 1shy800shy362shy1504 Phone 1shy888shy346shy9562

ALASKA ndash Medicaid KANSAS ndash Medicaid Website httphealthhssstateakusdpaprogramsmedicaid Website httpswwwkhpaksgov Phone (Outside of Anchorage) 1shy888shy318shy8890 Phone 1shy800shy792shy4884 Phone (Anchorage) 907shy269shy6529

ARIZONA ndash CHIP KENTUCKY ndash Medicaid Website httpwwwazahcccsgovapplicantsdefaultaspx Website httpchfskygovdmsdefaulthtm Phone (Outside of Maricopa County) 1shy877shy764shy5437 Phone 1shy800shy635shy2570 Phone (Maricopa County) 602shy417shy5437

ARKANSAS ndash CHIP LOUISIANA ndash Medicaid Website httpwwwarkidsfirstcom Website httpwwwlahippdhhlouisianagov Phone 1shy888shy474shy8275 Phone 1shy888shy342shy6207

CALIFORNIA ndash Medicaid MAINE ndash Medicaid Website httpwwwdhcscagovservicesPagesTPLRD_CAU_contaspx Website httpwwwmainegovdhhsOIASpublicshyassistanceindexhtml Phone 1shy866shy298shy8443 Phone 1shy800shy321shy5557

COLORADO ndash Medicaid and CHIP MASSACHUSETTS ndash Medicaid and CHIP Medicaid Website httpwwwcoloradogov Medicaid amp CHIP Website httpwwwmassgovMassHealth Medicaid Phone 1shy800shy866shy3513 Medicaid amp CHIP Phone 1shy800shy462shy1120 CHIP Website http wwwCHPplusorg CHIP Phone 303shy866shy3243

FLORIDA ndash Medicaid MINNESOTA ndash Medicaid Website httpwwwfdhcstateflusMedicaidindexshtml Website httpwwwdhsstatemnus (Health Care then Medical Assistance) Phone 1shy877shy357shy3268 Phone (Outside of Twin Cities area) 800shy657shy3739

Phone (Twin Cities area) 651shy431shy2670

GEORGIA ndash Medicaid MISSOURI ndash Medicaid Website httpdchgeorgiagov (Programs then Medicaid) Website httpwwwdssmogovmhdindexhtm Phone 1shy800shy869shy1150 Phone 573shy751shy6944

IDAHO ndash Medicaid and CHIP MONTANA ndash Medicaid Medicaid Website wwwaccesstohealthinsuranceidahogov Website httpmedicaidproviderhhsmtgovclientpagesclientindexshtml Medicaid Phone 1shy800shy926shy2588 Telephone 1shy800shy694shy3084 CHIP Website wwwmedicaididahogov CHIP Phone 1shy800shy926shy2588

INDIANA ndash Medicaid NEBRASKA ndash Medicaid Website httpwwwingovfssa Website httpwwwdhhsnegovmedmedindexhtm Phone 1shy800shy889shy9948 Phone 1shy877shy255shy3092

94


NEVADA ndash Medicaid and CHIP Medicaid Website httpdwssnvgov Medicaid Phone 1shy800shy992shy0900 CHIP Website httpwwwnevadacheckupnvorg CHIP Phone 1shy877shy543shy7669

SOUTH CAROLINA ndash Medicaid Website httpwwwscdhhsgov Phone 1shy888shy549shy0820

NEW HAMPSHIRE ndash Medicaid Website httpwwwdhhsnhgovombpindexhtm Phone 603shy271shy4238

TEXAS ndash Medicaid Website httpswwwgethipptexascom Phone 1shy800shy440shy0493

NEW JERSEY ndash Medicaid and CHIP Medicaid Website httpwwwstatenjushumanservicesdmahsclientsmedicaid Medicaid Phone 1shy800shy356shy1561 CHIP Website httpwwwnjfamilycareorgindexhtml CHIP Phone 1shy800shy701shy0710

UTAH ndash Medicaid Website httphealthutahgovupp Phone 1shy866shy435shy7414

NEW MEXICO ndash Medicaid and CHIP Medicaid Website httpwwwhsdstatenmusmadindexhtml Medicaid Phone 1shy888shy997shy2583 CHIP Website httpwwwhsdstatenmusmadindexhtml (Insure New Mexico) CHIP Phone 1shy888shy997shy2583

VERMONTndash Medicaid Website httpwwwgreenmountaincareorg Telephone 1shy800shy250shy8427

NEW YORK ndash Medicaid Website httpwwwnyhealthgovhealth_caremedicaid Phone 1shy800shy541shy2831

NORTH CAROLINA ndash Medicaid Website httpwwwncgov Phone 919shy855shy4100

VIRGINIA ndash Medicaid and CHIP Medicaid Website httpwwwdmasvirginiagovrcpshyHIPPhtm Medicaid Phone 1shy800shy432shy5924 CHIP Website httpwwwfamisorg CHIP Phone 1shy866shy873shy2647

NORTH DAKOTA ndash Medicaid Website httpwwwndgovdhsservicesmedicalservmedicaid Phone 1shy800shy755shy2604

WASHINGTON ndash Medicaid Website httphrsadshswagovpremiumpymtApplyshtm Phone 1shy800shy562shy3022 ext 15473

OKLAHOMA ndash Medicaid Website httpwwwinsureoklahomaorg Phone 1shy888shy365shy3742

WEST VIRGINIA ndash Medicaid Website httpwwwwvrecoverycomhipphtm Phone 304shy342shy1604

OREGON ndash Medicaid and CHIP Medicaid amp CHIP Website httpwwworegonhealthykidsgov Medicaid amp CHIP Phone 1shy877shy314shy5678

WISCONSIN ndash Medicaid Website httpwwwbadgercareplusorgpubspshy10095htm Phone 1shy800shy362shy3002

PENNSYLVANIA ndash Medicaid Website httpwwwdpwstatepauspartnersprovidersmedicalassistancedoingbusiness003670053htm Phone 1shy800shy644shy7730

RHODE ISLAND ndash Medicaid WYOMING ndash Medicaid Website wwwdhsrigov Website httpwwwhealthwyogovhealthcarefinindexhtml Phone 401shy462shy5300 Telephone 307shy777shy7531

To see if any more States have added a premium assistance program since January 31 2011 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

OMB Control Number 1210shy0137 (expires 09302013)

95

Summary Information




















wwwopmgovinsurelife




96

Summary Information




















wwwopmgovinsurelife




Table of Contents

Page






























1


2











3








4
















5


Current Employees



























6

















7







FSAFEDS




8



FEGLI












9






Key FEHB facts













10














11


When can I enroll



How do I enroll




12















13






Key FEDVIP facts














14

















15


When can I enroll




How do I enroll








16


















17





Key FSAFEDS facts













18













19




When can I enroll











20


How do I enroll










21




Key FEGLI facts



















22




When can I enroll







How do I enroll








23




Key FLTCIP facts












24





How do I apply








25


26


















27
















pay more








28












29


Definitions













30















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



31














32









33











Enrollment Code


Monthly Biweekly















421 422 13272 32275 6126 14896




34




Plan

Benefit Type





RampB

Prescription Drugs


Office Visits


Calendar Year

Prescription Drug

APWU shyhigh

BCBS shystd

BCBS shybasic

GEHA shyhigh

GEHA shystd

MHBP shystd

MHBP shyValue

NALC shyhigh

SAMBA shyhigh

SAMBA shystd

CRHP

FSBP

PCABP

Rural

PPO NonshyPPO

PPO NonshyPPO

PPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

POS FFS

PPO NonshyPPO

$275 None $500 None

$350 None $350 None

None None

$350 None $350 None

$350 None $350 None

$400 None $600 None


$300 None $300 None

$300 None $300 None

$350 None $350 None

$300 None $350 None

$300 None $300 None

None None None None

$350 $200 $400 $200


None $300

$250 $350

$150day x 5

$100 $300

None None

$200 $500

None None

$200 $350

$200 $300

$150 up to $450 $200 up to $600

$150 $350

Nothing $200

$100 $25

$100 $300

$18 10 30+diff 30+diff

$20 15 35 35

$25 $150

$20 10 25 25

$10 15 35 35

$20 10 30 30

$30 20 40 40

$20 15 30 30

$20 10 30 30

$20 15 35 35

$10 Nothing 30 30

10 10 30 30

50 50 $5 Nothing

$20 10 25 25

10 30

Nothing 35

Nothing

Nothing Nothing

15 35

Nothing 30

20 40

Nothing 30

Nothing 30

Nothing 35

Nothing 30

Nothing 20

50 Nothing

Nothing 20

$8 2525 Yes 50 5050 Yes

20 (15MCare B) 3030 Yes 45 + 45+45+ Yes

$10 $50$150 NA



$10 30($200 max)50($200 max) Yes 50 5050 Yes


20 3030 Yes 45 45+ 45+45+ Yes



$5 $3030 or $45 Yes $5 $3030 or $45 Yes


20 2020 No 20 2020 No

30 3030 Yes 30 3030 Yes


35













Plan Code


Getting needed care


How well doctors


Claims processing



FFS National A

47

verage 774

78

916

898

91

921

948

938

897

837

929

898

725

737 47





MHBP shystd 45 706 916 917 943 898 927 713 45


NALC shyhigh 32 811 934 914 951 923 951 766 32

SAMBA shyhigh 44 893 946 937 968 901 973 791 44

SAMBA shystd 44 745 923 933 952 903 925 74



44

42

roups Average 774 916 91 948 897 929 725

42




36



Location Plan Name


Plan Code


Getting needed care


How well doctors


Claims processing











37


38















39





Arizona




Arkansas



California












Colorado





40


Primary care



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

Arizona


HMOP

$35$65

OS Nationa

Yes

l Average 659

583

855

842

855

864

935

883

839

858

876

884

664

636



Arkansas


$15$40

$20$30

$250day x 3

$100max$500

$10

$0

$40$70

$40$60

Yes

Yes

702

61

878

845

868

873

921

935

863

877

946

887

675



California


$20$40

$20$35

$200max$1000

$250day x 4

$5

$10

$40$60

$35$65

Yes

Yes

61

612

845

808

873

822

935

922

877

813

887

882

652

608











Colorado


$20$35

$20$40

$150day x 4

$250

$10

$10

$35$60

$35$60

Yes

Yes

692

716

787

833

824

862

935

918

761

77

88

876

588

684



$25$45

$20$35

$250day x 3

$150day x 5

$15

$10

$40$80

$35$65

Yes

Yes

716

616

833

884

862

88

918

943

77

857

876

932

684

631


41







Self amp family


























42


Primary care



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


HMO

$35$65

POS National

Yes

Average 659

659

855

871

855

87

935

918

839

901

876

874

664

667







MD IPAshyHigh


$25$40

$15$40

$150day x 3

$150day x 5

$7

$5

$30$150$250

$30$5030

Yes

No

632

724

838

869

871

855

925

913

841

894

90

853

65

648










$25$40

$20$35

$500day x 3

$250day x 4

$10

$10

$40$60

$35$65

Yes

Yes 569 888 835 927 882 873 589









43





Guam






Idaho





Illinois











44


Primary care



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

Guam


HMOP

$15$25$50

OS Nationa

No

l Average 659

642

855

726

855

626

935

895

839

694

876

664

664

563

TakeCareshyStd


$25$40

$15$15

$150day for 5 days

$100

$15

$7

$20$40$80

$30$65

No

Yes

642

833

726

924

626

91

895

959

694

837

664

941

563


$65+20 No 833 924 91 959 837 941 666



Idaho


$30$30

$20$30

10

$200

$20

$7

$20$20

$25$50

Yes

Yes

751

556

821

86

797

88

935

948

792

817

853

853

707

625




Illinois


$25+20$25+20

$20$35

$500day x 3

$250day x 4

$20

$10

$40$60

$35$65

Yes

Yes

691

615

839

826

844

82

926

909

867

866

896

823

711

642











45







Self amp family

Indiana








Iowa









Kansas






46


Primary care



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

$35$65

OS Nationa

Yes

l Average 659

615

855

826

855

82

935

909

839

866

876

823

664

642







Iowa


$15$15

$20$45

20

15

$10

$3$10

$25$50

$40$65

Yes

Yes

583

567

879

857

88

867

952

966

905

824

944

907

603

675









Kansas


$25$45

$20$35

Nothing

$250day x 4

$10

$10

$35$50

$35$65

Yes

Yes

524 873 853 956 798 886 622





47





Kentucky





Louisiana



Maryland










Massachusetts


48


Primary care



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

Kentucky


HMO

$40$60

POS National

Yes

Average 659 855 855 935 839 876 664




Louisiana


$25$40

$25$45

$500day x 3

$100

$10

$5

$40$60

$40$75

Yes

Yes 579 866 853 964 793 843 677


Maryland


$30$55

$15$30

30

$150day x3

$5

$5

$40$75

$35$65

Yes

Yes

579

659

866

871

853

87

964

918

793

901

843

874

677

667









MD IPAshyHigh

Massachusetts


$25$40

$25$35

$150day x 3

$150 to $750max

$7

$10

$30$150$250

$30$60

Yes

Yes

632

61

838

862

871

883

925

95

841

828

90

799

65

627

49























Enrollment Code


Michigan

H61 H62

J31 J32

K51 K52

LX1 LX2

RL1 RL2

RL4 RL5

521 522

GY4 GY5

X51 X52

9U4 9U5

Minnesota

V31 V32

V34 V35

Missouri HY1 HY2

9G1 9G2

HA1 HA2

HA4 HA5

MS1 MS2

MS4 MS5

B91 B92

Telephone Number

800shy662shy6667

800shy662shy6667

800shy662shy6667

800shy662shy6667

616shy949shy2410

616shy949shy2410

800shy556shy9765

800shy556shy9765

800shy332shy9161

866shy539shy3342

952shy883shy5000

952shy883shy5000

877shy459shy6604

888shy811shy2092

800shy969shy3343

800shy969shy3343

888shy393shy6765

888shy393shy6765

877shy835shy9861

50

Monthly


17455 60199

20874 69088

15762 37947

12930 44648

19006 64274

12973 45145

15511 44042

12822 33321

12002 34959

20141 55759

32886 78427

8987 20671

11817 36274

26208 54102

12196 32723

10096 23722

45714 103636

13457 31059

19353 43374

Biweekly


8056 27784

9634 31887

7275 17514

5968 20607

8772 29665

5987 20836

7159 20327

5918 15379

5539 16135

9296 25735

15178 36197

4148 9540

5454 16742

12096 24970

5629 15103

4660 10948

21099 47832

6211 14335

8932 20019


Primary care



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


HMO

$50NA

POS National

Yes

Average 659 855 855 935 839 876 664










Minnesota


$20Nothing

$25$45

20

Nothing

$15

$12

$25$50

$45$90

Yes

Yes

774

641

906

873

886

897

964

951

893

888

887

912

69

66




$250day x 4

$9

$10

$40$70

$35$65

Yes

Yes

641 873 897 951 888 912 66








51








Nevada

HF1 HF2 10582 33646 4884 15529

NM1 NM2 10448 24635 4822 11370

Telephone Number

877shy459shy6604

800shy777shy1840

New Jersey







New Mexico



52

Q11 Q12 22873 58561 10557 27028

P21 P22 17370 41076 8017 18958


Primary care



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

Nevada


HMO

$35$65

POS National

Yes

Average 659 855 855 935 839 876 664


New Jersey


$10$20

$20$35

$150

$150day x 5

$5

$10

$35$55

$35$65

Yes

Yes

567

617

709

855

706

886

898

937

78

852

845

861

561

605






New Mexico


$25$25

$20$35

$250day x 3

$250 after ded

$5

$5

$25$50

$35$6050

Yes

Yes

604

623

856

807

861

786

926

896

763

807

772

862

572

746


53




























54


Primary care



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


HMO

$35$65

POS National

Yes

Average 659

651

855

828

855

853

935

927

839

873

876

875

664

60























55





North Dakota




Ohio






Oklahoma


Oregon



56


Primary care



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 Dakota


HMO

$45$90

POS National

Yes

Average 659

641

855

873

855

897

935

951

839

888

876

912

664

66



Ohio

AultCare HMOshyHigh

2020

$15$20

20

$150

NA

$15

NA

$30$45

NA

No 865 935 926 946 946 958 863





Oklahoma


Oregon


$10$20

$15$35

$15$25

$250

$150day x 3

$200

$15

$10

$15

$30$50

$30$40

$40$40

Yes

Yes

Yes

739

56

677

905

731

769

89

812

778

963

941

893

927

715

864

957

883

848

758

626

679


57





Pennsylvania











South Dakota





Tennessee




58


Primary care



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

Pennsylvania


HMO

$35$65

POS National

Yes

Average 659

567

855

873

855

885

935

946

839

752

876

886

664

682









$20$35

$5$5

None

None

$5

$250

$35$70

$10$15

Yes

Yes

764

753

903

807

871

815

959

936

87

834

885

811

716




South Dakota


$750+10$10+10

$25$45

10 +

Nothing

NA

$12

NA NA

$45$90

No

Yes

716

641

857

873

796

897

968

951

683

888

695

912

514

66




Tennessee


4040

$20$35

40

$250day x 4

NA

$10

NA NA

$35$65

No

Yes

53

639

831

877

861

842

963

936

905

85

907

919

703

708



59





Texas










Utah




Virgin Islands












60


Primary care



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

$35$65

OS Nationa

Yes

l Average 659

698

855

833

855

793

935

896

839

829

876

886

664

652









Utah


$20$40

$20$30

$250day x 5

$200

$10

$7

$35$60

$25$50

Yes

Yes

654

556

864

86

842

88

936

948

797

817

905

853

646

625


SelectHealthshyHigh

Virgin Islands


$15$25

$750$10

$100

None

$5

$5 or $12

$2550


NA

Yes x

553 834 823 93 935 92 712



$10 amp 10+

$150day x3 $5 $35$65 Yes 659 871 87 918 901 874 667











61





Washington







West Virginia


Wisconsin







Wyoming



62


Primary care



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

Washington


HMOP

$40$60

OS National

Yes

Average 659

691

855

839

855

844

935

926

839

867

876

896

664

711









West Virginia


Wisconsin


$25$35

$10$20

$10$10

$500

$250

None

$20

$15

$10

$40$40

$30$50

30$75max30

Yes

Yes

No

677

739

77

769

905

871

778

89

883

893

963

962

864

927

854

848

957

921

679

758

689






Wyoming


$10$10

$20$30

Nothing

$200

$10

$7

3050

$25$50

No

Yes

766

556

86

86

889

88

95

948

901

817

912

853

723

625


63











64



















insurance plans

65



ELIGIBILITY

FUNDING







CONTRIBUTIONS

DISTRIBUTIONS







ANNUAL ROLLOVER







66




67












Self only

Self amp family

Self only

Self amp family

Self only

Self amp family




866shy833shy3463

800shy821shy6136

800shy694shy9901

474 475

341 342

481 482

8923 20072

9996 22832

11557 26186

4118 9264

4614 10538

5334 12086

68













69












Plan Code


Getting needed care


How well doctors


Claims processing






22

34

48

60

637

54

856

864

868

893

885

877

935

923

936

859

852

839

90

876

892

592

593

547


Plan Code


Getting needed care


How well doctors


Claims processing






22

47

TU TV

60

643

489

856

884

806

893

868

841

935

924

929

859

803

839

90

809

891

592

657

609

70


71





Plan Name

Telephone Number


Self only

Self amp family

Self only

Self amp family

Self only

Self amp family



877shy459shy6604

877shy459shy6604

221 222

224 225

15604 37056

9412 20613

7202 17103

4344 9514


Florida







Idaho


Plan Name

800shy441shy5501

888shy393shy6765

888shy393shy6765

888shy393shy6765

888shy393shy6765

671shy647shy3526

800shy377shy4161

Telephone Number


J41

MJ1

QP1

AD1

LM1

KX1

9K4

Self only

J42

MJ2

QP2

AD2

LM2

KX2

9K5

Self amp family

11570

12685

10873

11477

11840

8138

8704

Self only

28710

28542

24465

25824

26639

21442

18033

Self amp family

5340

5855

5018

5297

5464

3756

4017

Self only

13251

13173

11291

11919

12295

9896

8323

Self amp family

72



Benefit Type


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs




Benefit Type


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Florida


Plan Name

$8334$16667 $2500$5000 $5000$10000 $10 20 20 Nothing $5$35$5020






OutshyNetwork

InshyNetwork

NA

$8333

$3000$6000

$1000$2000

$4000$8000

$3000$6000

30

$25

30

$300day x 5

30

$150

30

Nothing

$10+$40+$60+



Guam TakeCareshy

OutshyNetwork

InshyNetwork

NA

$8666$22208

$3000$6000

$3000$6000

$4000$8000

$5000$10000

30

20afterDed

30

20 after Ded

30

20 after Ded

30

Nothing

$10+$40+$60+


Idaho

Altius Health Plans


$4583$9166

$3000$6000

$1200$2400

$10000$20000

$5000$10000 $20

30 afterDed

10


10

1st $300ded

Nothing

30 after Ded

$7$25$50

73












Plan Name

888shy393shy6765

888shy393shy6765

888shy393shy6765

800shy257shy4692

800shy969shy3343

888shy393shy6765

888shy393shy6765

800shy833shy7423

Telephone Number


GB1

MW1

MW1

SV4

9H1

PH1

6N1

GZ1

Self only

GB2

MW2

MW2

SV5

9H2

PH2

6N2

GZ2

Self amp family

12685

12081

12081

8608

9721

10873

10064

9834

Self only

28542

27182

27182

20544

22845

24464

22644

22508

Self amp family

5855

5576

5576

3973

4486

5018

4645

4539

Self only

13173

12546

12546

9482

10544

11291

10451

10388

Self amp family

74










75

A








Pennsylvania







Plan Name

800shy969shy3343

888shy393shy6765

800shy501shy3439

330shy363shy6360

866shy351shy5946

866shy351shy5946

888shy876shy2756

888shy393shy6765

888shy393shy6765

888shy393shy6765

Telephone Number


9H1

PH1

QA4

3A4

Y61

YW1

8W4

TP1

TU1

TV1

Self only

9H2

PH2

QA5

3A5

Y62

YW2

8W5

TP2

TU2

TV2

Self amp family

9721

10873

9633

7760

11914

14046

11884

11840

12081

12284

Self only

22845

24464

24717

15548

27430

30756

26620

26640

27182

27639

Self amp family

4486

5018

4446

3581

5499

6483

5485

5464

5576

5669

Self only

10544

11291

11408

7176

12660

14195

12286

12295

12546

12756

Self amp family

76






Pennsylvania








77





Wyoming


Plan Name

800shy377shy4161

800shy552shy7114

800shy377shy4161

Telephone Number


9K4

L14

9K4

Self only

9K5

L15

9K5

Self amp family

8704

9545

8704

Self only

18033

20857

18033

Self amp family

4017

4405

4017

Self only

8323

9626

8323

Self amp family

78



Washington $10$3550


Wyoming


79


80

Appendix F


Waiting Periods





Contributions


Salary Deduction





81


















82






Increase Enrollment

Type

Decrease Enrollment

Type







Yes Yes No No No


No No No No Yes


or spouse)

No No No Yes No



Yes No No No No




No No No Yes No







83

Appendix I



Reading the Chart


Dental Insurance









Vision Insurance



84



Plan Name

Telephone amp

Website


Class A

Class B

Class C

Class D

Deductible





0 40 60 70 $0





0 45 65 50 $0


0 20 50 50 $0


0 20 50 50 $0












wwwuccifedvipcom




40 60 50 $0


85




Plan Name

Telephone amp

Website

Class A

Class B

Class C

Class D Deductible





Class B and Class C


787shy774shy6060 787shy749shy4777

0 30 60 30






86








FEP BlueVision High





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

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

$0

$0

















87




Salud




















88



Rating Areas




















OH 453shy455 2 2 2 1 1 2 1 NA NA




89




Salud















90








3 $1471 $2941 $4411 $3187 $6372 $9557 4 $1622 $3243 $4865 $3514 $7027 $10541 5 $1760 $3521 $5281 $3813 $7629 $11442


3 $1132 $2262 $3393 $2453 $4901 $7352 4 $1221 $2441 $3662 $2646 $5289 $7934 5 $1355 $2710 $4064 $2936 $5872 $8805


3 $1857 $3715 $5573 $4024 $8049 $12075 4 $2005 $4010 $6017 $4344 $8688 $13037 5 $2225 $4453 $6681 $4821 $9648 $14476


3 $1022 $2042 $3064 $2214 $4424 $6639 4 $1135 $2270 $3404 $2459 $4918 $7375 5 $1246 $2492 $3739 $2700 $5399 $8101


3 $1910 $3815 $5725 $4138 $8266 $12404 4 $2066 $4129 $6194 $4476 $8946 $13420 5 $2313 $4625 $6937 $5012 $10021 $15030


3 $1767 $3529 $5295 $3829 $7646 $11473 4 $1906 $3806 $5713 $4130 $8246 $12378 5 $2054 $4107 $6160 $4450 $8899 $13347

9911








Self amp Family




1 $1618 $3234 $4852 $3506 $7007 $10513



1 $435 $869 $1141 $943 $1883 $2472


Plan Name




Self amp Family

Aetna

GEHA Standard

GEHA High

MetLife Standard

MetLife High

United Concordia

$1882

$908

$1489

$1246

$2313

$2054

$3762

$1816

$2977

$2492

$4625

$4107

$5644

$2726

$4469

$3739

$6937

$6160

$4078

$1967

$3226

$2700

$5012

$4450

$8151

$3935

$6450

$5399

$10021

$8899

$12229

$5906

$9683

$8101

$15030

$13347

92


Premium Rate Charts



Plan Option




Self amp Family

FEP BlueVision







Standard High

Standard High

Standard High

$377 $475

$300 $423

$413 $617

$752 $949

$585 $824

$825 $1233

$1129 $1425

$871 $1228

$1238 $1850

$817 $1029

$650 $916

$895 $1337

$1629 $2056

$1269 $1786

$1788 $2672

$2446 $3088

$1887 $2660

$2682 $4008



Plan Option




Self amp Family

FEP BlueVision







Standard High

Standard High

Standard High

$377 $475

$300 $423

$413 $617

$752 $949

$585 $824

$825 $1233

$1129 $1425

$871 $1228

$1238 $1850

$817 $1029

$650 $916

$895 $1337

$1629 $2056

$1269 $1786

$1788 $2672

$2446 $3088

$1887 $2660

$2682 $4008

93


















94
























95

Summary Information




















wwwopmgovinsurelife




96

Table of Contents

Page






























1


2











3








4
















5


Current Employees



























6

















7







FSAFEDS




8



FEGLI












9






Key FEHB facts













10














11


When can I enroll



How do I enroll




12















13






Key FEDVIP facts














14

















15


When can I enroll




How do I enroll








16


















17





Key FSAFEDS facts













18













19




When can I enroll











20


How do I enroll










21




Key FEGLI facts



















22




When can I enroll







How do I enroll








23




Key FLTCIP facts












24





How do I apply








25


26


















27
















pay more








28












29


Definitions













30















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



31














32









33











Enrollment Code


Monthly Biweekly















421 422 13272 32275 6126 14896




34




Plan

Benefit Type





RampB

Prescription Drugs


Office Visits


Calendar Year

Prescription Drug

APWU shyhigh

BCBS shystd

BCBS shybasic

GEHA shyhigh

GEHA shystd

MHBP shystd

MHBP shyValue

NALC shyhigh

SAMBA shyhigh

SAMBA shystd

CRHP

FSBP

PCABP

Rural

PPO NonshyPPO

PPO NonshyPPO

PPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

POS FFS

PPO NonshyPPO

$275 None $500 None

$350 None $350 None

None None

$350 None $350 None

$350 None $350 None

$400 None $600 None


$300 None $300 None

$300 None $300 None

$350 None $350 None

$300 None $350 None

$300 None $300 None

None None None None

$350 $200 $400 $200


None $300

$250 $350

$150day x 5

$100 $300

None None

$200 $500

None None

$200 $350

$200 $300

$150 up to $450 $200 up to $600

$150 $350

Nothing $200

$100 $25

$100 $300

$18 10 30+diff 30+diff

$20 15 35 35

$25 $150

$20 10 25 25

$10 15 35 35

$20 10 30 30

$30 20 40 40

$20 15 30 30

$20 10 30 30

$20 15 35 35

$10 Nothing 30 30

10 10 30 30

50 50 $5 Nothing

$20 10 25 25

10 30

Nothing 35

Nothing

Nothing Nothing

15 35

Nothing 30

20 40

Nothing 30

Nothing 30

Nothing 35

Nothing 30

Nothing 20

50 Nothing

Nothing 20

$8 2525 Yes 50 5050 Yes

20 (15MCare B) 3030 Yes 45 + 45+45+ Yes

$10 $50$150 NA



$10 30($200 max)50($200 max) Yes 50 5050 Yes


20 3030 Yes 45 45+ 45+45+ Yes



$5 $3030 or $45 Yes $5 $3030 or $45 Yes


20 2020 No 20 2020 No

30 3030 Yes 30 3030 Yes


35













Plan Code


Getting needed care


How well doctors


Claims processing



FFS National A

47

verage 774

78

916

898

91

921

948

938

897

837

929

898

725

737 47





MHBP shystd 45 706 916 917 943 898 927 713 45


NALC shyhigh 32 811 934 914 951 923 951 766 32

SAMBA shyhigh 44 893 946 937 968 901 973 791 44

SAMBA shystd 44 745 923 933 952 903 925 74



44

42

roups Average 774 916 91 948 897 929 725

42




36



Location Plan Name


Plan Code


Getting needed care


How well doctors


Claims processing











37


38















39





Arizona




Arkansas



California












Colorado





40


Primary care



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

Arizona


HMOP

$35$65

OS Nationa

Yes

l Average 659

583

855

842

855

864

935

883

839

858

876

884

664

636



Arkansas


$15$40

$20$30

$250day x 3

$100max$500

$10

$0

$40$70

$40$60

Yes

Yes

702

61

878

845

868

873

921

935

863

877

946

887

675



California


$20$40

$20$35

$200max$1000

$250day x 4

$5

$10

$40$60

$35$65

Yes

Yes

61

612

845

808

873

822

935

922

877

813

887

882

652

608











Colorado


$20$35

$20$40

$150day x 4

$250

$10

$10

$35$60

$35$60

Yes

Yes

692

716

787

833

824

862

935

918

761

77

88

876

588

684



$25$45

$20$35

$250day x 3

$150day x 5

$15

$10

$40$80

$35$65

Yes

Yes

716

616

833

884

862

88

918

943

77

857

876

932

684

631


41







Self amp family


























42


Primary care



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


HMO

$35$65

POS National

Yes

Average 659

659

855

871

855

87

935

918

839

901

876

874

664

667







MD IPAshyHigh


$25$40

$15$40

$150day x 3

$150day x 5

$7

$5

$30$150$250

$30$5030

Yes

No

632

724

838

869

871

855

925

913

841

894

90

853

65

648










$25$40

$20$35

$500day x 3

$250day x 4

$10

$10

$40$60

$35$65

Yes

Yes 569 888 835 927 882 873 589









43





Guam






Idaho





Illinois











44


Primary care



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

Guam


HMOP

$15$25$50

OS Nationa

No

l Average 659

642

855

726

855

626

935

895

839

694

876

664

664

563

TakeCareshyStd


$25$40

$15$15

$150day for 5 days

$100

$15

$7

$20$40$80

$30$65

No

Yes

642

833

726

924

626

91

895

959

694

837

664

941

563


$65+20 No 833 924 91 959 837 941 666



Idaho


$30$30

$20$30

10

$200

$20

$7

$20$20

$25$50

Yes

Yes

751

556

821

86

797

88

935

948

792

817

853

853

707

625




Illinois


$25+20$25+20

$20$35

$500day x 3

$250day x 4

$20

$10

$40$60

$35$65

Yes

Yes

691

615

839

826

844

82

926

909

867

866

896

823

711

642











45







Self amp family

Indiana








Iowa









Kansas






46


Primary care



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

$35$65

OS Nationa

Yes

l Average 659

615

855

826

855

82

935

909

839

866

876

823

664

642







Iowa


$15$15

$20$45

20

15

$10

$3$10

$25$50

$40$65

Yes

Yes

583

567

879

857

88

867

952

966

905

824

944

907

603

675









Kansas


$25$45

$20$35

Nothing

$250day x 4

$10

$10

$35$50

$35$65

Yes

Yes

524 873 853 956 798 886 622





47





Kentucky





Louisiana



Maryland










Massachusetts


48


Primary care



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

Kentucky


HMO

$40$60

POS National

Yes

Average 659 855 855 935 839 876 664




Louisiana


$25$40

$25$45

$500day x 3

$100

$10

$5

$40$60

$40$75

Yes

Yes 579 866 853 964 793 843 677


Maryland


$30$55

$15$30

30

$150day x3

$5

$5

$40$75

$35$65

Yes

Yes

579

659

866

871

853

87

964

918

793

901

843

874

677

667









MD IPAshyHigh

Massachusetts


$25$40

$25$35

$150day x 3

$150 to $750max

$7

$10

$30$150$250

$30$60

Yes

Yes

632

61

838

862

871

883

925

95

841

828

90

799

65

627

49























Enrollment Code


Michigan

H61 H62

J31 J32

K51 K52

LX1 LX2

RL1 RL2

RL4 RL5

521 522

GY4 GY5

X51 X52

9U4 9U5

Minnesota

V31 V32

V34 V35

Missouri HY1 HY2

9G1 9G2

HA1 HA2

HA4 HA5

MS1 MS2

MS4 MS5

B91 B92

Telephone Number

800shy662shy6667

800shy662shy6667

800shy662shy6667

800shy662shy6667

616shy949shy2410

616shy949shy2410

800shy556shy9765

800shy556shy9765

800shy332shy9161

866shy539shy3342

952shy883shy5000

952shy883shy5000

877shy459shy6604

888shy811shy2092

800shy969shy3343

800shy969shy3343

888shy393shy6765

888shy393shy6765

877shy835shy9861

50

Monthly


17455 60199

20874 69088

15762 37947

12930 44648

19006 64274

12973 45145

15511 44042

12822 33321

12002 34959

20141 55759

32886 78427

8987 20671

11817 36274

26208 54102

12196 32723

10096 23722

45714 103636

13457 31059

19353 43374

Biweekly


8056 27784

9634 31887

7275 17514

5968 20607

8772 29665

5987 20836

7159 20327

5918 15379

5539 16135

9296 25735

15178 36197

4148 9540

5454 16742

12096 24970

5629 15103

4660 10948

21099 47832

6211 14335

8932 20019


Primary care



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


HMO

$50NA

POS National

Yes

Average 659 855 855 935 839 876 664










Minnesota


$20Nothing

$25$45

20

Nothing

$15

$12

$25$50

$45$90

Yes

Yes

774

641

906

873

886

897

964

951

893

888

887

912

69

66




$250day x 4

$9

$10

$40$70

$35$65

Yes

Yes

641 873 897 951 888 912 66








51








Nevada

HF1 HF2 10582 33646 4884 15529

NM1 NM2 10448 24635 4822 11370

Telephone Number

877shy459shy6604

800shy777shy1840

New Jersey







New Mexico



52

Q11 Q12 22873 58561 10557 27028

P21 P22 17370 41076 8017 18958


Primary care



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

Nevada


HMO

$35$65

POS National

Yes

Average 659 855 855 935 839 876 664


New Jersey


$10$20

$20$35

$150

$150day x 5

$5

$10

$35$55

$35$65

Yes

Yes

567

617

709

855

706

886

898

937

78

852

845

861

561

605






New Mexico


$25$25

$20$35

$250day x 3

$250 after ded

$5

$5

$25$50

$35$6050

Yes

Yes

604

623

856

807

861

786

926

896

763

807

772

862

572

746


53




























54


Primary care



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


HMO

$35$65

POS National

Yes

Average 659

651

855

828

855

853

935

927

839

873

876

875

664

60























55





North Dakota




Ohio






Oklahoma


Oregon



56


Primary care



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 Dakota


HMO

$45$90

POS National

Yes

Average 659

641

855

873

855

897

935

951

839

888

876

912

664

66



Ohio

AultCare HMOshyHigh

2020

$15$20

20

$150

NA

$15

NA

$30$45

NA

No 865 935 926 946 946 958 863





Oklahoma


Oregon


$10$20

$15$35

$15$25

$250

$150day x 3

$200

$15

$10

$15

$30$50

$30$40

$40$40

Yes

Yes

Yes

739

56

677

905

731

769

89

812

778

963

941

893

927

715

864

957

883

848

758

626

679


57





Pennsylvania











South Dakota





Tennessee




58


Primary care



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

Pennsylvania


HMO

$35$65

POS National

Yes

Average 659

567

855

873

855

885

935

946

839

752

876

886

664

682









$20$35

$5$5

None

None

$5

$250

$35$70

$10$15

Yes

Yes

764

753

903

807

871

815

959

936

87

834

885

811

716




South Dakota


$750+10$10+10

$25$45

10 +

Nothing

NA

$12

NA NA

$45$90

No

Yes

716

641

857

873

796

897

968

951

683

888

695

912

514

66




Tennessee


4040

$20$35

40

$250day x 4

NA

$10

NA NA

$35$65

No

Yes

53

639

831

877

861

842

963

936

905

85

907

919

703

708



59





Texas










Utah




Virgin Islands












60


Primary care



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

$35$65

OS Nationa

Yes

l Average 659

698

855

833

855

793

935

896

839

829

876

886

664

652









Utah


$20$40

$20$30

$250day x 5

$200

$10

$7

$35$60

$25$50

Yes

Yes

654

556

864

86

842

88

936

948

797

817

905

853

646

625


SelectHealthshyHigh

Virgin Islands


$15$25

$750$10

$100

None

$5

$5 or $12

$2550


NA

Yes x

553 834 823 93 935 92 712



$10 amp 10+

$150day x3 $5 $35$65 Yes 659 871 87 918 901 874 667











61





Washington







West Virginia


Wisconsin







Wyoming



62


Primary care



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

Washington


HMOP

$40$60

OS National

Yes

Average 659

691

855

839

855

844

935

926

839

867

876

896

664

711









West Virginia


Wisconsin


$25$35

$10$20

$10$10

$500

$250

None

$20

$15

$10

$40$40

$30$50

30$75max30

Yes

Yes

No

677

739

77

769

905

871

778

89

883

893

963

962

864

927

854

848

957

921

679

758

689






Wyoming


$10$10

$20$30

Nothing

$200

$10

$7

3050

$25$50

No

Yes

766

556

86

86

889

88

95

948

901

817

912

853

723

625


63











64



















insurance plans

65



ELIGIBILITY

FUNDING







CONTRIBUTIONS

DISTRIBUTIONS







ANNUAL ROLLOVER







66




67












Self only

Self amp family

Self only

Self amp family

Self only

Self amp family




866shy833shy3463

800shy821shy6136

800shy694shy9901

474 475

341 342

481 482

8923 20072

9996 22832

11557 26186

4118 9264

4614 10538

5334 12086

68













69












Plan Code


Getting needed care


How well doctors


Claims processing






22

34

48

60

637

54

856

864

868

893

885

877

935

923

936

859

852

839

90

876

892

592

593

547


Plan Code


Getting needed care


How well doctors


Claims processing






22

47

TU TV

60

643

489

856

884

806

893

868

841

935

924

929

859

803

839

90

809

891

592

657

609

70


71





Plan Name

Telephone Number


Self only

Self amp family

Self only

Self amp family

Self only

Self amp family



877shy459shy6604

877shy459shy6604

221 222

224 225

15604 37056

9412 20613

7202 17103

4344 9514


Florida







Idaho


Plan Name

800shy441shy5501

888shy393shy6765

888shy393shy6765

888shy393shy6765

888shy393shy6765

671shy647shy3526

800shy377shy4161

Telephone Number


J41

MJ1

QP1

AD1

LM1

KX1

9K4

Self only

J42

MJ2

QP2

AD2

LM2

KX2

9K5

Self amp family

11570

12685

10873

11477

11840

8138

8704

Self only

28710

28542

24465

25824

26639

21442

18033

Self amp family

5340

5855

5018

5297

5464

3756

4017

Self only

13251

13173

11291

11919

12295

9896

8323

Self amp family

72



Benefit Type


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs




Benefit Type


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Florida


Plan Name

$8334$16667 $2500$5000 $5000$10000 $10 20 20 Nothing $5$35$5020






OutshyNetwork

InshyNetwork

NA

$8333

$3000$6000

$1000$2000

$4000$8000

$3000$6000

30

$25

30

$300day x 5

30

$150

30

Nothing

$10+$40+$60+



Guam TakeCareshy

OutshyNetwork

InshyNetwork

NA

$8666$22208

$3000$6000

$3000$6000

$4000$8000

$5000$10000

30

20afterDed

30

20 after Ded

30

20 after Ded

30

Nothing

$10+$40+$60+


Idaho

Altius Health Plans


$4583$9166

$3000$6000

$1200$2400

$10000$20000

$5000$10000 $20

30 afterDed

10


10

1st $300ded

Nothing

30 after Ded

$7$25$50

73












Plan Name

888shy393shy6765

888shy393shy6765

888shy393shy6765

800shy257shy4692

800shy969shy3343

888shy393shy6765

888shy393shy6765

800shy833shy7423

Telephone Number


GB1

MW1

MW1

SV4

9H1

PH1

6N1

GZ1

Self only

GB2

MW2

MW2

SV5

9H2

PH2

6N2

GZ2

Self amp family

12685

12081

12081

8608

9721

10873

10064

9834

Self only

28542

27182

27182

20544

22845

24464

22644

22508

Self amp family

5855

5576

5576

3973

4486

5018

4645

4539

Self only

13173

12546

12546

9482

10544

11291

10451

10388

Self amp family

74










75

A








Pennsylvania







Plan Name

800shy969shy3343

888shy393shy6765

800shy501shy3439

330shy363shy6360

866shy351shy5946

866shy351shy5946

888shy876shy2756

888shy393shy6765

888shy393shy6765

888shy393shy6765

Telephone Number


9H1

PH1

QA4

3A4

Y61

YW1

8W4

TP1

TU1

TV1

Self only

9H2

PH2

QA5

3A5

Y62

YW2

8W5

TP2

TU2

TV2

Self amp family

9721

10873

9633

7760

11914

14046

11884

11840

12081

12284

Self only

22845

24464

24717

15548

27430

30756

26620

26640

27182

27639

Self amp family

4486

5018

4446

3581

5499

6483

5485

5464

5576

5669

Self only

10544

11291

11408

7176

12660

14195

12286

12295

12546

12756

Self amp family

76






Pennsylvania








77





Wyoming


Plan Name

800shy377shy4161

800shy552shy7114

800shy377shy4161

Telephone Number


9K4

L14

9K4

Self only

9K5

L15

9K5

Self amp family

8704

9545

8704

Self only

18033

20857

18033

Self amp family

4017

4405

4017

Self only

8323

9626

8323

Self amp family

78



Washington $10$3550


Wyoming


79


80

Appendix F


Waiting Periods





Contributions


Salary Deduction





81


















82






Increase Enrollment

Type

Decrease Enrollment

Type







Yes Yes No No No


No No No No Yes


or spouse)

No No No Yes No



Yes No No No No




No No No Yes No







83

Appendix I



Reading the Chart


Dental Insurance









Vision Insurance



84



Plan Name

Telephone amp

Website


Class A

Class B

Class C

Class D

Deductible





0 40 60 70 $0





0 45 65 50 $0


0 20 50 50 $0


0 20 50 50 $0












wwwuccifedvipcom




40 60 50 $0


85




Plan Name

Telephone amp

Website

Class A

Class B

Class C

Class D Deductible





Class B and Class C


787shy774shy6060 787shy749shy4777

0 30 60 30






86








FEP BlueVision High





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

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

$0

$0

















87




Salud




















88



Rating Areas




















OH 453shy455 2 2 2 1 1 2 1 NA NA




89




Salud















90








3 $1471 $2941 $4411 $3187 $6372 $9557 4 $1622 $3243 $4865 $3514 $7027 $10541 5 $1760 $3521 $5281 $3813 $7629 $11442


3 $1132 $2262 $3393 $2453 $4901 $7352 4 $1221 $2441 $3662 $2646 $5289 $7934 5 $1355 $2710 $4064 $2936 $5872 $8805


3 $1857 $3715 $5573 $4024 $8049 $12075 4 $2005 $4010 $6017 $4344 $8688 $13037 5 $2225 $4453 $6681 $4821 $9648 $14476


3 $1022 $2042 $3064 $2214 $4424 $6639 4 $1135 $2270 $3404 $2459 $4918 $7375 5 $1246 $2492 $3739 $2700 $5399 $8101


3 $1910 $3815 $5725 $4138 $8266 $12404 4 $2066 $4129 $6194 $4476 $8946 $13420 5 $2313 $4625 $6937 $5012 $10021 $15030


3 $1767 $3529 $5295 $3829 $7646 $11473 4 $1906 $3806 $5713 $4130 $8246 $12378 5 $2054 $4107 $6160 $4450 $8899 $13347

9911








Self amp Family




1 $1618 $3234 $4852 $3506 $7007 $10513



1 $435 $869 $1141 $943 $1883 $2472


Plan Name




Self amp Family

Aetna

GEHA Standard

GEHA High

MetLife Standard

MetLife High

United Concordia

$1882

$908

$1489

$1246

$2313

$2054

$3762

$1816

$2977

$2492

$4625

$4107

$5644

$2726

$4469

$3739

$6937

$6160

$4078

$1967

$3226

$2700

$5012

$4450

$8151

$3935

$6450

$5399

$10021

$8899

$12229

$5906

$9683

$8101

$15030

$13347

92


Premium Rate Charts



Plan Option




Self amp Family

FEP BlueVision







Standard High

Standard High

Standard High

$377 $475

$300 $423

$413 $617

$752 $949

$585 $824

$825 $1233

$1129 $1425

$871 $1228

$1238 $1850

$817 $1029

$650 $916

$895 $1337

$1629 $2056

$1269 $1786

$1788 $2672

$2446 $3088

$1887 $2660

$2682 $4008



Plan Option




Self amp Family

FEP BlueVision







Standard High

Standard High

Standard High

$377 $475

$300 $423

$413 $617

$752 $949

$585 $824

$825 $1233

$1129 $1425

$871 $1228

$1238 $1850

$817 $1029

$650 $916

$895 $1337

$1629 $2056

$1269 $1786

$1788 $2672

$2446 $3088

$1887 $2660

$2682 $4008

93


















94
























95

Summary Information




















wwwopmgovinsurelife




96


2











3








4
















5


Current Employees



























6

















7







FSAFEDS




8



FEGLI












9






Key FEHB facts













10














11


When can I enroll



How do I enroll




12















13






Key FEDVIP facts














14

















15


When can I enroll




How do I enroll








16


















17





Key FSAFEDS facts













18













19




When can I enroll











20


How do I enroll










21




Key FEGLI facts



















22




When can I enroll







How do I enroll








23




Key FLTCIP facts












24





How do I apply








25


26


















27
















pay more








28












29


Definitions













30















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



31














32









33











Enrollment Code


Monthly Biweekly















421 422 13272 32275 6126 14896




34




Plan

Benefit Type





RampB

Prescription Drugs


Office Visits


Calendar Year

Prescription Drug

APWU shyhigh

BCBS shystd

BCBS shybasic

GEHA shyhigh

GEHA shystd

MHBP shystd

MHBP shyValue

NALC shyhigh

SAMBA shyhigh

SAMBA shystd

CRHP

FSBP

PCABP

Rural

PPO NonshyPPO

PPO NonshyPPO

PPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

POS FFS

PPO NonshyPPO

$275 None $500 None

$350 None $350 None

None None

$350 None $350 None

$350 None $350 None

$400 None $600 None


$300 None $300 None

$300 None $300 None

$350 None $350 None

$300 None $350 None

$300 None $300 None

None None None None

$350 $200 $400 $200


None $300

$250 $350

$150day x 5

$100 $300

None None

$200 $500

None None

$200 $350

$200 $300

$150 up to $450 $200 up to $600

$150 $350

Nothing $200

$100 $25

$100 $300

$18 10 30+diff 30+diff

$20 15 35 35

$25 $150

$20 10 25 25

$10 15 35 35

$20 10 30 30

$30 20 40 40

$20 15 30 30

$20 10 30 30

$20 15 35 35

$10 Nothing 30 30

10 10 30 30

50 50 $5 Nothing

$20 10 25 25

10 30

Nothing 35

Nothing

Nothing Nothing

15 35

Nothing 30

20 40

Nothing 30

Nothing 30

Nothing 35

Nothing 30

Nothing 20

50 Nothing

Nothing 20

$8 2525 Yes 50 5050 Yes

20 (15MCare B) 3030 Yes 45 + 45+45+ Yes

$10 $50$150 NA



$10 30($200 max)50($200 max) Yes 50 5050 Yes


20 3030 Yes 45 45+ 45+45+ Yes



$5 $3030 or $45 Yes $5 $3030 or $45 Yes


20 2020 No 20 2020 No

30 3030 Yes 30 3030 Yes


35













Plan Code


Getting needed care


How well doctors


Claims processing



FFS National A

47

verage 774

78

916

898

91

921

948

938

897

837

929

898

725

737 47





MHBP shystd 45 706 916 917 943 898 927 713 45


NALC shyhigh 32 811 934 914 951 923 951 766 32

SAMBA shyhigh 44 893 946 937 968 901 973 791 44

SAMBA shystd 44 745 923 933 952 903 925 74



44

42

roups Average 774 916 91 948 897 929 725

42




36



Location Plan Name


Plan Code


Getting needed care


How well doctors


Claims processing











37


38















39





Arizona




Arkansas



California












Colorado





40


Primary care



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

Arizona


HMOP

$35$65

OS Nationa

Yes

l Average 659

583

855

842

855

864

935

883

839

858

876

884

664

636



Arkansas


$15$40

$20$30

$250day x 3

$100max$500

$10

$0

$40$70

$40$60

Yes

Yes

702

61

878

845

868

873

921

935

863

877

946

887

675



California


$20$40

$20$35

$200max$1000

$250day x 4

$5

$10

$40$60

$35$65

Yes

Yes

61

612

845

808

873

822

935

922

877

813

887

882

652

608











Colorado


$20$35

$20$40

$150day x 4

$250

$10

$10

$35$60

$35$60

Yes

Yes

692

716

787

833

824

862

935

918

761

77

88

876

588

684



$25$45

$20$35

$250day x 3

$150day x 5

$15

$10

$40$80

$35$65

Yes

Yes

716

616

833

884

862

88

918

943

77

857

876

932

684

631


41







Self amp family


























42


Primary care



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


HMO

$35$65

POS National

Yes

Average 659

659

855

871

855

87

935

918

839

901

876

874

664

667







MD IPAshyHigh


$25$40

$15$40

$150day x 3

$150day x 5

$7

$5

$30$150$250

$30$5030

Yes

No

632

724

838

869

871

855

925

913

841

894

90

853

65

648










$25$40

$20$35

$500day x 3

$250day x 4

$10

$10

$40$60

$35$65

Yes

Yes 569 888 835 927 882 873 589









43





Guam






Idaho





Illinois











44


Primary care



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

Guam


HMOP

$15$25$50

OS Nationa

No

l Average 659

642

855

726

855

626

935

895

839

694

876

664

664

563

TakeCareshyStd


$25$40

$15$15

$150day for 5 days

$100

$15

$7

$20$40$80

$30$65

No

Yes

642

833

726

924

626

91

895

959

694

837

664

941

563


$65+20 No 833 924 91 959 837 941 666



Idaho


$30$30

$20$30

10

$200

$20

$7

$20$20

$25$50

Yes

Yes

751

556

821

86

797

88

935

948

792

817

853

853

707

625




Illinois


$25+20$25+20

$20$35

$500day x 3

$250day x 4

$20

$10

$40$60

$35$65

Yes

Yes

691

615

839

826

844

82

926

909

867

866

896

823

711

642











45







Self amp family

Indiana








Iowa









Kansas






46


Primary care



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

$35$65

OS Nationa

Yes

l Average 659

615

855

826

855

82

935

909

839

866

876

823

664

642







Iowa


$15$15

$20$45

20

15

$10

$3$10

$25$50

$40$65

Yes

Yes

583

567

879

857

88

867

952

966

905

824

944

907

603

675









Kansas


$25$45

$20$35

Nothing

$250day x 4

$10

$10

$35$50

$35$65

Yes

Yes

524 873 853 956 798 886 622





47





Kentucky





Louisiana



Maryland










Massachusetts


48


Primary care



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

Kentucky


HMO

$40$60

POS National

Yes

Average 659 855 855 935 839 876 664




Louisiana


$25$40

$25$45

$500day x 3

$100

$10

$5

$40$60

$40$75

Yes

Yes 579 866 853 964 793 843 677


Maryland


$30$55

$15$30

30

$150day x3

$5

$5

$40$75

$35$65

Yes

Yes

579

659

866

871

853

87

964

918

793

901

843

874

677

667









MD IPAshyHigh

Massachusetts


$25$40

$25$35

$150day x 3

$150 to $750max

$7

$10

$30$150$250

$30$60

Yes

Yes

632

61

838

862

871

883

925

95

841

828

90

799

65

627

49























Enrollment Code


Michigan

H61 H62

J31 J32

K51 K52

LX1 LX2

RL1 RL2

RL4 RL5

521 522

GY4 GY5

X51 X52

9U4 9U5

Minnesota

V31 V32

V34 V35

Missouri HY1 HY2

9G1 9G2

HA1 HA2

HA4 HA5

MS1 MS2

MS4 MS5

B91 B92

Telephone Number

800shy662shy6667

800shy662shy6667

800shy662shy6667

800shy662shy6667

616shy949shy2410

616shy949shy2410

800shy556shy9765

800shy556shy9765

800shy332shy9161

866shy539shy3342

952shy883shy5000

952shy883shy5000

877shy459shy6604

888shy811shy2092

800shy969shy3343

800shy969shy3343

888shy393shy6765

888shy393shy6765

877shy835shy9861

50

Monthly


17455 60199

20874 69088

15762 37947

12930 44648

19006 64274

12973 45145

15511 44042

12822 33321

12002 34959

20141 55759

32886 78427

8987 20671

11817 36274

26208 54102

12196 32723

10096 23722

45714 103636

13457 31059

19353 43374

Biweekly


8056 27784

9634 31887

7275 17514

5968 20607

8772 29665

5987 20836

7159 20327

5918 15379

5539 16135

9296 25735

15178 36197

4148 9540

5454 16742

12096 24970

5629 15103

4660 10948

21099 47832

6211 14335

8932 20019


Primary care



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


HMO

$50NA

POS National

Yes

Average 659 855 855 935 839 876 664










Minnesota


$20Nothing

$25$45

20

Nothing

$15

$12

$25$50

$45$90

Yes

Yes

774

641

906

873

886

897

964

951

893

888

887

912

69

66




$250day x 4

$9

$10

$40$70

$35$65

Yes

Yes

641 873 897 951 888 912 66








51








Nevada

HF1 HF2 10582 33646 4884 15529

NM1 NM2 10448 24635 4822 11370

Telephone Number

877shy459shy6604

800shy777shy1840

New Jersey







New Mexico



52

Q11 Q12 22873 58561 10557 27028

P21 P22 17370 41076 8017 18958


Primary care



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

Nevada


HMO

$35$65

POS National

Yes

Average 659 855 855 935 839 876 664


New Jersey


$10$20

$20$35

$150

$150day x 5

$5

$10

$35$55

$35$65

Yes

Yes

567

617

709

855

706

886

898

937

78

852

845

861

561

605






New Mexico


$25$25

$20$35

$250day x 3

$250 after ded

$5

$5

$25$50

$35$6050

Yes

Yes

604

623

856

807

861

786

926

896

763

807

772

862

572

746


53




























54


Primary care



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


HMO

$35$65

POS National

Yes

Average 659

651

855

828

855

853

935

927

839

873

876

875

664

60























55





North Dakota




Ohio






Oklahoma


Oregon



56


Primary care



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 Dakota


HMO

$45$90

POS National

Yes

Average 659

641

855

873

855

897

935

951

839

888

876

912

664

66



Ohio

AultCare HMOshyHigh

2020

$15$20

20

$150

NA

$15

NA

$30$45

NA

No 865 935 926 946 946 958 863





Oklahoma


Oregon


$10$20

$15$35

$15$25

$250

$150day x 3

$200

$15

$10

$15

$30$50

$30$40

$40$40

Yes

Yes

Yes

739

56

677

905

731

769

89

812

778

963

941

893

927

715

864

957

883

848

758

626

679


57





Pennsylvania











South Dakota





Tennessee




58


Primary care



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

Pennsylvania


HMO

$35$65

POS National

Yes

Average 659

567

855

873

855

885

935

946

839

752

876

886

664

682









$20$35

$5$5

None

None

$5

$250

$35$70

$10$15

Yes

Yes

764

753

903

807

871

815

959

936

87

834

885

811

716




South Dakota


$750+10$10+10

$25$45

10 +

Nothing

NA

$12

NA NA

$45$90

No

Yes

716

641

857

873

796

897

968

951

683

888

695

912

514

66




Tennessee


4040

$20$35

40

$250day x 4

NA

$10

NA NA

$35$65

No

Yes

53

639

831

877

861

842

963

936

905

85

907

919

703

708



59





Texas










Utah




Virgin Islands












60


Primary care



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

$35$65

OS Nationa

Yes

l Average 659

698

855

833

855

793

935

896

839

829

876

886

664

652









Utah


$20$40

$20$30

$250day x 5

$200

$10

$7

$35$60

$25$50

Yes

Yes

654

556

864

86

842

88

936

948

797

817

905

853

646

625


SelectHealthshyHigh

Virgin Islands


$15$25

$750$10

$100

None

$5

$5 or $12

$2550


NA

Yes x

553 834 823 93 935 92 712



$10 amp 10+

$150day x3 $5 $35$65 Yes 659 871 87 918 901 874 667











61





Washington







West Virginia


Wisconsin







Wyoming



62


Primary care



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

Washington


HMOP

$40$60

OS National

Yes

Average 659

691

855

839

855

844

935

926

839

867

876

896

664

711









West Virginia


Wisconsin


$25$35

$10$20

$10$10

$500

$250

None

$20

$15

$10

$40$40

$30$50

30$75max30

Yes

Yes

No

677

739

77

769

905

871

778

89

883

893

963

962

864

927

854

848

957

921

679

758

689






Wyoming


$10$10

$20$30

Nothing

$200

$10

$7

3050

$25$50

No

Yes

766

556

86

86

889

88

95

948

901

817

912

853

723

625


63











64



















insurance plans

65



ELIGIBILITY

FUNDING







CONTRIBUTIONS

DISTRIBUTIONS







ANNUAL ROLLOVER







66




67












Self only

Self amp family

Self only

Self amp family

Self only

Self amp family




866shy833shy3463

800shy821shy6136

800shy694shy9901

474 475

341 342

481 482

8923 20072

9996 22832

11557 26186

4118 9264

4614 10538

5334 12086

68













69












Plan Code


Getting needed care


How well doctors


Claims processing






22

34

48

60

637

54

856

864

868

893

885

877

935

923

936

859

852

839

90

876

892

592

593

547


Plan Code


Getting needed care


How well doctors


Claims processing






22

47

TU TV

60

643

489

856

884

806

893

868

841

935

924

929

859

803

839

90

809

891

592

657

609

70


71





Plan Name

Telephone Number


Self only

Self amp family

Self only

Self amp family

Self only

Self amp family



877shy459shy6604

877shy459shy6604

221 222

224 225

15604 37056

9412 20613

7202 17103

4344 9514


Florida







Idaho


Plan Name

800shy441shy5501

888shy393shy6765

888shy393shy6765

888shy393shy6765

888shy393shy6765

671shy647shy3526

800shy377shy4161

Telephone Number


J41

MJ1

QP1

AD1

LM1

KX1

9K4

Self only

J42

MJ2

QP2

AD2

LM2

KX2

9K5

Self amp family

11570

12685

10873

11477

11840

8138

8704

Self only

28710

28542

24465

25824

26639

21442

18033

Self amp family

5340

5855

5018

5297

5464

3756

4017

Self only

13251

13173

11291

11919

12295

9896

8323

Self amp family

72



Benefit Type


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs




Benefit Type


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Florida


Plan Name

$8334$16667 $2500$5000 $5000$10000 $10 20 20 Nothing $5$35$5020






OutshyNetwork

InshyNetwork

NA

$8333

$3000$6000

$1000$2000

$4000$8000

$3000$6000

30

$25

30

$300day x 5

30

$150

30

Nothing

$10+$40+$60+



Guam TakeCareshy

OutshyNetwork

InshyNetwork

NA

$8666$22208

$3000$6000

$3000$6000

$4000$8000

$5000$10000

30

20afterDed

30

20 after Ded

30

20 after Ded

30

Nothing

$10+$40+$60+


Idaho

Altius Health Plans


$4583$9166

$3000$6000

$1200$2400

$10000$20000

$5000$10000 $20

30 afterDed

10


10

1st $300ded

Nothing

30 after Ded

$7$25$50

73












Plan Name

888shy393shy6765

888shy393shy6765

888shy393shy6765

800shy257shy4692

800shy969shy3343

888shy393shy6765

888shy393shy6765

800shy833shy7423

Telephone Number


GB1

MW1

MW1

SV4

9H1

PH1

6N1

GZ1

Self only

GB2

MW2

MW2

SV5

9H2

PH2

6N2

GZ2

Self amp family

12685

12081

12081

8608

9721

10873

10064

9834

Self only

28542

27182

27182

20544

22845

24464

22644

22508

Self amp family

5855

5576

5576

3973

4486

5018

4645

4539

Self only

13173

12546

12546

9482

10544

11291

10451

10388

Self amp family

74










75

A








Pennsylvania







Plan Name

800shy969shy3343

888shy393shy6765

800shy501shy3439

330shy363shy6360

866shy351shy5946

866shy351shy5946

888shy876shy2756

888shy393shy6765

888shy393shy6765

888shy393shy6765

Telephone Number


9H1

PH1

QA4

3A4

Y61

YW1

8W4

TP1

TU1

TV1

Self only

9H2

PH2

QA5

3A5

Y62

YW2

8W5

TP2

TU2

TV2

Self amp family

9721

10873

9633

7760

11914

14046

11884

11840

12081

12284

Self only

22845

24464

24717

15548

27430

30756

26620

26640

27182

27639

Self amp family

4486

5018

4446

3581

5499

6483

5485

5464

5576

5669

Self only

10544

11291

11408

7176

12660

14195

12286

12295

12546

12756

Self amp family

76






Pennsylvania








77





Wyoming


Plan Name

800shy377shy4161

800shy552shy7114

800shy377shy4161

Telephone Number


9K4

L14

9K4

Self only

9K5

L15

9K5

Self amp family

8704

9545

8704

Self only

18033

20857

18033

Self amp family

4017

4405

4017

Self only

8323

9626

8323

Self amp family

78



Washington $10$3550


Wyoming


79


80

Appendix F


Waiting Periods





Contributions


Salary Deduction





81


















82






Increase Enrollment

Type

Decrease Enrollment

Type







Yes Yes No No No


No No No No Yes


or spouse)

No No No Yes No



Yes No No No No




No No No Yes No







83

Appendix I



Reading the Chart


Dental Insurance









Vision Insurance



84



Plan Name

Telephone amp

Website


Class A

Class B

Class C

Class D

Deductible





0 40 60 70 $0





0 45 65 50 $0


0 20 50 50 $0


0 20 50 50 $0












wwwuccifedvipcom




40 60 50 $0


85




Plan Name

Telephone amp

Website

Class A

Class B

Class C

Class D Deductible





Class B and Class C


787shy774shy6060 787shy749shy4777

0 30 60 30






86








FEP BlueVision High





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

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

$0

$0

















87




Salud




















88



Rating Areas




















OH 453shy455 2 2 2 1 1 2 1 NA NA




89




Salud















90








3 $1471 $2941 $4411 $3187 $6372 $9557 4 $1622 $3243 $4865 $3514 $7027 $10541 5 $1760 $3521 $5281 $3813 $7629 $11442


3 $1132 $2262 $3393 $2453 $4901 $7352 4 $1221 $2441 $3662 $2646 $5289 $7934 5 $1355 $2710 $4064 $2936 $5872 $8805


3 $1857 $3715 $5573 $4024 $8049 $12075 4 $2005 $4010 $6017 $4344 $8688 $13037 5 $2225 $4453 $6681 $4821 $9648 $14476


3 $1022 $2042 $3064 $2214 $4424 $6639 4 $1135 $2270 $3404 $2459 $4918 $7375 5 $1246 $2492 $3739 $2700 $5399 $8101


3 $1910 $3815 $5725 $4138 $8266 $12404 4 $2066 $4129 $6194 $4476 $8946 $13420 5 $2313 $4625 $6937 $5012 $10021 $15030


3 $1767 $3529 $5295 $3829 $7646 $11473 4 $1906 $3806 $5713 $4130 $8246 $12378 5 $2054 $4107 $6160 $4450 $8899 $13347

9911








Self amp Family




1 $1618 $3234 $4852 $3506 $7007 $10513



1 $435 $869 $1141 $943 $1883 $2472


Plan Name




Self amp Family

Aetna

GEHA Standard

GEHA High

MetLife Standard

MetLife High

United Concordia

$1882

$908

$1489

$1246

$2313

$2054

$3762

$1816

$2977

$2492

$4625

$4107

$5644

$2726

$4469

$3739

$6937

$6160

$4078

$1967

$3226

$2700

$5012

$4450

$8151

$3935

$6450

$5399

$10021

$8899

$12229

$5906

$9683

$8101

$15030

$13347

92


Premium Rate Charts



Plan Option




Self amp Family

FEP BlueVision







Standard High

Standard High

Standard High

$377 $475

$300 $423

$413 $617

$752 $949

$585 $824

$825 $1233

$1129 $1425

$871 $1228

$1238 $1850

$817 $1029

$650 $916

$895 $1337

$1629 $2056

$1269 $1786

$1788 $2672

$2446 $3088

$1887 $2660

$2682 $4008



Plan Option




Self amp Family

FEP BlueVision







Standard High

Standard High

Standard High

$377 $475

$300 $423

$413 $617

$752 $949

$585 $824

$825 $1233

$1129 $1425

$871 $1228

$1238 $1850

$817 $1029

$650 $916

$895 $1337

$1629 $2056

$1269 $1786

$1788 $2672

$2446 $3088

$1887 $2660

$2682 $4008

93


















94
























95

Summary Information




















wwwopmgovinsurelife




96











3








4
















5


Current Employees



























6

















7







FSAFEDS




8



FEGLI












9






Key FEHB facts













10














11


When can I enroll



How do I enroll




12















13






Key FEDVIP facts














14

















15


When can I enroll




How do I enroll








16


















17





Key FSAFEDS facts













18













19




When can I enroll











20


How do I enroll










21




Key FEGLI facts



















22




When can I enroll







How do I enroll








23




Key FLTCIP facts












24





How do I apply








25


26


















27
















pay more








28












29


Definitions













30















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



31














32









33











Enrollment Code


Monthly Biweekly















421 422 13272 32275 6126 14896




34




Plan

Benefit Type





RampB

Prescription Drugs


Office Visits


Calendar Year

Prescription Drug

APWU shyhigh

BCBS shystd

BCBS shybasic

GEHA shyhigh

GEHA shystd

MHBP shystd

MHBP shyValue

NALC shyhigh

SAMBA shyhigh

SAMBA shystd

CRHP

FSBP

PCABP

Rural

PPO NonshyPPO

PPO NonshyPPO

PPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

POS FFS

PPO NonshyPPO

$275 None $500 None

$350 None $350 None

None None

$350 None $350 None

$350 None $350 None

$400 None $600 None


$300 None $300 None

$300 None $300 None

$350 None $350 None

$300 None $350 None

$300 None $300 None

None None None None

$350 $200 $400 $200


None $300

$250 $350

$150day x 5

$100 $300

None None

$200 $500

None None

$200 $350

$200 $300

$150 up to $450 $200 up to $600

$150 $350

Nothing $200

$100 $25

$100 $300

$18 10 30+diff 30+diff

$20 15 35 35

$25 $150

$20 10 25 25

$10 15 35 35

$20 10 30 30

$30 20 40 40

$20 15 30 30

$20 10 30 30

$20 15 35 35

$10 Nothing 30 30

10 10 30 30

50 50 $5 Nothing

$20 10 25 25

10 30

Nothing 35

Nothing

Nothing Nothing

15 35

Nothing 30

20 40

Nothing 30

Nothing 30

Nothing 35

Nothing 30

Nothing 20

50 Nothing

Nothing 20

$8 2525 Yes 50 5050 Yes

20 (15MCare B) 3030 Yes 45 + 45+45+ Yes

$10 $50$150 NA



$10 30($200 max)50($200 max) Yes 50 5050 Yes


20 3030 Yes 45 45+ 45+45+ Yes



$5 $3030 or $45 Yes $5 $3030 or $45 Yes


20 2020 No 20 2020 No

30 3030 Yes 30 3030 Yes


35













Plan Code


Getting needed care


How well doctors


Claims processing



FFS National A

47

verage 774

78

916

898

91

921

948

938

897

837

929

898

725

737 47





MHBP shystd 45 706 916 917 943 898 927 713 45


NALC shyhigh 32 811 934 914 951 923 951 766 32

SAMBA shyhigh 44 893 946 937 968 901 973 791 44

SAMBA shystd 44 745 923 933 952 903 925 74



44

42

roups Average 774 916 91 948 897 929 725

42




36



Location Plan Name


Plan Code


Getting needed care


How well doctors


Claims processing











37


38















39





Arizona




Arkansas



California












Colorado





40


Primary care



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

Arizona


HMOP

$35$65

OS Nationa

Yes

l Average 659

583

855

842

855

864

935

883

839

858

876

884

664

636



Arkansas


$15$40

$20$30

$250day x 3

$100max$500

$10

$0

$40$70

$40$60

Yes

Yes

702

61

878

845

868

873

921

935

863

877

946

887

675



California


$20$40

$20$35

$200max$1000

$250day x 4

$5

$10

$40$60

$35$65

Yes

Yes

61

612

845

808

873

822

935

922

877

813

887

882

652

608











Colorado


$20$35

$20$40

$150day x 4

$250

$10

$10

$35$60

$35$60

Yes

Yes

692

716

787

833

824

862

935

918

761

77

88

876

588

684



$25$45

$20$35

$250day x 3

$150day x 5

$15

$10

$40$80

$35$65

Yes

Yes

716

616

833

884

862

88

918

943

77

857

876

932

684

631


41







Self amp family


























42


Primary care



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


HMO

$35$65

POS National

Yes

Average 659

659

855

871

855

87

935

918

839

901

876

874

664

667







MD IPAshyHigh


$25$40

$15$40

$150day x 3

$150day x 5

$7

$5

$30$150$250

$30$5030

Yes

No

632

724

838

869

871

855

925

913

841

894

90

853

65

648










$25$40

$20$35

$500day x 3

$250day x 4

$10

$10

$40$60

$35$65

Yes

Yes 569 888 835 927 882 873 589









43





Guam






Idaho





Illinois











44


Primary care



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

Guam


HMOP

$15$25$50

OS Nationa

No

l Average 659

642

855

726

855

626

935

895

839

694

876

664

664

563

TakeCareshyStd


$25$40

$15$15

$150day for 5 days

$100

$15

$7

$20$40$80

$30$65

No

Yes

642

833

726

924

626

91

895

959

694

837

664

941

563


$65+20 No 833 924 91 959 837 941 666



Idaho


$30$30

$20$30

10

$200

$20

$7

$20$20

$25$50

Yes

Yes

751

556

821

86

797

88

935

948

792

817

853

853

707

625




Illinois


$25+20$25+20

$20$35

$500day x 3

$250day x 4

$20

$10

$40$60

$35$65

Yes

Yes

691

615

839

826

844

82

926

909

867

866

896

823

711

642











45







Self amp family

Indiana








Iowa









Kansas






46


Primary care



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

$35$65

OS Nationa

Yes

l Average 659

615

855

826

855

82

935

909

839

866

876

823

664

642







Iowa


$15$15

$20$45

20

15

$10

$3$10

$25$50

$40$65

Yes

Yes

583

567

879

857

88

867

952

966

905

824

944

907

603

675









Kansas


$25$45

$20$35

Nothing

$250day x 4

$10

$10

$35$50

$35$65

Yes

Yes

524 873 853 956 798 886 622





47





Kentucky





Louisiana



Maryland










Massachusetts


48


Primary care



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

Kentucky


HMO

$40$60

POS National

Yes

Average 659 855 855 935 839 876 664




Louisiana


$25$40

$25$45

$500day x 3

$100

$10

$5

$40$60

$40$75

Yes

Yes 579 866 853 964 793 843 677


Maryland


$30$55

$15$30

30

$150day x3

$5

$5

$40$75

$35$65

Yes

Yes

579

659

866

871

853

87

964

918

793

901

843

874

677

667









MD IPAshyHigh

Massachusetts


$25$40

$25$35

$150day x 3

$150 to $750max

$7

$10

$30$150$250

$30$60

Yes

Yes

632

61

838

862

871

883

925

95

841

828

90

799

65

627

49























Enrollment Code


Michigan

H61 H62

J31 J32

K51 K52

LX1 LX2

RL1 RL2

RL4 RL5

521 522

GY4 GY5

X51 X52

9U4 9U5

Minnesota

V31 V32

V34 V35

Missouri HY1 HY2

9G1 9G2

HA1 HA2

HA4 HA5

MS1 MS2

MS4 MS5

B91 B92

Telephone Number

800shy662shy6667

800shy662shy6667

800shy662shy6667

800shy662shy6667

616shy949shy2410

616shy949shy2410

800shy556shy9765

800shy556shy9765

800shy332shy9161

866shy539shy3342

952shy883shy5000

952shy883shy5000

877shy459shy6604

888shy811shy2092

800shy969shy3343

800shy969shy3343

888shy393shy6765

888shy393shy6765

877shy835shy9861

50

Monthly


17455 60199

20874 69088

15762 37947

12930 44648

19006 64274

12973 45145

15511 44042

12822 33321

12002 34959

20141 55759

32886 78427

8987 20671

11817 36274

26208 54102

12196 32723

10096 23722

45714 103636

13457 31059

19353 43374

Biweekly


8056 27784

9634 31887

7275 17514

5968 20607

8772 29665

5987 20836

7159 20327

5918 15379

5539 16135

9296 25735

15178 36197

4148 9540

5454 16742

12096 24970

5629 15103

4660 10948

21099 47832

6211 14335

8932 20019


Primary care



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


HMO

$50NA

POS National

Yes

Average 659 855 855 935 839 876 664










Minnesota


$20Nothing

$25$45

20

Nothing

$15

$12

$25$50

$45$90

Yes

Yes

774

641

906

873

886

897

964

951

893

888

887

912

69

66




$250day x 4

$9

$10

$40$70

$35$65

Yes

Yes

641 873 897 951 888 912 66








51








Nevada

HF1 HF2 10582 33646 4884 15529

NM1 NM2 10448 24635 4822 11370

Telephone Number

877shy459shy6604

800shy777shy1840

New Jersey







New Mexico



52

Q11 Q12 22873 58561 10557 27028

P21 P22 17370 41076 8017 18958


Primary care



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

Nevada


HMO

$35$65

POS National

Yes

Average 659 855 855 935 839 876 664


New Jersey


$10$20

$20$35

$150

$150day x 5

$5

$10

$35$55

$35$65

Yes

Yes

567

617

709

855

706

886

898

937

78

852

845

861

561

605






New Mexico


$25$25

$20$35

$250day x 3

$250 after ded

$5

$5

$25$50

$35$6050

Yes

Yes

604

623

856

807

861

786

926

896

763

807

772

862

572

746


53




























54


Primary care



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


HMO

$35$65

POS National

Yes

Average 659

651

855

828

855

853

935

927

839

873

876

875

664

60























55





North Dakota




Ohio






Oklahoma


Oregon



56


Primary care



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 Dakota


HMO

$45$90

POS National

Yes

Average 659

641

855

873

855

897

935

951

839

888

876

912

664

66



Ohio

AultCare HMOshyHigh

2020

$15$20

20

$150

NA

$15

NA

$30$45

NA

No 865 935 926 946 946 958 863





Oklahoma


Oregon


$10$20

$15$35

$15$25

$250

$150day x 3

$200

$15

$10

$15

$30$50

$30$40

$40$40

Yes

Yes

Yes

739

56

677

905

731

769

89

812

778

963

941

893

927

715

864

957

883

848

758

626

679


57





Pennsylvania











South Dakota





Tennessee




58


Primary care



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

Pennsylvania


HMO

$35$65

POS National

Yes

Average 659

567

855

873

855

885

935

946

839

752

876

886

664

682









$20$35

$5$5

None

None

$5

$250

$35$70

$10$15

Yes

Yes

764

753

903

807

871

815

959

936

87

834

885

811

716




South Dakota


$750+10$10+10

$25$45

10 +

Nothing

NA

$12

NA NA

$45$90

No

Yes

716

641

857

873

796

897

968

951

683

888

695

912

514

66




Tennessee


4040

$20$35

40

$250day x 4

NA

$10

NA NA

$35$65

No

Yes

53

639

831

877

861

842

963

936

905

85

907

919

703

708



59





Texas










Utah




Virgin Islands












60


Primary care



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

$35$65

OS Nationa

Yes

l Average 659

698

855

833

855

793

935

896

839

829

876

886

664

652









Utah


$20$40

$20$30

$250day x 5

$200

$10

$7

$35$60

$25$50

Yes

Yes

654

556

864

86

842

88

936

948

797

817

905

853

646

625


SelectHealthshyHigh

Virgin Islands


$15$25

$750$10

$100

None

$5

$5 or $12

$2550


NA

Yes x

553 834 823 93 935 92 712



$10 amp 10+

$150day x3 $5 $35$65 Yes 659 871 87 918 901 874 667











61





Washington







West Virginia


Wisconsin







Wyoming



62


Primary care



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

Washington


HMOP

$40$60

OS National

Yes

Average 659

691

855

839

855

844

935

926

839

867

876

896

664

711









West Virginia


Wisconsin


$25$35

$10$20

$10$10

$500

$250

None

$20

$15

$10

$40$40

$30$50

30$75max30

Yes

Yes

No

677

739

77

769

905

871

778

89

883

893

963

962

864

927

854

848

957

921

679

758

689






Wyoming


$10$10

$20$30

Nothing

$200

$10

$7

3050

$25$50

No

Yes

766

556

86

86

889

88

95

948

901

817

912

853

723

625


63











64



















insurance plans

65



ELIGIBILITY

FUNDING







CONTRIBUTIONS

DISTRIBUTIONS







ANNUAL ROLLOVER







66




67












Self only

Self amp family

Self only

Self amp family

Self only

Self amp family




866shy833shy3463

800shy821shy6136

800shy694shy9901

474 475

341 342

481 482

8923 20072

9996 22832

11557 26186

4118 9264

4614 10538

5334 12086

68













69












Plan Code


Getting needed care


How well doctors


Claims processing






22

34

48

60

637

54

856

864

868

893

885

877

935

923

936

859

852

839

90

876

892

592

593

547


Plan Code


Getting needed care


How well doctors


Claims processing






22

47

TU TV

60

643

489

856

884

806

893

868

841

935

924

929

859

803

839

90

809

891

592

657

609

70


71





Plan Name

Telephone Number


Self only

Self amp family

Self only

Self amp family

Self only

Self amp family



877shy459shy6604

877shy459shy6604

221 222

224 225

15604 37056

9412 20613

7202 17103

4344 9514


Florida







Idaho


Plan Name

800shy441shy5501

888shy393shy6765

888shy393shy6765

888shy393shy6765

888shy393shy6765

671shy647shy3526

800shy377shy4161

Telephone Number


J41

MJ1

QP1

AD1

LM1

KX1

9K4

Self only

J42

MJ2

QP2

AD2

LM2

KX2

9K5

Self amp family

11570

12685

10873

11477

11840

8138

8704

Self only

28710

28542

24465

25824

26639

21442

18033

Self amp family

5340

5855

5018

5297

5464

3756

4017

Self only

13251

13173

11291

11919

12295

9896

8323

Self amp family

72



Benefit Type


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs




Benefit Type


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Florida


Plan Name

$8334$16667 $2500$5000 $5000$10000 $10 20 20 Nothing $5$35$5020






OutshyNetwork

InshyNetwork

NA

$8333

$3000$6000

$1000$2000

$4000$8000

$3000$6000

30

$25

30

$300day x 5

30

$150

30

Nothing

$10+$40+$60+



Guam TakeCareshy

OutshyNetwork

InshyNetwork

NA

$8666$22208

$3000$6000

$3000$6000

$4000$8000

$5000$10000

30

20afterDed

30

20 after Ded

30

20 after Ded

30

Nothing

$10+$40+$60+


Idaho

Altius Health Plans


$4583$9166

$3000$6000

$1200$2400

$10000$20000

$5000$10000 $20

30 afterDed

10


10

1st $300ded

Nothing

30 after Ded

$7$25$50

73












Plan Name

888shy393shy6765

888shy393shy6765

888shy393shy6765

800shy257shy4692

800shy969shy3343

888shy393shy6765

888shy393shy6765

800shy833shy7423

Telephone Number


GB1

MW1

MW1

SV4

9H1

PH1

6N1

GZ1

Self only

GB2

MW2

MW2

SV5

9H2

PH2

6N2

GZ2

Self amp family

12685

12081

12081

8608

9721

10873

10064

9834

Self only

28542

27182

27182

20544

22845

24464

22644

22508

Self amp family

5855

5576

5576

3973

4486

5018

4645

4539

Self only

13173

12546

12546

9482

10544

11291

10451

10388

Self amp family

74










75

A








Pennsylvania







Plan Name

800shy969shy3343

888shy393shy6765

800shy501shy3439

330shy363shy6360

866shy351shy5946

866shy351shy5946

888shy876shy2756

888shy393shy6765

888shy393shy6765

888shy393shy6765

Telephone Number


9H1

PH1

QA4

3A4

Y61

YW1

8W4

TP1

TU1

TV1

Self only

9H2

PH2

QA5

3A5

Y62

YW2

8W5

TP2

TU2

TV2

Self amp family

9721

10873

9633

7760

11914

14046

11884

11840

12081

12284

Self only

22845

24464

24717

15548

27430

30756

26620

26640

27182

27639

Self amp family

4486

5018

4446

3581

5499

6483

5485

5464

5576

5669

Self only

10544

11291

11408

7176

12660

14195

12286

12295

12546

12756

Self amp family

76






Pennsylvania








77





Wyoming


Plan Name

800shy377shy4161

800shy552shy7114

800shy377shy4161

Telephone Number


9K4

L14

9K4

Self only

9K5

L15

9K5

Self amp family

8704

9545

8704

Self only

18033

20857

18033

Self amp family

4017

4405

4017

Self only

8323

9626

8323

Self amp family

78



Washington $10$3550


Wyoming


79


80

Appendix F


Waiting Periods





Contributions


Salary Deduction





81


















82






Increase Enrollment

Type

Decrease Enrollment

Type







Yes Yes No No No


No No No No Yes


or spouse)

No No No Yes No



Yes No No No No




No No No Yes No







83

Appendix I



Reading the Chart


Dental Insurance









Vision Insurance



84



Plan Name

Telephone amp

Website


Class A

Class B

Class C

Class D

Deductible





0 40 60 70 $0





0 45 65 50 $0


0 20 50 50 $0


0 20 50 50 $0












wwwuccifedvipcom




40 60 50 $0


85




Plan Name

Telephone amp

Website

Class A

Class B

Class C

Class D Deductible





Class B and Class C


787shy774shy6060 787shy749shy4777

0 30 60 30






86








FEP BlueVision High





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

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

$0

$0

















87




Salud




















88



Rating Areas




















OH 453shy455 2 2 2 1 1 2 1 NA NA




89




Salud















90








3 $1471 $2941 $4411 $3187 $6372 $9557 4 $1622 $3243 $4865 $3514 $7027 $10541 5 $1760 $3521 $5281 $3813 $7629 $11442


3 $1132 $2262 $3393 $2453 $4901 $7352 4 $1221 $2441 $3662 $2646 $5289 $7934 5 $1355 $2710 $4064 $2936 $5872 $8805


3 $1857 $3715 $5573 $4024 $8049 $12075 4 $2005 $4010 $6017 $4344 $8688 $13037 5 $2225 $4453 $6681 $4821 $9648 $14476


3 $1022 $2042 $3064 $2214 $4424 $6639 4 $1135 $2270 $3404 $2459 $4918 $7375 5 $1246 $2492 $3739 $2700 $5399 $8101


3 $1910 $3815 $5725 $4138 $8266 $12404 4 $2066 $4129 $6194 $4476 $8946 $13420 5 $2313 $4625 $6937 $5012 $10021 $15030


3 $1767 $3529 $5295 $3829 $7646 $11473 4 $1906 $3806 $5713 $4130 $8246 $12378 5 $2054 $4107 $6160 $4450 $8899 $13347

9911








Self amp Family




1 $1618 $3234 $4852 $3506 $7007 $10513



1 $435 $869 $1141 $943 $1883 $2472


Plan Name




Self amp Family

Aetna

GEHA Standard

GEHA High

MetLife Standard

MetLife High

United Concordia

$1882

$908

$1489

$1246

$2313

$2054

$3762

$1816

$2977

$2492

$4625

$4107

$5644

$2726

$4469

$3739

$6937

$6160

$4078

$1967

$3226

$2700

$5012

$4450

$8151

$3935

$6450

$5399

$10021

$8899

$12229

$5906

$9683

$8101

$15030

$13347

92


Premium Rate Charts



Plan Option




Self amp Family

FEP BlueVision







Standard High

Standard High

Standard High

$377 $475

$300 $423

$413 $617

$752 $949

$585 $824

$825 $1233

$1129 $1425

$871 $1228

$1238 $1850

$817 $1029

$650 $916

$895 $1337

$1629 $2056

$1269 $1786

$1788 $2672

$2446 $3088

$1887 $2660

$2682 $4008



Plan Option




Self amp Family

FEP BlueVision







Standard High

Standard High

Standard High

$377 $475

$300 $423

$413 $617

$752 $949

$585 $824

$825 $1233

$1129 $1425

$871 $1228

$1238 $1850

$817 $1029

$650 $916

$895 $1337

$1629 $2056

$1269 $1786

$1788 $2672

$2446 $3088

$1887 $2660

$2682 $4008

93


















94
























95

Summary Information




















wwwopmgovinsurelife




96








4
















5


Current Employees



























6

















7







FSAFEDS




8



FEGLI












9






Key FEHB facts













10














11


When can I enroll



How do I enroll




12















13






Key FEDVIP facts














14

















15


When can I enroll




How do I enroll








16


















17





Key FSAFEDS facts













18













19




When can I enroll











20


How do I enroll










21




Key FEGLI facts



















22




When can I enroll







How do I enroll








23




Key FLTCIP facts












24





How do I apply








25


26


















27
















pay more








28












29


Definitions













30















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



31














32









33











Enrollment Code


Monthly Biweekly















421 422 13272 32275 6126 14896




34




Plan

Benefit Type





RampB

Prescription Drugs


Office Visits


Calendar Year

Prescription Drug

APWU shyhigh

BCBS shystd

BCBS shybasic

GEHA shyhigh

GEHA shystd

MHBP shystd

MHBP shyValue

NALC shyhigh

SAMBA shyhigh

SAMBA shystd

CRHP

FSBP

PCABP

Rural

PPO NonshyPPO

PPO NonshyPPO

PPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

POS FFS

PPO NonshyPPO

$275 None $500 None

$350 None $350 None

None None

$350 None $350 None

$350 None $350 None

$400 None $600 None


$300 None $300 None

$300 None $300 None

$350 None $350 None

$300 None $350 None

$300 None $300 None

None None None None

$350 $200 $400 $200


None $300

$250 $350

$150day x 5

$100 $300

None None

$200 $500

None None

$200 $350

$200 $300

$150 up to $450 $200 up to $600

$150 $350

Nothing $200

$100 $25

$100 $300

$18 10 30+diff 30+diff

$20 15 35 35

$25 $150

$20 10 25 25

$10 15 35 35

$20 10 30 30

$30 20 40 40

$20 15 30 30

$20 10 30 30

$20 15 35 35

$10 Nothing 30 30

10 10 30 30

50 50 $5 Nothing

$20 10 25 25

10 30

Nothing 35

Nothing

Nothing Nothing

15 35

Nothing 30

20 40

Nothing 30

Nothing 30

Nothing 35

Nothing 30

Nothing 20

50 Nothing

Nothing 20

$8 2525 Yes 50 5050 Yes

20 (15MCare B) 3030 Yes 45 + 45+45+ Yes

$10 $50$150 NA



$10 30($200 max)50($200 max) Yes 50 5050 Yes


20 3030 Yes 45 45+ 45+45+ Yes



$5 $3030 or $45 Yes $5 $3030 or $45 Yes


20 2020 No 20 2020 No

30 3030 Yes 30 3030 Yes


35













Plan Code


Getting needed care


How well doctors


Claims processing



FFS National A

47

verage 774

78

916

898

91

921

948

938

897

837

929

898

725

737 47





MHBP shystd 45 706 916 917 943 898 927 713 45


NALC shyhigh 32 811 934 914 951 923 951 766 32

SAMBA shyhigh 44 893 946 937 968 901 973 791 44

SAMBA shystd 44 745 923 933 952 903 925 74



44

42

roups Average 774 916 91 948 897 929 725

42




36



Location Plan Name


Plan Code


Getting needed care


How well doctors


Claims processing











37


38















39





Arizona




Arkansas



California












Colorado





40


Primary care



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

Arizona


HMOP

$35$65

OS Nationa

Yes

l Average 659

583

855

842

855

864

935

883

839

858

876

884

664

636



Arkansas


$15$40

$20$30

$250day x 3

$100max$500

$10

$0

$40$70

$40$60

Yes

Yes

702

61

878

845

868

873

921

935

863

877

946

887

675



California


$20$40

$20$35

$200max$1000

$250day x 4

$5

$10

$40$60

$35$65

Yes

Yes

61

612

845

808

873

822

935

922

877

813

887

882

652

608











Colorado


$20$35

$20$40

$150day x 4

$250

$10

$10

$35$60

$35$60

Yes

Yes

692

716

787

833

824

862

935

918

761

77

88

876

588

684



$25$45

$20$35

$250day x 3

$150day x 5

$15

$10

$40$80

$35$65

Yes

Yes

716

616

833

884

862

88

918

943

77

857

876

932

684

631


41







Self amp family


























42


Primary care



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


HMO

$35$65

POS National

Yes

Average 659

659

855

871

855

87

935

918

839

901

876

874

664

667







MD IPAshyHigh


$25$40

$15$40

$150day x 3

$150day x 5

$7

$5

$30$150$250

$30$5030

Yes

No

632

724

838

869

871

855

925

913

841

894

90

853

65

648










$25$40

$20$35

$500day x 3

$250day x 4

$10

$10

$40$60

$35$65

Yes

Yes 569 888 835 927 882 873 589









43





Guam






Idaho





Illinois











44


Primary care



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

Guam


HMOP

$15$25$50

OS Nationa

No

l Average 659

642

855

726

855

626

935

895

839

694

876

664

664

563

TakeCareshyStd


$25$40

$15$15

$150day for 5 days

$100

$15

$7

$20$40$80

$30$65

No

Yes

642

833

726

924

626

91

895

959

694

837

664

941

563


$65+20 No 833 924 91 959 837 941 666



Idaho


$30$30

$20$30

10

$200

$20

$7

$20$20

$25$50

Yes

Yes

751

556

821

86

797

88

935

948

792

817

853

853

707

625




Illinois


$25+20$25+20

$20$35

$500day x 3

$250day x 4

$20

$10

$40$60

$35$65

Yes

Yes

691

615

839

826

844

82

926

909

867

866

896

823

711

642











45







Self amp family

Indiana








Iowa









Kansas






46


Primary care



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

$35$65

OS Nationa

Yes

l Average 659

615

855

826

855

82

935

909

839

866

876

823

664

642







Iowa


$15$15

$20$45

20

15

$10

$3$10

$25$50

$40$65

Yes

Yes

583

567

879

857

88

867

952

966

905

824

944

907

603

675









Kansas


$25$45

$20$35

Nothing

$250day x 4

$10

$10

$35$50

$35$65

Yes

Yes

524 873 853 956 798 886 622





47





Kentucky





Louisiana



Maryland










Massachusetts


48


Primary care



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

Kentucky


HMO

$40$60

POS National

Yes

Average 659 855 855 935 839 876 664




Louisiana


$25$40

$25$45

$500day x 3

$100

$10

$5

$40$60

$40$75

Yes

Yes 579 866 853 964 793 843 677


Maryland


$30$55

$15$30

30

$150day x3

$5

$5

$40$75

$35$65

Yes

Yes

579

659

866

871

853

87

964

918

793

901

843

874

677

667









MD IPAshyHigh

Massachusetts


$25$40

$25$35

$150day x 3

$150 to $750max

$7

$10

$30$150$250

$30$60

Yes

Yes

632

61

838

862

871

883

925

95

841

828

90

799

65

627

49























Enrollment Code


Michigan

H61 H62

J31 J32

K51 K52

LX1 LX2

RL1 RL2

RL4 RL5

521 522

GY4 GY5

X51 X52

9U4 9U5

Minnesota

V31 V32

V34 V35

Missouri HY1 HY2

9G1 9G2

HA1 HA2

HA4 HA5

MS1 MS2

MS4 MS5

B91 B92

Telephone Number

800shy662shy6667

800shy662shy6667

800shy662shy6667

800shy662shy6667

616shy949shy2410

616shy949shy2410

800shy556shy9765

800shy556shy9765

800shy332shy9161

866shy539shy3342

952shy883shy5000

952shy883shy5000

877shy459shy6604

888shy811shy2092

800shy969shy3343

800shy969shy3343

888shy393shy6765

888shy393shy6765

877shy835shy9861

50

Monthly


17455 60199

20874 69088

15762 37947

12930 44648

19006 64274

12973 45145

15511 44042

12822 33321

12002 34959

20141 55759

32886 78427

8987 20671

11817 36274

26208 54102

12196 32723

10096 23722

45714 103636

13457 31059

19353 43374

Biweekly


8056 27784

9634 31887

7275 17514

5968 20607

8772 29665

5987 20836

7159 20327

5918 15379

5539 16135

9296 25735

15178 36197

4148 9540

5454 16742

12096 24970

5629 15103

4660 10948

21099 47832

6211 14335

8932 20019


Primary care



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


HMO

$50NA

POS National

Yes

Average 659 855 855 935 839 876 664










Minnesota


$20Nothing

$25$45

20

Nothing

$15

$12

$25$50

$45$90

Yes

Yes

774

641

906

873

886

897

964

951

893

888

887

912

69

66




$250day x 4

$9

$10

$40$70

$35$65

Yes

Yes

641 873 897 951 888 912 66








51








Nevada

HF1 HF2 10582 33646 4884 15529

NM1 NM2 10448 24635 4822 11370

Telephone Number

877shy459shy6604

800shy777shy1840

New Jersey







New Mexico



52

Q11 Q12 22873 58561 10557 27028

P21 P22 17370 41076 8017 18958


Primary care



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

Nevada


HMO

$35$65

POS National

Yes

Average 659 855 855 935 839 876 664


New Jersey


$10$20

$20$35

$150

$150day x 5

$5

$10

$35$55

$35$65

Yes

Yes

567

617

709

855

706

886

898

937

78

852

845

861

561

605






New Mexico


$25$25

$20$35

$250day x 3

$250 after ded

$5

$5

$25$50

$35$6050

Yes

Yes

604

623

856

807

861

786

926

896

763

807

772

862

572

746


53




























54


Primary care



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


HMO

$35$65

POS National

Yes

Average 659

651

855

828

855

853

935

927

839

873

876

875

664

60























55





North Dakota




Ohio






Oklahoma


Oregon



56


Primary care



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 Dakota


HMO

$45$90

POS National

Yes

Average 659

641

855

873

855

897

935

951

839

888

876

912

664

66



Ohio

AultCare HMOshyHigh

2020

$15$20

20

$150

NA

$15

NA

$30$45

NA

No 865 935 926 946 946 958 863





Oklahoma


Oregon


$10$20

$15$35

$15$25

$250

$150day x 3

$200

$15

$10

$15

$30$50

$30$40

$40$40

Yes

Yes

Yes

739

56

677

905

731

769

89

812

778

963

941

893

927

715

864

957

883

848

758

626

679


57





Pennsylvania











South Dakota





Tennessee




58


Primary care



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

Pennsylvania


HMO

$35$65

POS National

Yes

Average 659

567

855

873

855

885

935

946

839

752

876

886

664

682









$20$35

$5$5

None

None

$5

$250

$35$70

$10$15

Yes

Yes

764

753

903

807

871

815

959

936

87

834

885

811

716




South Dakota


$750+10$10+10

$25$45

10 +

Nothing

NA

$12

NA NA

$45$90

No

Yes

716

641

857

873

796

897

968

951

683

888

695

912

514

66




Tennessee


4040

$20$35

40

$250day x 4

NA

$10

NA NA

$35$65

No

Yes

53

639

831

877

861

842

963

936

905

85

907

919

703

708



59





Texas










Utah




Virgin Islands












60


Primary care



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

$35$65

OS Nationa

Yes

l Average 659

698

855

833

855

793

935

896

839

829

876

886

664

652









Utah


$20$40

$20$30

$250day x 5

$200

$10

$7

$35$60

$25$50

Yes

Yes

654

556

864

86

842

88

936

948

797

817

905

853

646

625


SelectHealthshyHigh

Virgin Islands


$15$25

$750$10

$100

None

$5

$5 or $12

$2550


NA

Yes x

553 834 823 93 935 92 712



$10 amp 10+

$150day x3 $5 $35$65 Yes 659 871 87 918 901 874 667











61





Washington







West Virginia


Wisconsin







Wyoming



62


Primary care



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

Washington


HMOP

$40$60

OS National

Yes

Average 659

691

855

839

855

844

935

926

839

867

876

896

664

711









West Virginia


Wisconsin


$25$35

$10$20

$10$10

$500

$250

None

$20

$15

$10

$40$40

$30$50

30$75max30

Yes

Yes

No

677

739

77

769

905

871

778

89

883

893

963

962

864

927

854

848

957

921

679

758

689






Wyoming


$10$10

$20$30

Nothing

$200

$10

$7

3050

$25$50

No

Yes

766

556

86

86

889

88

95

948

901

817

912

853

723

625


63











64



















insurance plans

65



ELIGIBILITY

FUNDING







CONTRIBUTIONS

DISTRIBUTIONS







ANNUAL ROLLOVER







66




67












Self only

Self amp family

Self only

Self amp family

Self only

Self amp family




866shy833shy3463

800shy821shy6136

800shy694shy9901

474 475

341 342

481 482

8923 20072

9996 22832

11557 26186

4118 9264

4614 10538

5334 12086

68













69












Plan Code


Getting needed care


How well doctors


Claims processing






22

34

48

60

637

54

856

864

868

893

885

877

935

923

936

859

852

839

90

876

892

592

593

547


Plan Code


Getting needed care


How well doctors


Claims processing






22

47

TU TV

60

643

489

856

884

806

893

868

841

935

924

929

859

803

839

90

809

891

592

657

609

70


71





Plan Name

Telephone Number


Self only

Self amp family

Self only

Self amp family

Self only

Self amp family



877shy459shy6604

877shy459shy6604

221 222

224 225

15604 37056

9412 20613

7202 17103

4344 9514


Florida







Idaho


Plan Name

800shy441shy5501

888shy393shy6765

888shy393shy6765

888shy393shy6765

888shy393shy6765

671shy647shy3526

800shy377shy4161

Telephone Number


J41

MJ1

QP1

AD1

LM1

KX1

9K4

Self only

J42

MJ2

QP2

AD2

LM2

KX2

9K5

Self amp family

11570

12685

10873

11477

11840

8138

8704

Self only

28710

28542

24465

25824

26639

21442

18033

Self amp family

5340

5855

5018

5297

5464

3756

4017

Self only

13251

13173

11291

11919

12295

9896

8323

Self amp family

72



Benefit Type


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs




Benefit Type


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Florida


Plan Name

$8334$16667 $2500$5000 $5000$10000 $10 20 20 Nothing $5$35$5020






OutshyNetwork

InshyNetwork

NA

$8333

$3000$6000

$1000$2000

$4000$8000

$3000$6000

30

$25

30

$300day x 5

30

$150

30

Nothing

$10+$40+$60+



Guam TakeCareshy

OutshyNetwork

InshyNetwork

NA

$8666$22208

$3000$6000

$3000$6000

$4000$8000

$5000$10000

30

20afterDed

30

20 after Ded

30

20 after Ded

30

Nothing

$10+$40+$60+


Idaho

Altius Health Plans


$4583$9166

$3000$6000

$1200$2400

$10000$20000

$5000$10000 $20

30 afterDed

10


10

1st $300ded

Nothing

30 after Ded

$7$25$50

73












Plan Name

888shy393shy6765

888shy393shy6765

888shy393shy6765

800shy257shy4692

800shy969shy3343

888shy393shy6765

888shy393shy6765

800shy833shy7423

Telephone Number


GB1

MW1

MW1

SV4

9H1

PH1

6N1

GZ1

Self only

GB2

MW2

MW2

SV5

9H2

PH2

6N2

GZ2

Self amp family

12685

12081

12081

8608

9721

10873

10064

9834

Self only

28542

27182

27182

20544

22845

24464

22644

22508

Self amp family

5855

5576

5576

3973

4486

5018

4645

4539

Self only

13173

12546

12546

9482

10544

11291

10451

10388

Self amp family

74










75

A








Pennsylvania







Plan Name

800shy969shy3343

888shy393shy6765

800shy501shy3439

330shy363shy6360

866shy351shy5946

866shy351shy5946

888shy876shy2756

888shy393shy6765

888shy393shy6765

888shy393shy6765

Telephone Number


9H1

PH1

QA4

3A4

Y61

YW1

8W4

TP1

TU1

TV1

Self only

9H2

PH2

QA5

3A5

Y62

YW2

8W5

TP2

TU2

TV2

Self amp family

9721

10873

9633

7760

11914

14046

11884

11840

12081

12284

Self only

22845

24464

24717

15548

27430

30756

26620

26640

27182

27639

Self amp family

4486

5018

4446

3581

5499

6483

5485

5464

5576

5669

Self only

10544

11291

11408

7176

12660

14195

12286

12295

12546

12756

Self amp family

76






Pennsylvania








77





Wyoming


Plan Name

800shy377shy4161

800shy552shy7114

800shy377shy4161

Telephone Number


9K4

L14

9K4

Self only

9K5

L15

9K5

Self amp family

8704

9545

8704

Self only

18033

20857

18033

Self amp family

4017

4405

4017

Self only

8323

9626

8323

Self amp family

78



Washington $10$3550


Wyoming


79


80

Appendix F


Waiting Periods





Contributions


Salary Deduction





81


















82






Increase Enrollment

Type

Decrease Enrollment

Type







Yes Yes No No No


No No No No Yes


or spouse)

No No No Yes No



Yes No No No No




No No No Yes No







83

Appendix I



Reading the Chart


Dental Insurance









Vision Insurance



84



Plan Name

Telephone amp

Website


Class A

Class B

Class C

Class D

Deductible





0 40 60 70 $0





0 45 65 50 $0


0 20 50 50 $0


0 20 50 50 $0












wwwuccifedvipcom




40 60 50 $0


85




Plan Name

Telephone amp

Website

Class A

Class B

Class C

Class D Deductible





Class B and Class C


787shy774shy6060 787shy749shy4777

0 30 60 30






86








FEP BlueVision High





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

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

$0

$0

















87




Salud




















88



Rating Areas




















OH 453shy455 2 2 2 1 1 2 1 NA NA




89




Salud















90








3 $1471 $2941 $4411 $3187 $6372 $9557 4 $1622 $3243 $4865 $3514 $7027 $10541 5 $1760 $3521 $5281 $3813 $7629 $11442


3 $1132 $2262 $3393 $2453 $4901 $7352 4 $1221 $2441 $3662 $2646 $5289 $7934 5 $1355 $2710 $4064 $2936 $5872 $8805


3 $1857 $3715 $5573 $4024 $8049 $12075 4 $2005 $4010 $6017 $4344 $8688 $13037 5 $2225 $4453 $6681 $4821 $9648 $14476


3 $1022 $2042 $3064 $2214 $4424 $6639 4 $1135 $2270 $3404 $2459 $4918 $7375 5 $1246 $2492 $3739 $2700 $5399 $8101


3 $1910 $3815 $5725 $4138 $8266 $12404 4 $2066 $4129 $6194 $4476 $8946 $13420 5 $2313 $4625 $6937 $5012 $10021 $15030


3 $1767 $3529 $5295 $3829 $7646 $11473 4 $1906 $3806 $5713 $4130 $8246 $12378 5 $2054 $4107 $6160 $4450 $8899 $13347

9911








Self amp Family




1 $1618 $3234 $4852 $3506 $7007 $10513



1 $435 $869 $1141 $943 $1883 $2472


Plan Name




Self amp Family

Aetna

GEHA Standard

GEHA High

MetLife Standard

MetLife High

United Concordia

$1882

$908

$1489

$1246

$2313

$2054

$3762

$1816

$2977

$2492

$4625

$4107

$5644

$2726

$4469

$3739

$6937

$6160

$4078

$1967

$3226

$2700

$5012

$4450

$8151

$3935

$6450

$5399

$10021

$8899

$12229

$5906

$9683

$8101

$15030

$13347

92


Premium Rate Charts



Plan Option




Self amp Family

FEP BlueVision







Standard High

Standard High

Standard High

$377 $475

$300 $423

$413 $617

$752 $949

$585 $824

$825 $1233

$1129 $1425

$871 $1228

$1238 $1850

$817 $1029

$650 $916

$895 $1337

$1629 $2056

$1269 $1786

$1788 $2672

$2446 $3088

$1887 $2660

$2682 $4008



Plan Option




Self amp Family

FEP BlueVision







Standard High

Standard High

Standard High

$377 $475

$300 $423

$413 $617

$752 $949

$585 $824

$825 $1233

$1129 $1425

$871 $1228

$1238 $1850

$817 $1029

$650 $916

$895 $1337

$1629 $2056

$1269 $1786

$1788 $2672

$2446 $3088

$1887 $2660

$2682 $4008

93


















94
























95

Summary Information




















wwwopmgovinsurelife




96
















5


Current Employees



























6

















7







FSAFEDS




8



FEGLI












9






Key FEHB facts













10














11


When can I enroll



How do I enroll




12















13






Key FEDVIP facts














14

















15


When can I enroll




How do I enroll








16


















17





Key FSAFEDS facts













18













19




When can I enroll











20


How do I enroll










21




Key FEGLI facts



















22




When can I enroll







How do I enroll








23




Key FLTCIP facts












24





How do I apply








25


26


















27
















pay more








28












29


Definitions













30















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



31














32









33











Enrollment Code


Monthly Biweekly















421 422 13272 32275 6126 14896




34




Plan

Benefit Type





RampB

Prescription Drugs


Office Visits


Calendar Year

Prescription Drug

APWU shyhigh

BCBS shystd

BCBS shybasic

GEHA shyhigh

GEHA shystd

MHBP shystd

MHBP shyValue

NALC shyhigh

SAMBA shyhigh

SAMBA shystd

CRHP

FSBP

PCABP

Rural

PPO NonshyPPO

PPO NonshyPPO

PPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

POS FFS

PPO NonshyPPO

$275 None $500 None

$350 None $350 None

None None

$350 None $350 None

$350 None $350 None

$400 None $600 None


$300 None $300 None

$300 None $300 None

$350 None $350 None

$300 None $350 None

$300 None $300 None

None None None None

$350 $200 $400 $200


None $300

$250 $350

$150day x 5

$100 $300

None None

$200 $500

None None

$200 $350

$200 $300

$150 up to $450 $200 up to $600

$150 $350

Nothing $200

$100 $25

$100 $300

$18 10 30+diff 30+diff

$20 15 35 35

$25 $150

$20 10 25 25

$10 15 35 35

$20 10 30 30

$30 20 40 40

$20 15 30 30

$20 10 30 30

$20 15 35 35

$10 Nothing 30 30

10 10 30 30

50 50 $5 Nothing

$20 10 25 25

10 30

Nothing 35

Nothing

Nothing Nothing

15 35

Nothing 30

20 40

Nothing 30

Nothing 30

Nothing 35

Nothing 30

Nothing 20

50 Nothing

Nothing 20

$8 2525 Yes 50 5050 Yes

20 (15MCare B) 3030 Yes 45 + 45+45+ Yes

$10 $50$150 NA



$10 30($200 max)50($200 max) Yes 50 5050 Yes


20 3030 Yes 45 45+ 45+45+ Yes



$5 $3030 or $45 Yes $5 $3030 or $45 Yes


20 2020 No 20 2020 No

30 3030 Yes 30 3030 Yes


35













Plan Code


Getting needed care


How well doctors


Claims processing



FFS National A

47

verage 774

78

916

898

91

921

948

938

897

837

929

898

725

737 47





MHBP shystd 45 706 916 917 943 898 927 713 45


NALC shyhigh 32 811 934 914 951 923 951 766 32

SAMBA shyhigh 44 893 946 937 968 901 973 791 44

SAMBA shystd 44 745 923 933 952 903 925 74



44

42

roups Average 774 916 91 948 897 929 725

42




36



Location Plan Name


Plan Code


Getting needed care


How well doctors


Claims processing











37


38















39





Arizona




Arkansas



California












Colorado





40


Primary care



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

Arizona


HMOP

$35$65

OS Nationa

Yes

l Average 659

583

855

842

855

864

935

883

839

858

876

884

664

636



Arkansas


$15$40

$20$30

$250day x 3

$100max$500

$10

$0

$40$70

$40$60

Yes

Yes

702

61

878

845

868

873

921

935

863

877

946

887

675



California


$20$40

$20$35

$200max$1000

$250day x 4

$5

$10

$40$60

$35$65

Yes

Yes

61

612

845

808

873

822

935

922

877

813

887

882

652

608











Colorado


$20$35

$20$40

$150day x 4

$250

$10

$10

$35$60

$35$60

Yes

Yes

692

716

787

833

824

862

935

918

761

77

88

876

588

684



$25$45

$20$35

$250day x 3

$150day x 5

$15

$10

$40$80

$35$65

Yes

Yes

716

616

833

884

862

88

918

943

77

857

876

932

684

631


41







Self amp family


























42


Primary care



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


HMO

$35$65

POS National

Yes

Average 659

659

855

871

855

87

935

918

839

901

876

874

664

667







MD IPAshyHigh


$25$40

$15$40

$150day x 3

$150day x 5

$7

$5

$30$150$250

$30$5030

Yes

No

632

724

838

869

871

855

925

913

841

894

90

853

65

648










$25$40

$20$35

$500day x 3

$250day x 4

$10

$10

$40$60

$35$65

Yes

Yes 569 888 835 927 882 873 589









43





Guam






Idaho





Illinois











44


Primary care



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

Guam


HMOP

$15$25$50

OS Nationa

No

l Average 659

642

855

726

855

626

935

895

839

694

876

664

664

563

TakeCareshyStd


$25$40

$15$15

$150day for 5 days

$100

$15

$7

$20$40$80

$30$65

No

Yes

642

833

726

924

626

91

895

959

694

837

664

941

563


$65+20 No 833 924 91 959 837 941 666



Idaho


$30$30

$20$30

10

$200

$20

$7

$20$20

$25$50

Yes

Yes

751

556

821

86

797

88

935

948

792

817

853

853

707

625




Illinois


$25+20$25+20

$20$35

$500day x 3

$250day x 4

$20

$10

$40$60

$35$65

Yes

Yes

691

615

839

826

844

82

926

909

867

866

896

823

711

642











45







Self amp family

Indiana








Iowa









Kansas






46


Primary care



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

$35$65

OS Nationa

Yes

l Average 659

615

855

826

855

82

935

909

839

866

876

823

664

642







Iowa


$15$15

$20$45

20

15

$10

$3$10

$25$50

$40$65

Yes

Yes

583

567

879

857

88

867

952

966

905

824

944

907

603

675









Kansas


$25$45

$20$35

Nothing

$250day x 4

$10

$10

$35$50

$35$65

Yes

Yes

524 873 853 956 798 886 622





47





Kentucky





Louisiana



Maryland










Massachusetts


48


Primary care



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

Kentucky


HMO

$40$60

POS National

Yes

Average 659 855 855 935 839 876 664




Louisiana


$25$40

$25$45

$500day x 3

$100

$10

$5

$40$60

$40$75

Yes

Yes 579 866 853 964 793 843 677


Maryland


$30$55

$15$30

30

$150day x3

$5

$5

$40$75

$35$65

Yes

Yes

579

659

866

871

853

87

964

918

793

901

843

874

677

667









MD IPAshyHigh

Massachusetts


$25$40

$25$35

$150day x 3

$150 to $750max

$7

$10

$30$150$250

$30$60

Yes

Yes

632

61

838

862

871

883

925

95

841

828

90

799

65

627

49























Enrollment Code


Michigan

H61 H62

J31 J32

K51 K52

LX1 LX2

RL1 RL2

RL4 RL5

521 522

GY4 GY5

X51 X52

9U4 9U5

Minnesota

V31 V32

V34 V35

Missouri HY1 HY2

9G1 9G2

HA1 HA2

HA4 HA5

MS1 MS2

MS4 MS5

B91 B92

Telephone Number

800shy662shy6667

800shy662shy6667

800shy662shy6667

800shy662shy6667

616shy949shy2410

616shy949shy2410

800shy556shy9765

800shy556shy9765

800shy332shy9161

866shy539shy3342

952shy883shy5000

952shy883shy5000

877shy459shy6604

888shy811shy2092

800shy969shy3343

800shy969shy3343

888shy393shy6765

888shy393shy6765

877shy835shy9861

50

Monthly


17455 60199

20874 69088

15762 37947

12930 44648

19006 64274

12973 45145

15511 44042

12822 33321

12002 34959

20141 55759

32886 78427

8987 20671

11817 36274

26208 54102

12196 32723

10096 23722

45714 103636

13457 31059

19353 43374

Biweekly


8056 27784

9634 31887

7275 17514

5968 20607

8772 29665

5987 20836

7159 20327

5918 15379

5539 16135

9296 25735

15178 36197

4148 9540

5454 16742

12096 24970

5629 15103

4660 10948

21099 47832

6211 14335

8932 20019


Primary care



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


HMO

$50NA

POS National

Yes

Average 659 855 855 935 839 876 664










Minnesota


$20Nothing

$25$45

20

Nothing

$15

$12

$25$50

$45$90

Yes

Yes

774

641

906

873

886

897

964

951

893

888

887

912

69

66




$250day x 4

$9

$10

$40$70

$35$65

Yes

Yes

641 873 897 951 888 912 66








51








Nevada

HF1 HF2 10582 33646 4884 15529

NM1 NM2 10448 24635 4822 11370

Telephone Number

877shy459shy6604

800shy777shy1840

New Jersey







New Mexico



52

Q11 Q12 22873 58561 10557 27028

P21 P22 17370 41076 8017 18958


Primary care



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

Nevada


HMO

$35$65

POS National

Yes

Average 659 855 855 935 839 876 664


New Jersey


$10$20

$20$35

$150

$150day x 5

$5

$10

$35$55

$35$65

Yes

Yes

567

617

709

855

706

886

898

937

78

852

845

861

561

605






New Mexico


$25$25

$20$35

$250day x 3

$250 after ded

$5

$5

$25$50

$35$6050

Yes

Yes

604

623

856

807

861

786

926

896

763

807

772

862

572

746


53




























54


Primary care



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


HMO

$35$65

POS National

Yes

Average 659

651

855

828

855

853

935

927

839

873

876

875

664

60























55





North Dakota




Ohio






Oklahoma


Oregon



56


Primary care



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 Dakota


HMO

$45$90

POS National

Yes

Average 659

641

855

873

855

897

935

951

839

888

876

912

664

66



Ohio

AultCare HMOshyHigh

2020

$15$20

20

$150

NA

$15

NA

$30$45

NA

No 865 935 926 946 946 958 863





Oklahoma


Oregon


$10$20

$15$35

$15$25

$250

$150day x 3

$200

$15

$10

$15

$30$50

$30$40

$40$40

Yes

Yes

Yes

739

56

677

905

731

769

89

812

778

963

941

893

927

715

864

957

883

848

758

626

679


57





Pennsylvania











South Dakota





Tennessee




58


Primary care



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

Pennsylvania


HMO

$35$65

POS National

Yes

Average 659

567

855

873

855

885

935

946

839

752

876

886

664

682









$20$35

$5$5

None

None

$5

$250

$35$70

$10$15

Yes

Yes

764

753

903

807

871

815

959

936

87

834

885

811

716




South Dakota


$750+10$10+10

$25$45

10 +

Nothing

NA

$12

NA NA

$45$90

No

Yes

716

641

857

873

796

897

968

951

683

888

695

912

514

66




Tennessee


4040

$20$35

40

$250day x 4

NA

$10

NA NA

$35$65

No

Yes

53

639

831

877

861

842

963

936

905

85

907

919

703

708



59





Texas










Utah




Virgin Islands












60


Primary care



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

$35$65

OS Nationa

Yes

l Average 659

698

855

833

855

793

935

896

839

829

876

886

664

652









Utah


$20$40

$20$30

$250day x 5

$200

$10

$7

$35$60

$25$50

Yes

Yes

654

556

864

86

842

88

936

948

797

817

905

853

646

625


SelectHealthshyHigh

Virgin Islands


$15$25

$750$10

$100

None

$5

$5 or $12

$2550


NA

Yes x

553 834 823 93 935 92 712



$10 amp 10+

$150day x3 $5 $35$65 Yes 659 871 87 918 901 874 667











61





Washington







West Virginia


Wisconsin







Wyoming



62


Primary care



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

Washington


HMOP

$40$60

OS National

Yes

Average 659

691

855

839

855

844

935

926

839

867

876

896

664

711









West Virginia


Wisconsin


$25$35

$10$20

$10$10

$500

$250

None

$20

$15

$10

$40$40

$30$50

30$75max30

Yes

Yes

No

677

739

77

769

905

871

778

89

883

893

963

962

864

927

854

848

957

921

679

758

689






Wyoming


$10$10

$20$30

Nothing

$200

$10

$7

3050

$25$50

No

Yes

766

556

86

86

889

88

95

948

901

817

912

853

723

625


63











64



















insurance plans

65



ELIGIBILITY

FUNDING







CONTRIBUTIONS

DISTRIBUTIONS







ANNUAL ROLLOVER







66




67












Self only

Self amp family

Self only

Self amp family

Self only

Self amp family




866shy833shy3463

800shy821shy6136

800shy694shy9901

474 475

341 342

481 482

8923 20072

9996 22832

11557 26186

4118 9264

4614 10538

5334 12086

68













69












Plan Code


Getting needed care


How well doctors


Claims processing






22

34

48

60

637

54

856

864

868

893

885

877

935

923

936

859

852

839

90

876

892

592

593

547


Plan Code


Getting needed care


How well doctors


Claims processing






22

47

TU TV

60

643

489

856

884

806

893

868

841

935

924

929

859

803

839

90

809

891

592

657

609

70


71





Plan Name

Telephone Number


Self only

Self amp family

Self only

Self amp family

Self only

Self amp family



877shy459shy6604

877shy459shy6604

221 222

224 225

15604 37056

9412 20613

7202 17103

4344 9514


Florida







Idaho


Plan Name

800shy441shy5501

888shy393shy6765

888shy393shy6765

888shy393shy6765

888shy393shy6765

671shy647shy3526

800shy377shy4161

Telephone Number


J41

MJ1

QP1

AD1

LM1

KX1

9K4

Self only

J42

MJ2

QP2

AD2

LM2

KX2

9K5

Self amp family

11570

12685

10873

11477

11840

8138

8704

Self only

28710

28542

24465

25824

26639

21442

18033

Self amp family

5340

5855

5018

5297

5464

3756

4017

Self only

13251

13173

11291

11919

12295

9896

8323

Self amp family

72



Benefit Type


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs




Benefit Type


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Florida


Plan Name

$8334$16667 $2500$5000 $5000$10000 $10 20 20 Nothing $5$35$5020






OutshyNetwork

InshyNetwork

NA

$8333

$3000$6000

$1000$2000

$4000$8000

$3000$6000

30

$25

30

$300day x 5

30

$150

30

Nothing

$10+$40+$60+



Guam TakeCareshy

OutshyNetwork

InshyNetwork

NA

$8666$22208

$3000$6000

$3000$6000

$4000$8000

$5000$10000

30

20afterDed

30

20 after Ded

30

20 after Ded

30

Nothing

$10+$40+$60+


Idaho

Altius Health Plans


$4583$9166

$3000$6000

$1200$2400

$10000$20000

$5000$10000 $20

30 afterDed

10


10

1st $300ded

Nothing

30 after Ded

$7$25$50

73












Plan Name

888shy393shy6765

888shy393shy6765

888shy393shy6765

800shy257shy4692

800shy969shy3343

888shy393shy6765

888shy393shy6765

800shy833shy7423

Telephone Number


GB1

MW1

MW1

SV4

9H1

PH1

6N1

GZ1

Self only

GB2

MW2

MW2

SV5

9H2

PH2

6N2

GZ2

Self amp family

12685

12081

12081

8608

9721

10873

10064

9834

Self only

28542

27182

27182

20544

22845

24464

22644

22508

Self amp family

5855

5576

5576

3973

4486

5018

4645

4539

Self only

13173

12546

12546

9482

10544

11291

10451

10388

Self amp family

74










75

A








Pennsylvania







Plan Name

800shy969shy3343

888shy393shy6765

800shy501shy3439

330shy363shy6360

866shy351shy5946

866shy351shy5946

888shy876shy2756

888shy393shy6765

888shy393shy6765

888shy393shy6765

Telephone Number


9H1

PH1

QA4

3A4

Y61

YW1

8W4

TP1

TU1

TV1

Self only

9H2

PH2

QA5

3A5

Y62

YW2

8W5

TP2

TU2

TV2

Self amp family

9721

10873

9633

7760

11914

14046

11884

11840

12081

12284

Self only

22845

24464

24717

15548

27430

30756

26620

26640

27182

27639

Self amp family

4486

5018

4446

3581

5499

6483

5485

5464

5576

5669

Self only

10544

11291

11408

7176

12660

14195

12286

12295

12546

12756

Self amp family

76






Pennsylvania








77





Wyoming


Plan Name

800shy377shy4161

800shy552shy7114

800shy377shy4161

Telephone Number


9K4

L14

9K4

Self only

9K5

L15

9K5

Self amp family

8704

9545

8704

Self only

18033

20857

18033

Self amp family

4017

4405

4017

Self only

8323

9626

8323

Self amp family

78



Washington $10$3550


Wyoming


79


80

Appendix F


Waiting Periods





Contributions


Salary Deduction





81


















82






Increase Enrollment

Type

Decrease Enrollment

Type







Yes Yes No No No


No No No No Yes


or spouse)

No No No Yes No



Yes No No No No




No No No Yes No







83

Appendix I



Reading the Chart


Dental Insurance









Vision Insurance



84



Plan Name

Telephone amp

Website


Class A

Class B

Class C

Class D

Deductible





0 40 60 70 $0





0 45 65 50 $0


0 20 50 50 $0


0 20 50 50 $0












wwwuccifedvipcom




40 60 50 $0


85




Plan Name

Telephone amp

Website

Class A

Class B

Class C

Class D Deductible





Class B and Class C


787shy774shy6060 787shy749shy4777

0 30 60 30






86








FEP BlueVision High





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

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

$0

$0

















87




Salud




















88



Rating Areas




















OH 453shy455 2 2 2 1 1 2 1 NA NA




89




Salud















90








3 $1471 $2941 $4411 $3187 $6372 $9557 4 $1622 $3243 $4865 $3514 $7027 $10541 5 $1760 $3521 $5281 $3813 $7629 $11442


3 $1132 $2262 $3393 $2453 $4901 $7352 4 $1221 $2441 $3662 $2646 $5289 $7934 5 $1355 $2710 $4064 $2936 $5872 $8805


3 $1857 $3715 $5573 $4024 $8049 $12075 4 $2005 $4010 $6017 $4344 $8688 $13037 5 $2225 $4453 $6681 $4821 $9648 $14476


3 $1022 $2042 $3064 $2214 $4424 $6639 4 $1135 $2270 $3404 $2459 $4918 $7375 5 $1246 $2492 $3739 $2700 $5399 $8101


3 $1910 $3815 $5725 $4138 $8266 $12404 4 $2066 $4129 $6194 $4476 $8946 $13420 5 $2313 $4625 $6937 $5012 $10021 $15030


3 $1767 $3529 $5295 $3829 $7646 $11473 4 $1906 $3806 $5713 $4130 $8246 $12378 5 $2054 $4107 $6160 $4450 $8899 $13347

9911








Self amp Family




1 $1618 $3234 $4852 $3506 $7007 $10513



1 $435 $869 $1141 $943 $1883 $2472


Plan Name




Self amp Family

Aetna

GEHA Standard

GEHA High

MetLife Standard

MetLife High

United Concordia

$1882

$908

$1489

$1246

$2313

$2054

$3762

$1816

$2977

$2492

$4625

$4107

$5644

$2726

$4469

$3739

$6937

$6160

$4078

$1967

$3226

$2700

$5012

$4450

$8151

$3935

$6450

$5399

$10021

$8899

$12229

$5906

$9683

$8101

$15030

$13347

92


Premium Rate Charts



Plan Option




Self amp Family

FEP BlueVision







Standard High

Standard High

Standard High

$377 $475

$300 $423

$413 $617

$752 $949

$585 $824

$825 $1233

$1129 $1425

$871 $1228

$1238 $1850

$817 $1029

$650 $916

$895 $1337

$1629 $2056

$1269 $1786

$1788 $2672

$2446 $3088

$1887 $2660

$2682 $4008



Plan Option




Self amp Family

FEP BlueVision







Standard High

Standard High

Standard High

$377 $475

$300 $423

$413 $617

$752 $949

$585 $824

$825 $1233

$1129 $1425

$871 $1228

$1238 $1850

$817 $1029

$650 $916

$895 $1337

$1629 $2056

$1269 $1786

$1788 $2672

$2446 $3088

$1887 $2660

$2682 $4008

93


















94
























95

Summary Information




















wwwopmgovinsurelife




96


Current Employees



























6

















7







FSAFEDS




8



FEGLI












9






Key FEHB facts













10














11


When can I enroll



How do I enroll




12















13






Key FEDVIP facts














14

















15


When can I enroll




How do I enroll








16


















17





Key FSAFEDS facts













18













19




When can I enroll











20


How do I enroll










21




Key FEGLI facts



















22




When can I enroll







How do I enroll








23




Key FLTCIP facts












24





How do I apply








25


26


















27
















pay more








28












29


Definitions













30















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



31














32









33











Enrollment Code


Monthly Biweekly















421 422 13272 32275 6126 14896




34




Plan

Benefit Type





RampB

Prescription Drugs


Office Visits


Calendar Year

Prescription Drug

APWU shyhigh

BCBS shystd

BCBS shybasic

GEHA shyhigh

GEHA shystd

MHBP shystd

MHBP shyValue

NALC shyhigh

SAMBA shyhigh

SAMBA shystd

CRHP

FSBP

PCABP

Rural

PPO NonshyPPO

PPO NonshyPPO

PPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

POS FFS

PPO NonshyPPO

$275 None $500 None

$350 None $350 None

None None

$350 None $350 None

$350 None $350 None

$400 None $600 None


$300 None $300 None

$300 None $300 None

$350 None $350 None

$300 None $350 None

$300 None $300 None

None None None None

$350 $200 $400 $200


None $300

$250 $350

$150day x 5

$100 $300

None None

$200 $500

None None

$200 $350

$200 $300

$150 up to $450 $200 up to $600

$150 $350

Nothing $200

$100 $25

$100 $300

$18 10 30+diff 30+diff

$20 15 35 35

$25 $150

$20 10 25 25

$10 15 35 35

$20 10 30 30

$30 20 40 40

$20 15 30 30

$20 10 30 30

$20 15 35 35

$10 Nothing 30 30

10 10 30 30

50 50 $5 Nothing

$20 10 25 25

10 30

Nothing 35

Nothing

Nothing Nothing

15 35

Nothing 30

20 40

Nothing 30

Nothing 30

Nothing 35

Nothing 30

Nothing 20

50 Nothing

Nothing 20

$8 2525 Yes 50 5050 Yes

20 (15MCare B) 3030 Yes 45 + 45+45+ Yes

$10 $50$150 NA



$10 30($200 max)50($200 max) Yes 50 5050 Yes


20 3030 Yes 45 45+ 45+45+ Yes



$5 $3030 or $45 Yes $5 $3030 or $45 Yes


20 2020 No 20 2020 No

30 3030 Yes 30 3030 Yes


35













Plan Code


Getting needed care


How well doctors


Claims processing



FFS National A

47

verage 774

78

916

898

91

921

948

938

897

837

929

898

725

737 47





MHBP shystd 45 706 916 917 943 898 927 713 45


NALC shyhigh 32 811 934 914 951 923 951 766 32

SAMBA shyhigh 44 893 946 937 968 901 973 791 44

SAMBA shystd 44 745 923 933 952 903 925 74



44

42

roups Average 774 916 91 948 897 929 725

42




36



Location Plan Name


Plan Code


Getting needed care


How well doctors


Claims processing











37


38















39





Arizona




Arkansas



California












Colorado





40


Primary care



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

Arizona


HMOP

$35$65

OS Nationa

Yes

l Average 659

583

855

842

855

864

935

883

839

858

876

884

664

636



Arkansas


$15$40

$20$30

$250day x 3

$100max$500

$10

$0

$40$70

$40$60

Yes

Yes

702

61

878

845

868

873

921

935

863

877

946

887

675



California


$20$40

$20$35

$200max$1000

$250day x 4

$5

$10

$40$60

$35$65

Yes

Yes

61

612

845

808

873

822

935

922

877

813

887

882

652

608











Colorado


$20$35

$20$40

$150day x 4

$250

$10

$10

$35$60

$35$60

Yes

Yes

692

716

787

833

824

862

935

918

761

77

88

876

588

684



$25$45

$20$35

$250day x 3

$150day x 5

$15

$10

$40$80

$35$65

Yes

Yes

716

616

833

884

862

88

918

943

77

857

876

932

684

631


41







Self amp family


























42


Primary care



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


HMO

$35$65

POS National

Yes

Average 659

659

855

871

855

87

935

918

839

901

876

874

664

667







MD IPAshyHigh


$25$40

$15$40

$150day x 3

$150day x 5

$7

$5

$30$150$250

$30$5030

Yes

No

632

724

838

869

871

855

925

913

841

894

90

853

65

648










$25$40

$20$35

$500day x 3

$250day x 4

$10

$10

$40$60

$35$65

Yes

Yes 569 888 835 927 882 873 589









43





Guam






Idaho





Illinois











44


Primary care



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

Guam


HMOP

$15$25$50

OS Nationa

No

l Average 659

642

855

726

855

626

935

895

839

694

876

664

664

563

TakeCareshyStd


$25$40

$15$15

$150day for 5 days

$100

$15

$7

$20$40$80

$30$65

No

Yes

642

833

726

924

626

91

895

959

694

837

664

941

563


$65+20 No 833 924 91 959 837 941 666



Idaho


$30$30

$20$30

10

$200

$20

$7

$20$20

$25$50

Yes

Yes

751

556

821

86

797

88

935

948

792

817

853

853

707

625




Illinois


$25+20$25+20

$20$35

$500day x 3

$250day x 4

$20

$10

$40$60

$35$65

Yes

Yes

691

615

839

826

844

82

926

909

867

866

896

823

711

642











45







Self amp family

Indiana








Iowa









Kansas






46


Primary care



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

$35$65

OS Nationa

Yes

l Average 659

615

855

826

855

82

935

909

839

866

876

823

664

642







Iowa


$15$15

$20$45

20

15

$10

$3$10

$25$50

$40$65

Yes

Yes

583

567

879

857

88

867

952

966

905

824

944

907

603

675









Kansas


$25$45

$20$35

Nothing

$250day x 4

$10

$10

$35$50

$35$65

Yes

Yes

524 873 853 956 798 886 622





47





Kentucky





Louisiana



Maryland










Massachusetts


48


Primary care



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

Kentucky


HMO

$40$60

POS National

Yes

Average 659 855 855 935 839 876 664




Louisiana


$25$40

$25$45

$500day x 3

$100

$10

$5

$40$60

$40$75

Yes

Yes 579 866 853 964 793 843 677


Maryland


$30$55

$15$30

30

$150day x3

$5

$5

$40$75

$35$65

Yes

Yes

579

659

866

871

853

87

964

918

793

901

843

874

677

667









MD IPAshyHigh

Massachusetts


$25$40

$25$35

$150day x 3

$150 to $750max

$7

$10

$30$150$250

$30$60

Yes

Yes

632

61

838

862

871

883

925

95

841

828

90

799

65

627

49























Enrollment Code


Michigan

H61 H62

J31 J32

K51 K52

LX1 LX2

RL1 RL2

RL4 RL5

521 522

GY4 GY5

X51 X52

9U4 9U5

Minnesota

V31 V32

V34 V35

Missouri HY1 HY2

9G1 9G2

HA1 HA2

HA4 HA5

MS1 MS2

MS4 MS5

B91 B92

Telephone Number

800shy662shy6667

800shy662shy6667

800shy662shy6667

800shy662shy6667

616shy949shy2410

616shy949shy2410

800shy556shy9765

800shy556shy9765

800shy332shy9161

866shy539shy3342

952shy883shy5000

952shy883shy5000

877shy459shy6604

888shy811shy2092

800shy969shy3343

800shy969shy3343

888shy393shy6765

888shy393shy6765

877shy835shy9861

50

Monthly


17455 60199

20874 69088

15762 37947

12930 44648

19006 64274

12973 45145

15511 44042

12822 33321

12002 34959

20141 55759

32886 78427

8987 20671

11817 36274

26208 54102

12196 32723

10096 23722

45714 103636

13457 31059

19353 43374

Biweekly


8056 27784

9634 31887

7275 17514

5968 20607

8772 29665

5987 20836

7159 20327

5918 15379

5539 16135

9296 25735

15178 36197

4148 9540

5454 16742

12096 24970

5629 15103

4660 10948

21099 47832

6211 14335

8932 20019


Primary care



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


HMO

$50NA

POS National

Yes

Average 659 855 855 935 839 876 664










Minnesota


$20Nothing

$25$45

20

Nothing

$15

$12

$25$50

$45$90

Yes

Yes

774

641

906

873

886

897

964

951

893

888

887

912

69

66




$250day x 4

$9

$10

$40$70

$35$65

Yes

Yes

641 873 897 951 888 912 66








51








Nevada

HF1 HF2 10582 33646 4884 15529

NM1 NM2 10448 24635 4822 11370

Telephone Number

877shy459shy6604

800shy777shy1840

New Jersey







New Mexico



52

Q11 Q12 22873 58561 10557 27028

P21 P22 17370 41076 8017 18958


Primary care



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

Nevada


HMO

$35$65

POS National

Yes

Average 659 855 855 935 839 876 664


New Jersey


$10$20

$20$35

$150

$150day x 5

$5

$10

$35$55

$35$65

Yes

Yes

567

617

709

855

706

886

898

937

78

852

845

861

561

605






New Mexico


$25$25

$20$35

$250day x 3

$250 after ded

$5

$5

$25$50

$35$6050

Yes

Yes

604

623

856

807

861

786

926

896

763

807

772

862

572

746


53




























54


Primary care



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


HMO

$35$65

POS National

Yes

Average 659

651

855

828

855

853

935

927

839

873

876

875

664

60























55





North Dakota




Ohio






Oklahoma


Oregon



56


Primary care



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 Dakota


HMO

$45$90

POS National

Yes

Average 659

641

855

873

855

897

935

951

839

888

876

912

664

66



Ohio

AultCare HMOshyHigh

2020

$15$20

20

$150

NA

$15

NA

$30$45

NA

No 865 935 926 946 946 958 863





Oklahoma


Oregon


$10$20

$15$35

$15$25

$250

$150day x 3

$200

$15

$10

$15

$30$50

$30$40

$40$40

Yes

Yes

Yes

739

56

677

905

731

769

89

812

778

963

941

893

927

715

864

957

883

848

758

626

679


57





Pennsylvania











South Dakota





Tennessee




58


Primary care



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

Pennsylvania


HMO

$35$65

POS National

Yes

Average 659

567

855

873

855

885

935

946

839

752

876

886

664

682









$20$35

$5$5

None

None

$5

$250

$35$70

$10$15

Yes

Yes

764

753

903

807

871

815

959

936

87

834

885

811

716




South Dakota


$750+10$10+10

$25$45

10 +

Nothing

NA

$12

NA NA

$45$90

No

Yes

716

641

857

873

796

897

968

951

683

888

695

912

514

66




Tennessee


4040

$20$35

40

$250day x 4

NA

$10

NA NA

$35$65

No

Yes

53

639

831

877

861

842

963

936

905

85

907

919

703

708



59





Texas










Utah




Virgin Islands












60


Primary care



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

$35$65

OS Nationa

Yes

l Average 659

698

855

833

855

793

935

896

839

829

876

886

664

652









Utah


$20$40

$20$30

$250day x 5

$200

$10

$7

$35$60

$25$50

Yes

Yes

654

556

864

86

842

88

936

948

797

817

905

853

646

625


SelectHealthshyHigh

Virgin Islands


$15$25

$750$10

$100

None

$5

$5 or $12

$2550


NA

Yes x

553 834 823 93 935 92 712



$10 amp 10+

$150day x3 $5 $35$65 Yes 659 871 87 918 901 874 667











61





Washington







West Virginia


Wisconsin







Wyoming



62


Primary care



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

Washington


HMOP

$40$60

OS National

Yes

Average 659

691

855

839

855

844

935

926

839

867

876

896

664

711









West Virginia


Wisconsin


$25$35

$10$20

$10$10

$500

$250

None

$20

$15

$10

$40$40

$30$50

30$75max30

Yes

Yes

No

677

739

77

769

905

871

778

89

883

893

963

962

864

927

854

848

957

921

679

758

689






Wyoming


$10$10

$20$30

Nothing

$200

$10

$7

3050

$25$50

No

Yes

766

556

86

86

889

88

95

948

901

817

912

853

723

625


63











64



















insurance plans

65



ELIGIBILITY

FUNDING







CONTRIBUTIONS

DISTRIBUTIONS







ANNUAL ROLLOVER







66




67












Self only

Self amp family

Self only

Self amp family

Self only

Self amp family




866shy833shy3463

800shy821shy6136

800shy694shy9901

474 475

341 342

481 482

8923 20072

9996 22832

11557 26186

4118 9264

4614 10538

5334 12086

68













69












Plan Code


Getting needed care


How well doctors


Claims processing






22

34

48

60

637

54

856

864

868

893

885

877

935

923

936

859

852

839

90

876

892

592

593

547


Plan Code


Getting needed care


How well doctors


Claims processing






22

47

TU TV

60

643

489

856

884

806

893

868

841

935

924

929

859

803

839

90

809

891

592

657

609

70


71





Plan Name

Telephone Number


Self only

Self amp family

Self only

Self amp family

Self only

Self amp family



877shy459shy6604

877shy459shy6604

221 222

224 225

15604 37056

9412 20613

7202 17103

4344 9514


Florida







Idaho


Plan Name

800shy441shy5501

888shy393shy6765

888shy393shy6765

888shy393shy6765

888shy393shy6765

671shy647shy3526

800shy377shy4161

Telephone Number


J41

MJ1

QP1

AD1

LM1

KX1

9K4

Self only

J42

MJ2

QP2

AD2

LM2

KX2

9K5

Self amp family

11570

12685

10873

11477

11840

8138

8704

Self only

28710

28542

24465

25824

26639

21442

18033

Self amp family

5340

5855

5018

5297

5464

3756

4017

Self only

13251

13173

11291

11919

12295

9896

8323

Self amp family

72



Benefit Type


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs




Benefit Type


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Florida


Plan Name

$8334$16667 $2500$5000 $5000$10000 $10 20 20 Nothing $5$35$5020






OutshyNetwork

InshyNetwork

NA

$8333

$3000$6000

$1000$2000

$4000$8000

$3000$6000

30

$25

30

$300day x 5

30

$150

30

Nothing

$10+$40+$60+



Guam TakeCareshy

OutshyNetwork

InshyNetwork

NA

$8666$22208

$3000$6000

$3000$6000

$4000$8000

$5000$10000

30

20afterDed

30

20 after Ded

30

20 after Ded

30

Nothing

$10+$40+$60+


Idaho

Altius Health Plans


$4583$9166

$3000$6000

$1200$2400

$10000$20000

$5000$10000 $20

30 afterDed

10


10

1st $300ded

Nothing

30 after Ded

$7$25$50

73












Plan Name

888shy393shy6765

888shy393shy6765

888shy393shy6765

800shy257shy4692

800shy969shy3343

888shy393shy6765

888shy393shy6765

800shy833shy7423

Telephone Number


GB1

MW1

MW1

SV4

9H1

PH1

6N1

GZ1

Self only

GB2

MW2

MW2

SV5

9H2

PH2

6N2

GZ2

Self amp family

12685

12081

12081

8608

9721

10873

10064

9834

Self only

28542

27182

27182

20544

22845

24464

22644

22508

Self amp family

5855

5576

5576

3973

4486

5018

4645

4539

Self only

13173

12546

12546

9482

10544

11291

10451

10388

Self amp family

74










75

A








Pennsylvania







Plan Name

800shy969shy3343

888shy393shy6765

800shy501shy3439

330shy363shy6360

866shy351shy5946

866shy351shy5946

888shy876shy2756

888shy393shy6765

888shy393shy6765

888shy393shy6765

Telephone Number


9H1

PH1

QA4

3A4

Y61

YW1

8W4

TP1

TU1

TV1

Self only

9H2

PH2

QA5

3A5

Y62

YW2

8W5

TP2

TU2

TV2

Self amp family

9721

10873

9633

7760

11914

14046

11884

11840

12081

12284

Self only

22845

24464

24717

15548

27430

30756

26620

26640

27182

27639

Self amp family

4486

5018

4446

3581

5499

6483

5485

5464

5576

5669

Self only

10544

11291

11408

7176

12660

14195

12286

12295

12546

12756

Self amp family

76






Pennsylvania








77





Wyoming


Plan Name

800shy377shy4161

800shy552shy7114

800shy377shy4161

Telephone Number


9K4

L14

9K4

Self only

9K5

L15

9K5

Self amp family

8704

9545

8704

Self only

18033

20857

18033

Self amp family

4017

4405

4017

Self only

8323

9626

8323

Self amp family

78



Washington $10$3550


Wyoming


79


80

Appendix F


Waiting Periods





Contributions


Salary Deduction





81


















82






Increase Enrollment

Type

Decrease Enrollment

Type







Yes Yes No No No


No No No No Yes


or spouse)

No No No Yes No



Yes No No No No




No No No Yes No







83

Appendix I



Reading the Chart


Dental Insurance









Vision Insurance



84



Plan Name

Telephone amp

Website


Class A

Class B

Class C

Class D

Deductible





0 40 60 70 $0





0 45 65 50 $0


0 20 50 50 $0


0 20 50 50 $0












wwwuccifedvipcom




40 60 50 $0


85




Plan Name

Telephone amp

Website

Class A

Class B

Class C

Class D Deductible





Class B and Class C


787shy774shy6060 787shy749shy4777

0 30 60 30






86








FEP BlueVision High





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

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

$0

$0

















87




Salud




















88



Rating Areas




















OH 453shy455 2 2 2 1 1 2 1 NA NA




89




Salud















90








3 $1471 $2941 $4411 $3187 $6372 $9557 4 $1622 $3243 $4865 $3514 $7027 $10541 5 $1760 $3521 $5281 $3813 $7629 $11442


3 $1132 $2262 $3393 $2453 $4901 $7352 4 $1221 $2441 $3662 $2646 $5289 $7934 5 $1355 $2710 $4064 $2936 $5872 $8805


3 $1857 $3715 $5573 $4024 $8049 $12075 4 $2005 $4010 $6017 $4344 $8688 $13037 5 $2225 $4453 $6681 $4821 $9648 $14476


3 $1022 $2042 $3064 $2214 $4424 $6639 4 $1135 $2270 $3404 $2459 $4918 $7375 5 $1246 $2492 $3739 $2700 $5399 $8101


3 $1910 $3815 $5725 $4138 $8266 $12404 4 $2066 $4129 $6194 $4476 $8946 $13420 5 $2313 $4625 $6937 $5012 $10021 $15030


3 $1767 $3529 $5295 $3829 $7646 $11473 4 $1906 $3806 $5713 $4130 $8246 $12378 5 $2054 $4107 $6160 $4450 $8899 $13347

9911








Self amp Family




1 $1618 $3234 $4852 $3506 $7007 $10513



1 $435 $869 $1141 $943 $1883 $2472


Plan Name




Self amp Family

Aetna

GEHA Standard

GEHA High

MetLife Standard

MetLife High

United Concordia

$1882

$908

$1489

$1246

$2313

$2054

$3762

$1816

$2977

$2492

$4625

$4107

$5644

$2726

$4469

$3739

$6937

$6160

$4078

$1967

$3226

$2700

$5012

$4450

$8151

$3935

$6450

$5399

$10021

$8899

$12229

$5906

$9683

$8101

$15030

$13347

92


Premium Rate Charts



Plan Option




Self amp Family

FEP BlueVision







Standard High

Standard High

Standard High

$377 $475

$300 $423

$413 $617

$752 $949

$585 $824

$825 $1233

$1129 $1425

$871 $1228

$1238 $1850

$817 $1029

$650 $916

$895 $1337

$1629 $2056

$1269 $1786

$1788 $2672

$2446 $3088

$1887 $2660

$2682 $4008



Plan Option




Self amp Family

FEP BlueVision







Standard High

Standard High

Standard High

$377 $475

$300 $423

$413 $617

$752 $949

$585 $824

$825 $1233

$1129 $1425

$871 $1228

$1238 $1850

$817 $1029

$650 $916

$895 $1337

$1629 $2056

$1269 $1786

$1788 $2672

$2446 $3088

$1887 $2660

$2682 $4008

93


















94
























95

Summary Information




















wwwopmgovinsurelife




96

















7







FSAFEDS




8



FEGLI












9






Key FEHB facts













10














11


When can I enroll



How do I enroll




12















13






Key FEDVIP facts














14

















15


When can I enroll




How do I enroll








16


















17





Key FSAFEDS facts













18













19




When can I enroll











20


How do I enroll










21




Key FEGLI facts



















22




When can I enroll







How do I enroll








23




Key FLTCIP facts












24





How do I apply








25


26


















27
















pay more








28












29


Definitions













30















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



31














32









33











Enrollment Code


Monthly Biweekly















421 422 13272 32275 6126 14896




34




Plan

Benefit Type





RampB

Prescription Drugs


Office Visits


Calendar Year

Prescription Drug

APWU shyhigh

BCBS shystd

BCBS shybasic

GEHA shyhigh

GEHA shystd

MHBP shystd

MHBP shyValue

NALC shyhigh

SAMBA shyhigh

SAMBA shystd

CRHP

FSBP

PCABP

Rural

PPO NonshyPPO

PPO NonshyPPO

PPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

PPO NonshyPPO

POS FFS

PPO NonshyPPO

$275 None $500 None

$350 None $350 None

None None

$350 None $350 None

$350 None $350 None

$400 None $600 None


$300 None $300 None

$300 None $300 None

$350 None $350 None

$300 None $350 None

$300 None $300 None

None None None None

$350 $200 $400 $200


None $300

$250 $350

$150day x 5

$100 $300

None None

$200 $500

None None

$200 $350

$200 $300

$150 up to $450 $200 up to $600

$150 $350

Nothing $200

$100 $25

$100 $300

$18 10 30+diff 30+diff

$20 15 35 35

$25 $150

$20 10 25 25

$10 15 35 35

$20 10 30 30

$30 20 40 40

$20 15 30 30

$20 10 30 30

$20 15 35 35

$10 Nothing 30 30

10 10 30 30

50 50 $5 Nothing

$20 10 25 25

10 30

Nothing 35

Nothing

Nothing Nothing

15 35

Nothing 30

20 40

Nothing 30

Nothing 30

Nothing 35

Nothing 30

Nothing 20

50 Nothing

Nothing 20

$8 2525 Yes 50 5050 Yes

20 (15MCare B) 3030 Yes 45 + 45+45+ Yes

$10 $50$150 NA



$10 30($200 max)50($200 max) Yes 50 5050 Yes


20 3030 Yes 45 45+ 45+45+ Yes



$5 $3030 or $45 Yes $5 $3030 or $45 Yes


20 2020 No 20 2020 No

30 3030 Yes 30 3030 Yes


35













Plan Code


Getting needed care


How well doctors


Claims processing



FFS National A

47

verage 774

78

916

898

91

921

948

938

897

837

929

898

725

737 47





MHBP shystd 45 706 916 917 943 898 927 713 45


NALC shyhigh 32 811 934 914 951 923 951 766 32

SAMBA shyhigh 44 893 946 937 968 901 973 791 44

SAMBA shystd 44 745 923 933 952 903 925 74



44

42

roups Average 774 916 91 948 897 929 725

42




36



Location Plan Name


Plan Code


Getting needed care


How well doctors


Claims processing











37


38















39





Arizona




Arkansas



California












Colorado





40


Primary care



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

Arizona


HMOP

$35$65

OS Nationa

Yes

l Average 659

583

855

842

855

864

935

883

839

858

876

884

664

636



Arkansas


$15$40

$20$30

$250day x 3

$100max$500

$10

$0

$40$70

$40$60

Yes

Yes

702

61

878

845

868

873

921

935

863

877

946

887

675



California


$20$40

$20$35

$200max$1000

$250day x 4

$5

$10

$40$60

$35$65

Yes

Yes

61

612

845

808

873

822

935

922

877

813

887

882

652

608











Colorado


$20$35

$20$40

$150day x 4

$250

$10

$10

$35$60

$35$60

Yes

Yes

692

716

787

833

824

862

935

918

761

77

88

876

588

684



$25$45

$20$35

$250day x 3

$150day x 5

$15

$10

$40$80

$35$65

Yes

Yes

716

616

833

884

862

88

918

943

77

857

876

932

684

631


41







Self amp family


























42


Primary care



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


HMO

$35$65

POS National

Yes

Average 659

659

855

871

855

87

935

918

839

901

876

874

664

667







MD IPAshyHigh


$25$40

$15$40

$150day x 3

$150day x 5

$7

$5

$30$150$250

$30$5030

Yes

No

632

724

838

869

871

855

925

913

841

894

90

853

65

648










$25$40

$20$35

$500day x 3

$250day x 4

$10

$10

$40$60

$35$65

Yes

Yes 569 888 835 927 882 873 589









43





Guam






Idaho





Illinois











44


Primary care



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

Guam


HMOP

$15$25$50

OS Nationa

No

l Average 659

642

855

726

855

626

935

895

839

694

876

664

664

563

TakeCareshyStd


$25$40

$15$15

$150day for 5 days

$100

$15

$7

$20$40$80

$30$65

No

Yes

642

833

726

924

626

91

895

959

694

837

664

941

563


$65+20 No 833 924 91 959 837 941 666



Idaho


$30$30

$20$30

10

$200

$20

$7

$20$20

$25$50

Yes

Yes

751

556

821

86

797

88

935

948

792

817

853

853

707

625




Illinois


$25+20$25+20

$20$35

$500day x 3

$250day x 4

$20

$10

$40$60

$35$65

Yes

Yes

691

615

839

826

844

82

926

909

867

866

896

823

711

642











45







Self amp family

Indiana








Iowa









Kansas






46


Primary care



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

$35$65

OS Nationa

Yes

l Average 659

615

855

826

855

82

935

909

839

866

876

823

664

642







Iowa


$15$15

$20$45

20

15

$10

$3$10

$25$50

$40$65

Yes

Yes

583

567

879

857

88

867

952

966

905

824

944

907

603

675









Kansas


$25$45

$20$35

Nothing

$250day x 4

$10

$10

$35$50

$35$65

Yes

Yes

524 873 853 956 798 886 622





47





Kentucky





Louisiana



Maryland










Massachusetts


48


Primary care



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

Kentucky


HMO

$40$60

POS National

Yes

Average 659 855 855 935 839 876 664




Louisiana


$25$40

$25$45

$500day x 3

$100

$10

$5

$40$60

$40$75

Yes

Yes 579 866 853 964 793 843 677


Maryland


$30$55

$15$30

30

$150day x3

$5

$5

$40$75

$35$65

Yes

Yes

579

659

866

871

853

87

964

918

793

901

843

874

677

667









MD IPAshyHigh

Massachusetts


$25$40

$25$35

$150day x 3

$150 to $750max

$7

$10

$30$150$250

$30$60

Yes

Yes

632

61

838

862

871

883

925

95

841

828

90

799

65

627

49























Enrollment Code


Michigan

H61 H62

J31 J32

K51 K52

LX1 LX2

RL1 RL2

RL4 RL5

521 522

GY4 GY5

X51 X52

9U4 9U5

Minnesota

V31 V32

V34 V35

Missouri HY1 HY2

9G1 9G2

HA1 HA2

HA4 HA5

MS1 MS2

MS4 MS5

B91 B92

Telephone Number

800shy662shy6667

800shy662shy6667

800shy662shy6667

800shy662shy6667

616shy949shy2410

616shy949shy2410

800shy556shy9765

800shy556shy9765

800shy332shy9161

866shy539shy3342

952shy883shy5000

952shy883shy5000

877shy459shy6604

888shy811shy2092

800shy969shy3343

800shy969shy3343

888shy393shy6765

888shy393shy6765

877shy835shy9861

50

Monthly


17455 60199

20874 69088

15762 37947

12930 44648

19006 64274

12973 45145

15511 44042

12822 33321

12002 34959

20141 55759

32886 78427

8987 20671

11817 36274

26208 54102

12196 32723

10096 23722

45714 103636

13457 31059

19353 43374

Biweekly


8056 27784

9634 31887

7275 17514

5968 20607

8772 29665

5987 20836

7159 20327

5918 15379

5539 16135

9296 25735

15178 36197

4148 9540

5454 16742

12096 24970

5629 15103

4660 10948

21099 47832

6211 14335

8932 20019


Primary care



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


HMO

$50NA

POS National

Yes

Average 659 855 855 935 839 876 664










Minnesota


$20Nothing

$25$45

20

Nothing

$15

$12

$25$50

$45$90

Yes

Yes

774

641

906

873

886

897

964

951

893

888

887

912

69

66




$250day x 4

$9

$10

$40$70

$35$65

Yes

Yes

641 873 897 951 888 912 66








51








Nevada

HF1 HF2 10582 33646 4884 15529

NM1 NM2 10448 24635 4822 11370

Telephone Number

877shy459shy6604

800shy777shy1840

New Jersey







New Mexico



52

Q11 Q12 22873 58561 10557 27028

P21 P22 17370 41076 8017 18958


Primary care



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

Nevada


HMO

$35$65

POS National

Yes

Average 659 855 855 935 839 876 664


New Jersey


$10$20

$20$35

$150

$150day x 5

$5

$10

$35$55

$35$65

Yes

Yes

567

617

709

855

706

886

898

937

78

852

845

861

561

605






New Mexico


$25$25

$20$35

$250day x 3

$250 after ded

$5

$5

$25$50

$35$6050

Yes

Yes

604

623

856

807

861

786

926

896

763

807

772

862

572

746


53




























54


Primary care



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


HMO

$35$65

POS National

Yes

Average 659

651

855

828

855

853

935

927

839

873

876

875

664

60























55





North Dakota




Ohio






Oklahoma


Oregon



56


Primary care



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 Dakota


HMO

$45$90

POS National

Yes

Average 659

641

855

873

855

897

935

951

839

888

876

912

664

66



Ohio

AultCare HMOshyHigh

2020

$15$20

20

$150

NA

$15

NA

$30$45

NA

No 865 935 926 946 946 958 863





Oklahoma


Oregon


$10$20

$15$35

$15$25

$250

$150day x 3

$200

$15

$10

$15

$30$50

$30$40

$40$40

Yes

Yes

Yes

739

56

677

905

731

769

89

812

778

963

941

893

927

715

864

957

883

848

758

626

679


57





Pennsylvania











South Dakota





Tennessee




58


Primary care



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

Pennsylvania


HMO

$35$65

POS National

Yes

Average 659

567

855

873

855

885

935

946

839

752

876

886

664

682









$20$35

$5$5

None

None

$5

$250

$35$70

$10$15

Yes

Yes

764

753

903

807

871

815

959

936

87

834

885

811

716




South Dakota


$750+10$10+10

$25$45

10 +

Nothing

NA

$12

NA NA

$45$90

No

Yes

716

641

857

873

796

897

968

951

683

888

695

912

514

66




Tennessee


4040

$20$35

40

$250day x 4

NA

$10

NA NA

$35$65

No

Yes

53

639

831

877

861

842

963

936

905

85

907

919

703

708



59





Texas










Utah




Virgin Islands












60


Primary care



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

$35$65

OS Nationa

Yes

l Average 659

698

855

833

855

793

935

896

839

829

876

886

664

652









Utah


$20$40

$20$30

$250day x 5

$200

$10

$7

$35$60

$25$50

Yes

Yes

654

556

864

86

842

88

936

948

797

817

905

853

646

625


SelectHealthshyHigh

Virgin Islands


$15$25

$750$10

$100

None

$5

$5 or $12

$2550


NA

Yes x

553 834 823 93 935 92 712



$10 amp 10+

$150day x3 $5 $35$65 Yes 659 871 87 918 901 874 667











61





Washington







West Virginia


Wisconsin







Wyoming



62


Primary care



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

Washington


HMOP

$40$60

OS National

Yes

Average 659

691

855

839

855

844

935

926

839

867

876

896

664

711









West Virginia


Wisconsin


$25$35

$10$20

$10$10

$500

$250

None

$20

$15

$10

$40$40

$30$50

30$75max30

Yes

Yes

No

677

739

77

769

905

871

778

89

883

893

963

962

864

927

854

848

957

921

679

758

689






Wyoming


$10$10

$20$30

Nothing

$200

$10

$7

3050

$25$50

No

Yes

766

556

86

86

889

88

95

948

901

817

912

853

723

625


63











64



















insurance plans

65



ELIGIBILITY

FUNDING







CONTRIBUTIONS

DISTRIBUTIONS







ANNUAL ROLLOVER







66




67












Self only

Self amp family

Self only

Self amp family

Self only

Self amp family




866shy833shy3463

800shy821shy6136

800shy694shy9901

474 475

341 342

481 482

8923 20072

9996 22832

11557 26186

4118 9264

4614 10538

5334 12086

68













69












Plan Code


Getting needed care


How well doctors


Claims processing






22

34

48

60

637

54

856

864

868

893

885

877

935

923

936

859

852

839

90

876

892

592

593

547


Plan Code


Getting needed care


How well doctors


Claims processing






22

47

TU TV

60

643

489

856

884

806

893

868

841

935

924

929

859

803

839

90

809

891

592

657

609

70


71





Plan Name

Telephone Number


Self only

Self amp family

Self only

Self amp family

Self only

Self amp family



877shy459shy6604

877shy459shy6604

221 222

224 225

15604 37056

9412 20613

7202 17103

4344 9514


Florida







Idaho


Plan Name

800shy441shy5501

888shy393shy6765

888shy393shy6765

888shy393shy6765

888shy393shy6765

671shy647shy3526

800shy377shy4161

Telephone Number


J41

MJ1

QP1

AD1

LM1

KX1

9K4

Self only

J42

MJ2

QP2

AD2

LM2

KX2

9K5

Self amp family

11570

12685

10873

11477

11840

8138

8704

Self only

28710

28542

24465

25824

26639

21442

18033

Self amp family

5340

5855

5018

5297

5464

3756

4017

Self only

13251

13173

11291

11919

12295

9896

8323

Self amp family

72



Benefit Type


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs




Benefit Type


CY Ded SelfFamily


Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Florida


Plan Name

$8334$16667 $2500$5000 $5000$10000 $10 20 20 Nothing $5$35$5020






OutshyNetwork

InshyNetwork

NA

$8333

$3000$6000

$1000$2000

$4000$8000

$3000$6000

30

$25

30

$300day x 5

30

$150

30

Nothing

$10+$40+$60+



Guam TakeCareshy

OutshyNetwork

InshyNetwork

NA

$8666$22208

$3000$6000

$3000$6000

$4000$8000

$5000$10000

30

20afterDed

30

20 after Ded

30

20 after Ded

30

Nothing

$10+$40+$60+


Idaho

Altius Health Plans


$4583$9166

$3000$6000

$1200$2400

$10000$20000

$5000$10000 $20

30 afterDed

10


10

1st $300ded

Nothing

30 after Ded

$7$25$50

73












Plan Name

888shy393shy6765

888shy393shy6765

888shy393shy6765

800shy257shy4692

800shy969shy3343

888shy393shy6765

888shy393shy6765

800shy833shy7423

Telephone Number


GB1

MW1

MW1

SV4

9H1

PH1

6N1

GZ1

Self only

GB2

MW2

MW2

SV5

9H2

PH2

6N2

GZ2

Self amp family

12685

12081

12081

8608

9721

10873

10064

9834

Self only

28542

27182

27182

20544

22845

24464

22644

22508

Self amp family

5855

5576

5576

3973

4486

5018

4645

4539

Self only

13173

12546

12546

9482

10544

11291

10451

10388

Self amp family

74










75

A








Pennsylvania







Plan Name

800shy969shy3343

888shy393shy6765

800shy501shy3439

330shy363shy6360

866shy351shy5946

866shy351shy5946

888shy876shy2756

888shy393shy6765

888shy393shy6765

888shy393shy6765

Telephone Number


9H1

PH1

QA4

3A4

Y61

YW1

8W4

TP1

TU1

TV1

Self only

9H2

PH2

QA5

3A5

Y62

YW2

8W5

TP2

TU2

TV2

Self amp family

9721

10873

9633

7760

11914

14046

11884

11840

12081

12284

Self only

22845

24464

24717

15548

27430

30756

26620

26640

27182

27639

Self amp family

4486

5018

4446

3581

5499

6483

5485

5464

5576

5669

Self only

10544

11291

11408

7176

12660

14195

12286

12295

12546

12756

Self amp family

76






Pennsylvania








77





Wyoming


Plan Name

800shy377shy4161

800shy552shy7114

800shy377shy4161

Telephone Number


9K4

L14

9K4

Self only

9K5

L15

9K5

Self amp family

8704

9545

8704

Self only

18033

20857

18033

Self amp family

4017

4405

4017

Self only

8323

9626

8323

Self amp family

78



Washington $10$3550


Wyoming


79


80

Appendix F


Waiting Periods





Contributions


Salary Deduction





81


















82






Increase Enrollment

Type

Decrease Enrollment

Type







Yes Yes No No No


No No No No Yes


or spouse)

No No No Yes No



Yes No No No No




No No No Yes No







83

Appendix I



Reading the Chart


Dental Insurance









Vision Insurance



84



Plan Name

Telephone amp

Website


Class A

Class B

Class C

Class D

Deductible





0 40 60 70 $0





0 45 65 50 $0


0 20 50 50 $0


0 20 50 50 $0












wwwuccifedvipcom




40 60 50 $0


85




Plan Name

Telephone amp

Website

Class A

Class B

Class C

Class D Deductible





Class B and Class C


787shy774shy6060 787shy749shy4777

0 30 60 30






86








FEP BlueVision High





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

Every 12 months

Every 12 months

Every 12 months

Every 12 months

Every 12 months

$0

$0

















87




Salud




















88



Rating Areas




















OH 453shy455 2 2 2 1 1 2 1 NA NA




89




Salud















90








3 $1471 $2941 $4411 $3187 $6372 $9557 4 $1622 $3243 $4865 $3514 $7027 $10541 5 $1760 $3521 $5281 $3813 $7629 $11442


3 $1132 $2262 $3393 $2453 $4901 $7352 4 $1221 $2441 $3662 $2646 $5289 $7934 5 $1355 $2710 $4064 $2936 $5872 $8805


3 $1857 $3715 $5573 $4024 $8049 $12075 4 $2005 $4010 $6017 $4344 $8688 $13037 5 $2225 $4453 $6681 $4821 $9648 $14476


3 $1022 $2042 $3064 $2214 $4424 $6639 4 $1135 $2270 $3404 $2459 $4918 $7375 5 $1246 $2492 $3739 $2700 $5399 $8101


3 $1910 $3815 $5725 $4138 $8266 $12404 4 $2066 $4129 $6194 $4476 $8946 $13420 5 $2313 $4625 $6937 $5012 $10021 $15030


3 $1767 $3529 $5295 $3829 $7646 $11473 4 $1906 $3806 $5713 $4130 $8246 $12378 5 $2054 $4107 $6160 $4450 $8899 $13347

9911








Self amp Family




1 $1618 $3234 $4852 $3506 $7007 $10513



1 $435 $869 $1141 $943 $1883 $2472


Plan Name




Self amp Family

Aetna

GEHA Standard

GEHA High

MetLife Standard

MetLife High

United Concordia

$1882

$908

$1489

$1246

$2313

$2054

$3762

$1816

$2977

$2492

$4625

$4107

$5644

$2726

$4469

$3739

$6937

$6160

$4078

$1967

$3226

$2700

$5012

$4450

$8151

$3935

$6450

$5399

$10021

$8899

$12229

$5906

$9683

$8101

$15030

$13347

92


Premium Rate Charts



Plan Option




Self amp Family

FEP BlueVision







Standard High

Standard High

Standard High

$377 $475

$300 $423

$413 $617

$752 $949

$585 $824

$825 $1233

$1129 $1425

$871 $1228

$1238 $1850

$817 $1029

$650 $916

$895 $1337

$1629 $2056

$1269 $1786

$1788 $2672

$2446 $3088

$1887 $2660

$2682 $4008



Plan Option




Self amp Family

FEP BlueVision







Standard High

Standard High

Standard High

$377 $475

$300 $423

$413 $617

$752 $949

$585 $824

$825 $1233

$1129 $1425

$871 $1228

$1238 $1850

$817 $1029

$650 $916

$895 $1337

$1629 $2056

$1269 $1786

$1788 $2672

$2446 $3088

$1887 $2660

$2682 $4008

93


















94
























95

Summary Information




















wwwopmgovinsurelife




96

Guide To Federal Benefits

Documents

Transcript of Guide To Federal Benefits