Individuals Receiving Compensation From the Office of Workers Compensation Programs OWCP

Guide to Federal Employees Health Benefits Plans For Individuals Receiving Compensation from the Office of Workers’ Compensation Programs (OWCP) Center for Retirement and Insurance Service Visit our web site at www.opm.gov/insure/health RI 70 -6 Revised November 2003 Dear Federal Employees Health Benefits Program Participant: It is hard to believe that a year has passed and the Federal Employees Health Benefits (FEHB) Open Season is here again. This is your annual opportunity to evaluate your personal needs and, if necessary, change health plans. I am pleased to present the 2004 FEHB Guide to help you with your evaluation. It takes a lot of information to help a consumer make wise healthcare decisions. The information in this Guide and our web-based resources make it easier than ever to get information about premiums, to compare benefits, to read customer service satisfaction ratings for the national and local plans that may be of interest, and to learn about quality information from the National Committee for Quality Assurance, the Joint Commission on Accreditation of Healthcare Organizations, and URAC. The FEHB Program continues to be an enviable national model that offers exceptional choice, and uses private-sector competition to keep costs reasonable, ensure high-quality care, and spur innovation. The Program, which began in 1960, is sound and has stood the test of time. It enjoys one of the highest levels of customer satisfaction of any healthcare program in the country. President Bush has chosen the FEHB as a model for modernizing and improving Medicare. I continue to take aggressive steps to keep the FEHB Program on the cutting edge of employersponsored health benefits. We demand cost-effective quality care from our FEHB carriers and we have encouraged Federal agencies and departments to pay the full FEHB health benefit premium for their employees called to active duty in the Reserve and National Guard so they can continue FEHB coverage for themselves and their families. Our carriers have also responded to my request to help our members to be prepared by making additional supplies of medications available for emergencies as well as call-up situations and you can help by getting an Emergency Preparedness Guide at www.opm.gov. OPM’s HealthierFeds campaign is another way the carriers are working with us to ensure Federal employees and retirees are informed on healthy living and best-treatment strategies. You can help to contain healthcare costs and keep premiums down by living a healthy life style. Open Season is your opportunity to review your choices and to become a better educated consumer to meet your healthcare needs. Use this Guide, the health plan brochures, and the web resources at www.opm.gov/insure to make your choice an informed one. Finally, if you know someone interested in Federal employment, refer them to www.usajobs.opm.gov. Sincerely, Kay Coles James Director Table of Contents Page: How to Change Enrollment ................................................................................................................................ 1 Picking a Health Plan .......................................................................................................................................... 2 Preventing Medical Mistakes ............................................................................................................................ 5 FEHB Web Resources............................................................................................................................................ 6 Program Features .................................................................................................................................................. 7 Definitions .............................................................................................................................................................. 8 Two New Federal Programs Complement FEHB Benefits The Federal Flexible Spending Account Program .................................................................................. 10 The Federal Long Term Care Insurance Program .................................................................................. 13 Stop Health Care Fraud ...................................................................................................................................... 14 Plan Comparisons Nationwide Fee-For-Service Plans and Consumer-Driven Plans Open to All .................................... 15 Nationwide Fee-For-Service Plans Open Only to Specific Groups ...................................................... 21 Health Maintenance Organization Plans, Plans Offering a Point of Service Product and Consumer-Driven Plans .................................................................................................................... 25 Things to Remember ✔ ■ The plan you choose can make a difference in your health. ✔ ■ Be aware of benefit changes for 2004. ✔ ■ Check the premium for 2004. The information in this Guide gives you an overview of the FEHB Program and its participating plans. Read the plan brochures before you make any final decisions about health plans. i This page intentionally left blank ii How to Change Enrollment I f you are enrolled and want to change your enrollment in Open Season, use the postcard on the back cover of this booklet to request a registration form to make a change. (Your health plan will send you its brochure. You can use the postcard to order brochures for other plans.) Do not cancel your enrollment before reading this section. date of your cancellation, and you lose the coverage because the enrollment ends or the enrollee changes from self and family to self only; or Cut the postcard along the perforated lines, fill in the information, and mail it to the OWCP address printed on the card. If you order brochures, you will be given another form to make a change. Your new plan will mail you an identification card. If you need services before you receive your new card, contact your new plan at the member services number in your brochure. If you decide not to change your enrollment, no action by you is necessary. You may voluntarily cancel your enrollment at any time. However, once your cancellation takes effect, you probably will not be able to enroll again as a retiree. You will not be entitled to a 31-day extension of coverage for conversion to a non-group (private) policy and neither you nor your family members will be entitled to temporarily continue coverage. You will not be able to reenroll in FEHB except under the following circumstances: • You have been continuously covered as a family member under another enrollment in FEHB since the • You suspended your FEHB coverage to enroll in a Medicare+Choice health plan under the Social Security Act or because you are eligible under Medicaid or a similar state-sponsored program of medical assistance for the needy. For more information on how to suspend your FEHB enrollment, contact the OWCP district office that handles your case. Time limitations and other restrictions apply. For instance, you must submit documentation that you are suspending FEHB to enroll in a Medicare+Choice health plan or furnish proof of eligibility for coverage under the Medicaid program or similar State-sponsored program of medical assistance for the needy, in case you wish to reenroll in the FEHB Program at a later time. If you had suspended FEHB coverage for either one of these reasons (and had submitted the required documentation) but now want to enroll in the FEHB Program again, you may enroll during Open Season. You may reenroll outside Open Season only if you move out of the Medicare+Choice health plan’s service area, the Medicare+Choice health plan is discontinued, or you involuntarily lose coverage under the Medicaid program or similar State-sponsored program of medical assistance for the needy. If you cancelled your coverage for any other reason, you cannot reenroll. 1 Picking a Health Plan Step 1: 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. This is because Fee-for-Service (FFS) plans -- with and without a Preferred Provider Organization (PPO) – Health Maintenance Organizations (HMO), Point-of-Service (POS) plans, and Consumer-Driven plans all operate differently. Health Maintenance Organization You generally must use the network; no benefits outside of the network – you pay all costs. Fee-for-Service w/PPO Choice of doctors, hospitals, pharmacies, and other providers You must use the plan’s network for full benefits. Not using PPO providers means only some or none of your benefits will be paid. Referral not required to get full benefits. Fee-for-Service w/o PPO You may use any doctor, hospital, etc. Benefits are not limited by where you get care. Point-of-Service You must use network for full benefits. You may go outside the network but it will cost you more. ConsumerDriven Plans You may use network and non-network providers. Not using the network will cost you more. Specialty care Referral not required to get full benefits. Referral generally required from primary care doctor to get benefits. Referral required to get full benefits. Referral not required to get full benefits. Out-ofpocket costs You pay fewer costs if you use a PPO provider than if you don’t. Some if you don’t use network providers. You pay regular plan out-ofpocket costs. Your out-ofpocket costs are generally limited to copayments. You pay less if you use a network provider than if you don’t. Little if you use the network. You will have to file your own claims if you don’t use the network. You pay less if you use a network provider than if you don’t. Some if you don’t use network providers. Paperwork You have to file your own claims. Little, if any. See Definitions starting on page 8 for a more detailed description of each type of plan. 2 Picking a Health Plan Step 2: What services are important to you and what health care do you expect to use? Refer to your medical and insurance records from last year as a guide to what services you might use this year. Add up the actual costs to you, including premiums. Estimate what you might spend on your health care for deductibles, coinsurance/copayments, and services that are not covered. Are there any annual limits for days or services covered and on the dollar amount the plan will spend on you? What is the maximum you will have to pay out-of-pocket each year? Consult the health plans’ brochures to find this benefit information. Copies of brochures as well as a tool to complete this sheet on-line are on our web site at www.opm.gov/insure/health. Health Plan _____________ Annual premium Office visit to primary care doctor Office visit to specialist Hospital inpatient deductible/copay/ coinsurance Hospital room & board charges Generic drug (local pharmacy) Brand name drug (local pharmacy) Catastrophic protection limit Mental health care visits Home health care visits Durable medical equipment Maternity care Well-child care Routine physicals Accreditation Health Plan _____________ Health Plan _____________ The following information can be found in the Member Survey Results section in the benefit charts. Overall member satisfaction with plan Getting needed care Getting care quickly How well doctors communicate Customer service Claims processing 3 Picking a Health Plan Step 3: Consider quality. Quality is how well health plans keep their members healthy or treat them when they are sick. Good quality doesn’t always mean receiving more care. Good quality health care means doing the right thing at the right time, in the right way, for the right person to achieve the best possible results. We provide two types of quality information in the plan benefit charts: independent evaluations (accreditation) from private organizations and evaluations by enrollees (member survey). Accreditation evaluations shown in this Guide are performed by the National Committee for Quality Assurance (NCQA), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and URAC. The following are the accreditation levels used by each organization. The codes correspond to a plan’s accreditation level as shown in the plan comparison section. National Committee for Quality Assurance (www.ncqa.org) Excellent – Levels of service and clinical quality that meet or exceed NCQA’s requirements for consumer protection and quality improvement AND achieve health plan performance results that are in the highest range of national or regional performance. Code N1 Accreditation with Full ComplianceDemonstrates satisfactory compliance with JCAHO standards in all performance areas. Code J1 Commendable – Meets or exceeds NCQA’s requirements for consumer protection and quality improvement. Code N2 Accredited – Meets most of NCQA’s requirements for consumer protection and quality improvement. Code N3 Provisional – Meets some but not all of NCQA’s requirements for consumer protection and quality improvement. Code N4 Conditional – Demonstrates failure to meet standard(s) or specific policy requirement(s) but is believed capable to do so in a specified time period. Code J4 New Health Plan – Applies to health plans that are less than two years old. Code N6 Joint Commission on Accreditation of Healthcare Organizations (www.jcaho.org) Accreditation with Requirements for Improvement – Demonstrates satisfactory compliance with JCAHO standards in most performance areas. Code J2 Conditional – Meets most of the standards but needs some improvement before achieving full compliance. Code U2 Provisional – Demonstrates a previously unaccredited plan’s satisfactory compliance with a subset of standards. Code J3 URAC (www.urac.org) Full Accreditation – Demonstrates full compliance with standards. Code U1 Provisional – A plan that has otherwise complied with all standards but has been in operation for less than 6 months. Code U3 Note: This chart shows the accreditation levels available under each accrediting organization listed. It is not intended to draw comparisons among the different accrediting organizations. Member Survey results, shown in the plan comparison sections, are collected, scored, and reported by an independent organization – not by the health plans. Here is a brief explanation of each survey category. Overall Plan Satisfaction Getting Needed Care Getting Care Quickly How Well Doctors Communicate Customer Service • How would you rate your overall experience with your health plan? • Were you satisfied with the choices your health plan gave you to select a personal doctor? • Were you satisfied with the time it takes to get a referral to a specialist? • Did you get the advice or help you needed when you called your doctor during regular office hours? • Could you get an appointment for regular or routine care when you wanted? • Did your doctor listen carefully to you and explain things in a way you could understand? • Did your doctor spend enough time with you? • Was your plan helpful when you called its customer service department? • Did you have paperwork problems? • Were the plan’s written materials understandable? • Did your plan pay your claims correctly and in a reasonable time? 4 Claims Processing Preventing Medical Mistakes An influential report from the Institute of Medicine estimates that up to 98,000 Americans die every year from medical mistakes in hospitals alone. That’s about 3,230 preventable deaths in the FEHB Program a year. While death is the most tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and even additional treatments. By asking questions, learning more and understanding your risks, you can improve the safety of your own health care, and that of your family members. Take these simple steps: 1. Ask questions if you have doubts or concerns. • Ask questions and make sure you understand the answers. • Choose a doctor with whom you feel comfortable talking. • Take a relative or friend with you to help you ask questions and understand answers. 2. Keep and bring a list of all the medicines you take. • Give your doctor and pharmacist a list of all the medicines that you take, including non-prescription medicines. • Tell them about any drug allergies you have. • Ask about side effects and what to avoid while taking the medicine. • Read the label when you get your medicine, including all warnings. • Make sure your medicine is what the doctor ordered and know how to use it. • Ask the pharmacist about your medicine if it looks different than you expected. 3. Get the results of any test or procedure. • Ask when and how you will get the results of tests or procedures. • Don’t assume the results are fine if you do not get them when expected, be it in person, by phone, or by mail. • Call your doctor and ask for your results. • Ask what the results mean for your care. 4. Talk to your doctor about which hospital is best for your health needs. • Ask your doctor which hospital has the best care and results for your condition if you have more than one hospital to choose from to get the health care you need. • Be sure you understand the instructions you get about follow-up care when you leave the hospital. 5. Make sure you understand what will happen if you need surgery. • Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation. • Ask your doctor, “Who will manage my care when I am in the hospital?” • Ask your surgeon: Exactly what will you be doing? About how long will it take? What will happen after surgery? How can I expect to feel during recovery? • Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reaction to anesthesia, and any medications you are taking. Want more information on patient safety? ➥ www.ahrq.gov/consumer/pathqpack.htm. The Agency for Healthcare Research and Quality makes available a wide-ranging list of topics not only to inform consumers about patient safety but to help choose quality healthcare providers and improve the quality of care you receive. ➥ www.npsf.org. The National Patient Safety Foundation has information on how to ensure safer healthcare for you and your family. ➥ www.talkaboutrx.org/consumer.html. The National Council on Patient Information and Education is dedicated to improving communication about the safe, appropriate use of medicines. ➥ www.leapfroggroup.org. The Leapfrog Group is active in promoting safe practices in hospital care. ➥ www.ahqa.org. The American Health Quality Association represents organizations and healthcare professionals working to improve patient safety. 5 FEHB Web Resources Use the FEHB web site for additional help in choosing the health plan that is right for you. The FEHB web site at www.opm.gov/insure/health can help you to choose your health plan and enroll. In addition to the information found in this Guide you will find: • An interactive tool that will allow you to find the health plans that service your area and will allow you to make side-by-side comparisons of the costs, benefits, and quality indicators of the plans that interest you. • Electronic versions of all health plan brochures. • An evaluation of how your plan compares to other plans and the FEHB average in important medical areas under the Health Plan Employer Data and Information Set (HEDIS). HEDIS is a set of standardized performance measures that allows users to reliably compare managed care health plan performance across specific clinical areas. The performance measures are related to many significant public health issues such as cancer, heart disease, asthma, and diabetes. Compare plan results at www.opm.gov/insure/health/hedis2002. • Information on enrolling, with the ability to enroll online for annuitants and employees of selected agencies. • Information on how plans in the FEHB Program coordinate benefit payments with Medicare. • A comprehensive set of Frequently Asked Questions and answers on all aspects of the Program. • An online version of the FEHB Handbook for detailed guidance on FEHB policies and procedures. 6 Program Features • No Waiting Periods. You can use your benefits as soon as your coverage becomes effective. There are no pre-existing condition limitations even if you change plans. • A Choice of Coverage. Choose between Self Only or Self and Family. • A Choice of Plans and Options. Select from Fee-For-Service (with the option of a Preferred Provider Organization), Health Maintenance Organization, Point of Service plans, or ConsumerDriven plans. • A Government Contribution. The Government pays 72 percent of the average premium toward the total cost of your premium, up to a maximum of 75 percent of the total premium for any plan. • Salary Deduction. You pay your share of the premium through a payroll deduction. • Annual Enrollment Opportunity. Each year you can change your health plan enrollment. This year the Open Season runs from November 10, 2003, through December 8, 2003. Other events allow for certain types of changes throughout the year. See your Human Resources office for details. • Continued Group Coverage. Eligible participants can continue coverage following divorce or death. Contact the OWCP district office that handles your case for more information. • Coverage after FEHB Ends. You or your family members may be eligible for temporary continuation of FEHB coverage or for conversion to non-group (private) coverage when FEHB coverage ends. Contact the OWCP district office that handles your case. • Consumer Protections. Go to www.opm.gov/insure/health/consumers to see your appeal rights to OPM if you and your plan have a dispute over a claim; to read the Patients’ Bill of Rights and the FEHB Program; and to learn about your privacy protections when it comes to your medical information. Better Information Better Choices Better Health 7 Definitions Accreditation - The status granted to a health care organization following a rigorous and comprehensive evaluation performed by independent organizations. The evaluation also includes an assessment of the care and service plans are delivering in important areas of public concern such as immunization rates, mammography rates, and member satisfaction. Brand name drug – A prescription drug that is protected by a patent, supplied by a single company, and marketed under the manufacturer’s brand name. Coinsurance - The amount you pay as your share of the medical services you receive, like for a doctor’s visit. Coinsurance is a percentage of the cost of the service (e.g., you pay 20%). Consumer-Driven plans - Describes a wide range of approaches to give you more incentive to control the cost of either your health benefits or health care. You have greater freedom in spending health care dollars up to a designated amount, and you receive full coverage for in-network preventive care. In return, you assume significantly higher cost sharing expenses after you have used up the designated amount. The catastrophic limit is usually higher than those common in other plans. Copayment - The amount you pay as your share of the medical services you receive, like for a doctor’s visit. A copayment is a fixed dollar amount (e.g., you pay $15). Fee-For-Service (FFS) - Health coverage in which doctors and other providers receive a fee for each service such as an office visit, test, procedure, or other health care service. The health plan will either pay the medical provider directly or reimburse you for covered services after you have paid the bill and filed an insurance claim. When you need medical attention, you visit the doctor or hospital of your choice. Formulary – A list of both generic and brand name drugs that are preferred by your health plan. Many prescription drugs produce the same results. Health plans choose formulary drugs that are medically safe and cost effective. A team including pharmacists and physicians meet to review the formulary and make changes as necessary. Generic drug – A prescription that is not protected by a drug patent. A generic medication is basically a copy of the brand name drug. A generic drug may have a different color or shape than its brand name counterpart, but it must have the same active ingredients, strength, and dosage form (i.e., pill, liquid, or injection), and provide the same effectiveness and safety. Generics generally cost less than brand name drugs. 8 Definitions Health Maintenance Organization (HMO) - A health plan that provides care through contracted or employed physicians and hospitals located in particular geographic or service areas. HMOs emphasize prevention and early detection of illness. Your eligibility to enroll in an HMO is determined by where you live or, in some plans, where you work. In-Network - 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. Examples include a Fee-ForService plan’s PPO or a Health Maintenance Organization. Members have fewer out-of-pocket costs when they use in-network providers. Out-of-Network - You receive treatment from doctors, hospitals, and medical practitioners other than those with whom the plan has an agreement, and pay more to do so. Members in a PPO-only option who receive services outside the PPO network generally pay all charges. Point of Service (POS) - A product offered by a health plan that has both in-network and out-of-network features. In a POS you don’t have to use the plan’s network of providers for every service but you generally pay more out of network. Preferred Provider Organization (PPO) - The PPO is similar to FFS insurance except it uses a network of providers. PPOs give you the choice of using doctors and other providers in the network or using non-network providers. You don’t have to use the PPO, but there are advantages if you do. (Be aware, however, that some of the services provided in a PPO hospital may not be covered by PPO arrangements. Room and board will be covered, but anesthesia and radiology, for instance, may be covered under non-PPO benefits.) Note that some FFS plans may offer an enrollment option that is “PPO-only.” You must use network providers to receive benefits from a PPO-only plan. Provider - A doctor, hospital, health care practitioner, pharmacy, or health care facility. 9 The Federal Flexible Spending Account Program OPM wants to be sure you know about two new Federal programs that complement the FEHB Program. First, the Flexible Spending Account (FSA) Program, also known as FSAFeds, lets you set aside tax-free money to pay for health and dependent care expenses. The result can be a discount of 20 to more than 40 percent on services you routinely pay for out-of-pocket. Second, the Federal Long Term Care Insurance Program (FLTCIP) covers long term care costs not covered under the FEHB Program. What is an FSA? It is a tax-favored benefit that allows you to set aside pre-tax money from your paychecks to pay for a variety of eligible expenses. By using an FSA, you can reduce your taxes while paying for services you would have to pay for anyway, producing a discount that can be over 40%. There are two types of FSAs offered by the FSAFeds Program: Health Care Flexible Spending Account (HCFSA) • Covers eligible health care expenses not reimbursed by your FEHB Plan, or any other medical, dental, or vision care plan you or your dependents may have. • Eligible dependents for this account include anyone you claim on your Federal income tax return as a qualified dependent under the U.S. Internal Revenue Service (IRS) definition and/or with whom you jointly file your Federal income tax return, even if you don’t have self and family health benefits coverage. Note: The IRS has a broader definition of a "family member" than is used under the FEHB Program to provide benefits by your FEHB Plan. • The maximum amount that can be allotted for the HCFSA is $3,000 annually. The minimum amount is $250 annually. Dependent Care Flexible Spending Account (DCFSA) • Covers eligible dependent care expenses incurred so you can work, or if you are married, so you and your spouse can work, or your spouse can look for work or attend school full-time. • Eligible dependents for this account include anyone you claim on your Federal income tax return as a qualified IRS dependent and/or with whom you jointly file your Federal income tax return. • The maximum that can be allotted for the DCFSA is $5,000 annually. The minimum amount is $250 annually. Note: The IRS limits contributions to a Dependent Care FSA. For single taxpayers and taxpayers filing a joint return, the maximum is $5,000 per year. For taxpayers who file their taxes separately with a spouse, the maximum is $2,500 per year. The limit includes any child care subsidy you may receive Enroll during Open Season You must make an election to enroll in an FSA during the FEHB Open Season. Even if you enrolled during the initial Open Season for 2003, you must make a new election to continue participating in 2004. Enrollment is easy. • Enroll online anytime during Open Season (November 10 through December 8, 2003) at www.fsafeds.com. • Call the toll –free number 1-877-FSAFeds (372-3337) Monday through Friday, from 9 a.m. until 9 p.m. eastern time and an FSAFeds Benefit Counselor will help you enroll. What is SHPS? SHPS is a third-party administrator hired by OPM to manage the FSAFeds Program. SHPS is the largest FSA administrator in the nation and will be responsible for enrollment, claims processing, customer service, and day-to-day operations of FSAFeds. If you are a Federal employee eligible for FEHB – even if you’re not enrolled in FEHB – you can choose to participate in either, or both, of the flexible spending accounts. If you are not eligible 10 Who is eligible to enroll? The Federal Flexible Spending Account Program for FEHB, you are not eligible to enroll for a Health Care FSA. However, almost all Federal employees are eligible to enroll for the Dependent Care FSA. The only exception is intermittent (also called when actually employed [WAE]) employees expected to work less than 180 days during the year. NOTE: FSAFeds is the FSA Program established for all Executive Branch employees and Legislative Branch employees whose employers signed on. Under IRS law, FSAs are not available to annuitants. In addition, the U.S. Postal Service and the Judicial Branch, among others, are Federal agencies that have their own plans with slightly different rules, but the advantages of having an FSA are the same no matter what agency you work for. How much should I contribute to my FSA? Plan carefully when deciding how much to contribute to an FSA. Because of the tax benefits of an FSA, the IRS places strict guidelines on them. You need to estimate how much you want to allocate to an FSA because current IRS regulations require you forfeit any funds remaining in your account(s) at the end of the FSA plan year. This is referred to as the "use-it-or-lose-it" rule. You will have until April 29, 2004 to submit claims for your eligible expenses incurred during 2003 if you enrolled in FSAFeds when it was initially offered. You will have until April 30, 2005 to submit claims for your eligible expenses incurred from January 1 through December 31, 2004 if you elect FSAFeds during this Open Season. The FSAFeds Calculator at www.fsafeds.com will help you plan your FSA allocations and provide an estimate of your tax savings based on your individual situation. What can my HCFSA pay for? Every FEHB health plan includes cost sharing features, such as deductibles you must meet before the Plan provides benefits, coinsurance or copayments that you pay when you and the Plan share costs, and medical services and supplies that are not covered by the Plan and for which you must pay. Your HCFSA will reimburse you for such costs when they are for tax deductible medical care for you and your dependents that is NOT covered by this FEHB Plan or any other coverage that you have. The IRS governs expenses reimbursable by a HCFSA. See Publication 502 for a comprehensive list of tax-deductible medical expenses. Note: While you will see insurance premiums listed in Publication 502, they are NOT a reimbursable expense for FSA purposes. Publication 502 can be found on the IRS Web site at http://www.irs.gov/pub/irs-pdf/p502.pdf. If you do not see your service or expense listed in Publication 502, please call an FSAFeds Benefit Counselor at 1877-FSAFeds (372-3337), who will be able to answer your specific questions. Tax savings with an FSA An FSA lets you allot money for eligible expenses before your agency deducts taxes from your paycheck. This means the amount of income that your taxes are based on will be lower, so your tax liability will also be lower. Without an FSA, you would still pay for these expenses, but you would do so using money remaining in your paycheck after Federal (and often state and local) taxes are deducted. The following chart illustrates a typical tax savings example: Annual Tax Savings Example With FSA If your taxable income is: ..............................................$50,000 And you deposit this amount into an FSA: ..................$ 2,000 Your taxable income is now:..........................................$48,000 Subtract Federal & Social Security taxes: ......................$13,807 If you spend after-tax dollars for expenses:..................-$0Your real spendable income is:......................................$34,193 Your tax savings:..............................................................$576 11 Without FSA $50,000 -$0$50,000 $14,383 $ 2,000 $33,617 -$0- The Federal Flexible Spending Account Program Note: This example is intended to demonstrate a typical tax savings based on 27% Federal and 7.65% FICA taxes. Actual savings will vary based upon in which retirement system you are enrolled (CSRS or FERS), as well as your individual tax situation. In this example, the individual received $2,000 in services for $1,424, a discount of almost 36%. You may also wish to consult a tax professional for more information on the tax implications of an FSA. Tax Credits and Deductions You cannot claim expenses on your Federal income tax return if you receive reimbursement for them from your HCFSA or DCFSA. Below are some guidelines that may help you decide whether to participate in FSAFeds. The HCFSA is tax-free from the first dollar. In addition, you may be reimbursed from the HCFSA at any time during the year for expenses up to the annual amount you've elected to contribute. Only health care expenses exceeding 7.5% of your adjusted gross income are eligible to be deducted on your Federal income tax return. Using the example listed in the above chart, only health care expenses exceeding $3,750 (7.5% of $50,000) would be eligible to be deducted on your Federal income tax return. In addition, money set aside through a HCFSA is also exempt from FICA taxes. This exception is not available on your Federal income tax return. Dependent Care Expenses The DCFSA generally allows many families to save more than they would with the Federal tax credit for dependent care expenses. Note that you may only be reimbursed from the DCFSA up to your current account balance. If you file a claim for more than your current balance, it will be held until additional payroll allotments have been added to your account. Visit www.fsafeds.com and download the Dependent Care Tax Credit Worksheet from the Quick Links box to help you determine what is best for your situation. You may also wish to consult a tax professional for more details. Does it cost me anything to participate in FSAFeds? Probably not. While there is an administrative fee of $4.00 per month for an HCFSA and 1.5% of the annual election for a DCFSA, most agencies have elected to pay these fees out of their share of employment tax savings. To be sure, check the FSAFeds.com web site or call 1-877-FSAFeds (372-3337). Also, remember that participating in FSAFeds can cost you money if you don’t spend your entire account balance by the end of the plan year and wind up forfeiting your end of year account balance, per the IRS "use-it-or-lose-it" rule. Health Care Expenses Contact us To find out more or to enroll, please visit the FSAFeds web site at www.fsafeds.com, or contact SHPS by email or by phone. SHPS Benefit Counselors are available from 9:00 a.m. until 9:00 p.m. eastern time, Monday through Friday. • E-mail: fsafeds@shps.net • Telephone: 1-877-FSAFeds (372-3337) • TTY: 1-800-952-0450 (for hearing impaired individuals that would like to utilize a text messaging service) 12 The Federal Long Term Care Insurance Program It’s important protection Here’s why you should consider enrolling in the Federal Long Term Care Insurance Program: • FEHB plans do not cover the cost of long term care. Also called “custodial care,” long term care is help you receive when you need assistance performing activities of daily living – such as bathing or dressing yourself. This need can strike anyone at any age and the cost of care can be substantial. • The Federal Long Term Care Insurance Program can help protect you from the potentially high cost of long term care. This coverage gives you control over the type of care you receive and where you receive it. It can also help you remain independent so you won’t have to worry about being a burden to your loved ones. • It’s to your advantage to apply sooner rather than later. Long term care insurance is something you must apply for and pass a medical screening (called underwriting) in order to be enrolled. Certain medical conditions will prevent some people from being approved for coverage. By applying while you’re in good health, you could avoid the risk of having a change in health disqualify you from obtaining coverage. Also, the younger you are when you apply the lower your premiums. • You don’t have to wait for an open season to apply. The Federal Long Term Care Insurance Program accepts applications from eligible persons at any time. You will have to complete a full underwriting application, which asks a number of questions about your health. However, if you are a new or newly eligible employee, you (and your spouse, if applicable) have a limited opportunity to apply using the abbreviated underwriting application, which asks fewer questions. If you marry, your new spouse will also have a limited opportunity to apply using abbreviated underwriting. Qualified relatives are also eligible to apply with full underwriting. To find out more and to request an application Call 1-800-LTC-FEDS (1-800-582-3337) (TTY 1-800-843-3557) or visit www.ltcfeds.com. 13 Stop Health Care Fraud F raud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program premium. OPM’s Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired. Protect Yourself From Fraud - Here are some things you can do to prevent fraud: • Be wary of giving your health plan identification number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative. • Let only the appropriate medical professionals review your medical record or recommend services. • Avoid health care providers who say that an item or service is not usually covered, but they know how to bill your health plan to get it paid. • Carefully review explanations of benefits (EOBs) that you receive from your health plan. • Do not ask your doctor to make false entries on certificates, bills or records in order to get your health plan to pay for an item or service. • If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following: • Call the provider and ask for an explanation. There may be an error. • If the provider does not resolve the matter, call your health plan and explain the situation. • If they do not resolve the issue: CALL -- THE HEALTH CARE FRAUD HOTLINE 202-418-3300 OR WRITE TO: The United States Office of Personnel Management Office of the Inspector General Fraud Hotline 1900 E Street, NW, Room 6400 Washington, DC 20415 • Remember, FEHB covered family members may not include: • your former spouse after a divorce decree or annulment is final (even if a court orders it); or • your child over age 22 unless he/she became incapable of self support before age 22. • If you have any questions about the eligibility of a dependent, check with your Human Resources office if you are employed or with OPM if you are retired. • You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB benefits or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in the Plan. 14 Plan Comparisons Nationwide Fee-For-Service Plans Open to All (Pages 16 through 19) Fee-For-Service (FFS) Plans with a Preferred Provider Organization (PPO) — An FFS plan that allows you to see medical providers who reduce their charges to the plan; you pay less money out-of-pocket when you use a PPO provider. When you visit a PPO you usually won’t have to file claims or paperwork. However, going to a PPO hospital does not guarantee PPO benefits for all services received within that hospital. For instance, lab work and radiology services from independent practitioners within the hospital are frequently not covered by the PPO agreement. Fee-For-Service (FFS) Plans (non-PPO) — An FFS plan that either pays the medical provider directly or reimburses you for covered medical expenses. When you need medical attention, you visit the doctor or hospital of your choice. In PPO-only options, you must use PPO providers to receive benefits. Consumer-Driven Plans — Describes a wide range of approaches to give you more incentive to control the cost of either your health benefits or health care. You have greater freedom in spending health care dollars up to a designated amount, and you receive full coverage for in-network preventive care. In return, you assume significantly higher cost sharing expenses after you have used up the designated amount. The catastrophic limit is usually higher than those common in other plans. 15 Nationwide Fee-for-Service Plans Open to All 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 out-of-pocket 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. The Generic drug figure is the copayment or coinsurance most commonly paid by members of this health plan for a Generic formulary drug. Enrollment Code Twice – Biweekly Premium Your Share Plan Name APWU Health Plan-High (APWU) APWU Health Plan-Consumer driven (APWU) Blue Cross and Blue Shield Service Benefit Plan-Std (BCBS) Blue Cross and Blue Shield Service Benefit Plan-Basic (BCBS) GEHA Benefit Plan-High (GEHA) GEHA Benefit Plan-Std (GEHA) Mail Handlers-High (MH) Mail Handlers-Std (MH) NALC PBP Health Plan-High (PBP) PBP Health Plan-Std (PBP) Telephone Number 800/222-2798 800/222-2798 Local phone # Local phone # 800/821-6136 800/821-6136 800/410-7778 800/410-7778 888/636-6252 800-544-7111 800-544-7111 Self only 471 474 104 111 311 314 451 454 321 361 364 Self & family 472 475 105 112 312 315 452 455 322 362 365 Self only 113.84 77.90 97.80 75.98 152.48 60.50 191.18 64.32 103.36 366.12 135.80 Self & family 228.50 181.40 225.76 177.98 306.10 137.50 361.22 139.62 185.56 759.56 303.40 16 Brand Name/Non-formulary is what you pay for a manufacturer’s Brand name drug on this health plan’s formulary. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in this column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a Non-formulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is "yes." If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is "no." The prescription drug copayments or coinsurances described in this chart do not represent the complete range of cost-sharing under these plans. Many plans have variations in their prescription drug benefits (e.g., 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). The prescription drug figures in this chart show what most plan members pay for their medications under each plan. You must read the plan brochure for a complete description of prescription drug and all other benefits. Medical-Surgical – You Pay Deductible Per Person Calendar Prescription Year Drug $275 $500 $600* $600* $250 $250 None $350 $350 $450 $450 $250 $300 $300 $350 $250 $300 $200 $500 $250 $600 None None None None None None None None None None None $200 $200 $400 $400 None $25 $90 $90 $90 $90 Copay ($)/Coinsurance (%) Doctors Hospital Inpatient None $300 None None $100 $300 $100/day x 5 $100 $300 None None $100 $300 $200 $400 None $100 None $150 None $250 Benefit Type Plan APWU-High APWU BCBS -Std BCBS -Basic GEHA -High GEHA -Std MH -High MH -Std NALC PBP -High PBP -Std PPO Non-PPO PPO Non-PPO PPO Non-PPO PPO PPO Non-PPO PPO Non-PPO PPO Non-PPO PPO Non-PPO PPO Non-PPO PPO Non-PPO PPO Non-PPO Office Visits $18 30% 15% 40% $15 25% $20/$30 $20 25% $10 35% $20/$10 30% $20/$10 30% $20 30% 10% 20% $8 30% Inpatient Surgical Services 10% 30% 15% 40% 10% 25% $100 10% 25% 15% 35% 10% 30% 10% 30% 10% 30% 10% 25% 9% 30% Hospital Inpatient R&B 10% 30% 15% 40% Nothing 30% Nothing Nothing Nothing 15% 35% Nothing 30% Nothing 30% Prescription Drugs Generic $8 50% 25% N/A 25% 45%+ $10 $5 $5 $5 $5 $10 50% $10 50% Brand Name / Nonformulary Mail Order Discounts Yes No No No Yes No No Yes Yes Yes Yes Yes Yes Yes Yes 25% 50% 25%/25% N/A 25% 45%+ $25/$35 or 50% $25 $25 50% 50% $25/$40 50% $30/$45 50% 10% 25% 25% Yes 30%--------------50%--------------------------50%+------------------------Yes 10% 25% 9% 30% $3 20%+ $4 30%+ $25 or 20%/$40 or 20% 20%+ $30 or 20%/$40 or 20% 30%+ Yes Yes Yes Yes *Rollover from previous year may reduce your deductible. 17 Nationwide Fee-for-Service Plans Open to All Member Survey results are collected, scored, and reported by an independent organization – not by the health plans. Here is a brief explanation of each survey category. Overall Plan Satisfaction Getting Needed Care Getting Care Quickly How Well Doctors Communicate Customer Service • How would you rate your overall experience with your health plan? • Were you satisfied with the choices your health plan gave you to select a personal doctor? • Were you satisfied with the time it takes to get a referral to a specialist? • Did you get the advice or help you needed when you called your doctor during regular office hours? • Could you get an appointment for regular or routine care when you wanted? • Did your doctor listen carefully to you and explain things in a way you could understand? • Did your doctor spend enough time with you? • Was your plan helpful when you called its customer service department? • Did you have paperwork problems? • Were the plan’s written materials understandable? • Did your plan pay your claims correctly and in a reasonable time? Claims Processing Member Survey Results h above average, * average, f below average Overall plan satisfaction Getting needed care Getting care quickly How well doctors communicate h h * f * * * * h h h Customer service Claims processing Plan Name APWU Health Plan-High APWU Health Plan-Consumer driven Blue Cross and Blue Shield Service Benefit Plan-Std Blue Cross and Blue Shield Service Benefit Plan-Basic GEHA Benefit Plan-High GEHA Benefit Plan-Std Mail Handlers-High Mail Handlers-Std NALC PBP Health Plan-High PBP Health Plan-Std Plan Code 47 47 10 11 31 31 45 45 32 36 36 h h * f h h f f h * * * * * f * * * * h * * h h * f * * f f h h h h h f f h h * * h f f h h * f h h * * h f f 18 Fee-For-Service Plans – Blue Cross and Blue Shield Service Benefit Plan – Member Survey Results for Select States 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. In the past, BCBS has conducted a single survey representing all of its members nation-wide. This year, however, we are able to provide local member satisfaction results for both the Standard Option plan and the Basic Option plan. In the future, we expect to increase the number of plans conducting local or regional Member Satisfaction surveys. We look forward to making those results available to help you select quality health plans. Below are Member Survey ratings for local BCBS plans by location: Member Survey Results h above average, * average, f below average Overall plan Getting Getting satisfaction needed care care quickly How well doctors communicate f f * f * f f f * f * f h f * f Plan Name Blue Cross and Blue Shield Service Benefit Plan Blue Cross and Blue Shield Service Benefit Plan Blue Cross and Blue Shield Service Benefit Plan Blue Cross and Blue Shield Service Benefit Plan Blue Cross and Blue Shield Service Benefit Plan Blue Cross and Blue Shield Service Benefit Plan Blue Cross and Blue Shield Service Benefit Plan Blue Cross and Blue Shield Service Benefit Plan - Standard - Basic - Standard - Basic Location Arizona California Plan Code 10 11 10 11 10 11 10 11 10 11 10 11 10 11 10 11 Customer service Claims processing h f h f * f h f * f * f h f h f f f f f * f * f h f * f * f * f f f * f f f f f * f * f * f * f * f * f * f * f * f f f * f h * h f h f * * h * * f * f * f h h - Standard - Basic District of Columbia - Standard - Basic - Standard - Basic - Standard - Basic - Standard - Basic - Standard - Basic Florida Illinois Maryland Texas Virginia 19 This page intentionally left blank 20 Plan Comparisons Nationwide Fee-For-Service Plans Open Only to Specific Groups (Pages 22 through 24) Fee-For-Service (FFS) Plans with a Preferred Provider Organization (PPO) — An FFS plan that allows you to see medical providers who reduce their charges to the plan; you pay less money out-of-pocket when you use a PPO provider. When you visit a PPO you usually won’t have to file claims or paperwork. However, going to a PPO hospital does not guarantee PPO benefits for all services received within that hospital. For instance, lab work and radiology services from independent practitioners within the hospital are frequently not covered by the PPO agreement. Fee-For-Service (FFS) Plans (non-PPO) — An FFS plan that either pays the medical provider directly or reimburses you for covered medical expenses. When you need medical attention, you visit the doctor or hospital of your choice. 21 Nationwide Fee-for-Service Plans Open Only to Specific Groups 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 out-of-pocket 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. The Generic drug figure is the copayment or coinsurance most commonly paid by members of this health plan for a Generic formulary drug. Enrollment Code Twice – Biweekly Premium Your Share Plan Name Association Benefit Plan (ABP) Foreign Service Benefit Plan (FS) Panama Canal Area Benefit Plan (PCA) Rural Carrier Benefit Plan (Rural) SAMBA Secret Service Employees Health Association (SSEHA) Telephone Number 800/634-0069 202/833-4910 800/548-8969 800/638-8432 800/638-6589 800/296-0724 Self only 421 401 431 381 441 Y71 Self & family 422 402 432 382 442 Y72 Self only 117.52 82.56 76.10 157.08 141.42 108.68 Self & family 275.84 233.82 158.86 259.46 350.66 278.82 22 Brand Name/Non-formulary is what you pay for a manufacturer’s Brand name drug on this health plan’s formulary. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in this column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a Non-formulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is "yes." If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is "no." The prescription drug copayments or coinsurances described in this chart do not represent the complete range of cost-sharing under these plans. Many plans have variations in their prescription drug benefits (e.g., 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). The prescription drug figures in this chart show what most plan members pay for their medications under each plan. You must read the plan brochure for a complete description of prescription drug and all other benefits. Medical-Surgical – You Pay Deductible Per Person Calendar Prescription Year Drug $300 $300 $300 $300 None None $350 $400 $350 $350 $200 $200 None None None None $400 $400 $200 $200 None None None None Copay ($)/Coinsurance (%) Doctors Hospital Inpatient $100 $300 Nothing $200 $50 $125 $100 $300 $200 $300 Benefit Type Plan ABP FS PCA Rural SAMBA SSEHA PPO Non-PPO PPO Non-PPO POS FFS PPO Non-PPO PPO Non-PPO Par Non-Par Office Visits $10 30% 10% 30% $10 50% $20 25% $20 30% Inpatient Surgical Services 10% 30% 10% 30% Nothing 50% 10% 20% 10% 30% 20% 20%+diff. Hospital Inpatient R&B Nothing 30% Nothing 20% Nothing 50% Nothing 20% Nothing 30% Nothing 20%+diff. Prescription Drugs Generic $5 $5 $10/25% $10/25% 50% 50% 30% 30% $10 $10 $10 All chgs. Brand Name / Mail Order Nonformulary Discounts Yes Yes Yes Yes No No Yes Yes Yes Yes Yes No $25/$40 $25/$40 $20/25%/N/A $20/25%/N/A 50% 50% 30% 30% $25/$40 $25/$40 $20 All chgs $100 20% $100+any diff. 20%+diff. *The Panama Canal Area Plan provides a point-of-service product within the Republic of Panama. 23 Nationwide Fee-for-Service Plans Open Only to Specific Groups Member Survey results are collected, scored, and reported by an independent organization – not by the health plans. Here is a brief explanation of each survey category. Overall Plan Satisfaction Getting Needed Care Getting Care Quickly How Well Doctors Communicate Customer Service • How would you rate your overall experience with your health plan? • Were you satisfied with the choices your health plan gave you to select a personal doctor? • Were you satisfied with the time it takes to get a referral to a specialist? • Did you get the advice or help you needed when you called your doctor during regular office hours? • Could you get an appointment for regular or routine care when you wanted? • Did your doctor listen carefully to you and explain things in a way you could understand? • Did your doctor spend enough time with you? • Was your plan helpful when you called its customer service department? • Did you have paperwork problems? • Were the plan’s written materials understandable? • Did your plan pay your claims correctly and in a reasonable time? Claims Processing Member Survey Results h above average, * average, f below average Overall plan satisfaction Getting needed care Getting care quickly How well doctors communicate Customer service Claims processing Plan Name Association Benefit Plan Foreign Service Benefit Plan Panama Canal Area Benefit Plan Rural Carrier Benefit Plan SAMBA Secret Service Employees Health Association Plan Code 42 40 43 38 44 Y7 h * f h h f * f h h f * h f * h * f * f h * * f h f h h * f h f f h h f 24 Plan Comparisons Health Maintenance Organization Plans, Plans Offering a Point of Service Product, and Local Consumer-Driven Plans (Pages 26 through 55) Health Maintenance Organization (HMO) — A health plan that 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. Some HMOs are affiliated with or have arrangements with HMOs in other service areas for non-emergency care if you travel or are away from home for extended periods ( reciprocity). Plans that offer reciprocity discuss it in their brochure. ● The HMO provides a comprehensive set of services — as long as you use the doctors and hospitals affiliated with the HMO. HMOs charge a copayment for primary physician and specialist visits and generally no coinsurance for inhospital care. ● Most HMOs ask you to choose a doctor or medical group to be your primary care physician (PCP). Your PCP provides your general medical care. In many HMOs, you must get authorization or a “referral” from your PCP to see other providers. The referral is a recommendation by your physician for you to be evaluated and/or treated by a different physician or medical professional. The referral ensures that you see the right provider for the care most appropriate to your condition. ● Care is not covered from a provider not in the plan’s network unless it’s emergency care or your plan has an arrangement with another plan. Plans Offering a Point of Service (POS) Product — A product similar to an HMO and FFS plan. The POS product lets you use providers who are not part of the HMO network for some services. However, you pay more for using these non-network providers. You usually pay higher deductibles and coinsurances than you pay with a plan provider. You will also need to file a claim for reimbursement, like in an FFS plan. The HMO plan wants you to use its network of providers, but recognizes that sometimes enrollees want to choose their own provider. The POS plans have two rows for “In Network” and “Out of Network” benefits. In Network shows what you pay if you go to the plan’s providers; Out of Network shows what you pay if you decide not to go to the plan’s providers. Consumer-Driven Plans — Describes a wide range of approaches to give you more incentive to control the cost of either your health benefits or health care. You have greater freedom in spending health care dollars up to a designated amount, and you receive full coverage for in-network preventive care. In return, you assume significantly higher cost sharing expenses after you have used up the designated amount. The catastrophic limit is usually higher than those common in other plans. 25 Health Maintenance Organization (HMO) and Point of Service (POS) 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. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay 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 is the amount you pay when you are admitted into a hospital. Enrollment Code Plan Name – Location Alabama HealthSpring of Alabama, Inc. - Birmingham/Other areas Telephone Number Self only Self & family Self Only Self & Family 800/947-5093 DF1 DF2 102.54 329.88 Arizona Aetna Health Inc. - Phoenix/Tucson Areas Health Net of Arizona, Inc. - Maricopa/Pima/Other AZ counties Humana CoverageFirst (Consumer Driven Plan) - Phoenix PacifiCare Desert Region (AZ) - Maricopa, Pima County & Apache Junction 800/537-9384 800/289-2818 888/393-6765 800-531-3341 WQ1 A71 DB1 A31 WQ2 A72 DB2 A32 57.74 70.82 45.64 64.18 158.62 179.42 104.96 159.84 NCQA 1 NCQA 2 NCQA 2 California Aetna Health Inc. - Los Angeles and San Diego Areas Aetna HealthFund (Consumer Driven Plan) - Northern/Central Valley/Southern CA Blue Cross- HMO - Most of California Blue Shield of CA Access+ - Most of California Health Net of California - Most of California Kaiser Permanente - Northern California Kaiser Permanente - Southern California PacifiCare of California - Most of California UHP Healthcare - LA/Orange/San Bernardino Counties Universal Care - Southern California 800/537-9384 888/238-6240 800/235-8631 800/880-8086 800/522-0088 800/464-4000 800/464-4000 800-531-3341 800/544-0088 800/635-6668 2X1 221 M51 SJ1 LB1 591 621 CY1 C41 6Q1 2X2 222 M52 SJ2 LB2 592 622 CY2 C42 6Q2 54.14 64.72 77.26 67.44 71.48 78.98 74.10 59.98 53.84 55.06 132.00 148.86 208.06 167.28 169.20 199.96 171.26 139.14 114.64 145.36 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 JCAHO 1 NCQA 2 NCQA 2 Colorado Kaiser Permanente - Denver/Colorado Springs areas PacifiCare of Colorado - Denver/Colorado Springs/Ft.Collins 800/632-9700 800/877-9777 651 D61 652 D62 71.50 78.00 184.50 191.48 NCQA 1 NCQA 1 26 Accredited Twice – Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 4 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 4 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name Alabama HealthSpring of Alabama, Inc. $20/$25 $100/day x 5 $10 $25/$50 Yes h h h h Customer service * Arizona Aetna Health Inc. Health Net of Arizona, Inc. Humana CoverageFirst - In-Network - Out-of-Network $20/$25 $15/$15 $20*/$35* 30%*/30%* $15/$30 $250/day x 3 $100/day x 5 $10 $10 $25/$40 $30/$45 Yes Yes No* No* Yes * f * * * h f f f f f f f f f f f * $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%* $25/$50+30%* $200/ day x 5 $15 $35/$50 PacifiCare Desert Region (AZ & NV) California Aetna Health Inc. Aetna HealthFund Blue Cross- HMO Blue Shield of CA Access+ Health Net of California Kaiser Permanente Kaiser Permanente PacifiCare of California UHP Healthcare Universal Care - In-Network15%*/15%* - Out-of-Network $20/$25 15%* 40%*/40%* $10/$10 $10/$10 $10/$10 $15/$15 $10/$10 $15/$30 $10/$10 $10/$10 $250/day x 3 $10* 40%* None None $100 None None $100/day x 3 $300 $300 $10 $25*/$40* $10* $5 $5 $10 $10 $10 $15 $10 $10 $25/$40 Yes* $25*/$40* $10/50% $10/$25 $20/$35 $25 $25 $35/$50 $30/$50 $20/$30 Yes Yes* Yes Yes Yes No No Yes No Yes * f f * * * * * * h h h f f f f f * f * f f f * * * * f f * * * f * h * * * * h * * * f f f * * Colorado Kaiser Permanente PacifiCare of Colorado $15/$25 $10/$40 $250 $150/day x 5 $10 $10 $20 $35/$50 No Yes * f * * * h f * * f * * * See Brochure for details on patient’s payment responsibility. 27 Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average * Health Maintenance Organization (HMO) and Point of Service (POS) 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. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay 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 is the amount you pay when you are admitted into a hospital. Enrollment Code Plan Name – Location Connecticut Aetna HealthFund (Consumer Driven Plan) - All of Connecticut ConnectiCare - All of Connecticut Telephone Number Self only Self & family Self Only Self & Family 888/238-6240 800/251-7722 221 TE1 222 TE2 64.72 76.18 148.86 243.86 NCQA 1 District of Columbia Aetna Health Inc.-High -Washington, DC Area Aetna Health Inc.-Std - Washington, DC Area Aetna HealthFund (Consumer Driven Plan) - All of Washington D.C. CareFirst BlueChoice - Washington, D.C. Metro Area Kaiser Permanente - Washington, DC area M.D. IPA - Washington, DC area 800/537-9384 800/537-9384 888/238-6240 866/520-6099 301/468-6000 800/251-0956 JN1 JN4 221 2G1 E31 JP1 JN2 JN5 222 2G2 E32 JP2 80.48 52.88 64.72 120.48 72.98 73.40 181.26 123.74 148.86 263.08 173.72 176.18 NCQA 2 NCQA 2 NCQA 1 NCQA 1 NCQA 1 Florida Av-Med Health Plan - Broward, Dade and Palm Beach Capital Health Plan - Tallahassee area Humana CoverageFirst (Consumer Driven Plan) - Tampa Humana CoverageFirst (Consumer Driven Plan) - Jacksonville Humana CoverageFirst (Consumer Driven Plan) - South Florida Humana Medical Plan - South Florida JMH Health Plan - Broward-Dade counties Total Health Choice - Broward/Dade/Palm Beach Counties Vista Healthplan - South Florida Vista Healthplan - Pensacola area Vista Healthplan - Gainesville Vista Healthplan - Tallahassee Vista Healthplan of South Florida - Southern Florida 800/882-8633 850/383-3311 888/393-6765 888/393-6765 888/393-6765 888/393-6765 800/721-2993 800/213-1133 866/847-8235 866/847-8235 866/847-8235 866/847-8235 800/441-5501 ML1 EA1 MJ1 MQ1 QP1 EE1 J81 4A1 3N1 RK1 UL1 Y91 5E1 ML2 EA2 MJ2 MQ2 QP2 EE2 J82 4A2 3N2 RK2 UL2 Y92 5E2 73.40 74.26 50.44 52.84 48.04 75.30 66.32 58.40 81.78 79.32 63.22 59.58 56.26 253.18 233.04 116.00 121.52 110.48 173.18 164.14 145.50 338.18 293.04 168.82 159.08 154.70 URAC 1 NCQA 2 NCQA 1 28 Accredited Twice – Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 4 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 4 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name Connecticut Aetna HealthFund ConnectiCare - In-Network - Out-of-Network 15%*/15%* 40%*/40%* $10/$10 15%* 40%* None $10* $10* $10 $25*/$40* $25*/$40* $20/$35 Yes* Yes* Yes h h h h h h District of Columbia Aetna Health Inc.-High Aetna Health Inc.-Std Aetna HealthFund CareFirst BlueChoice Kaiser Permanente M.D. IPA - In-Network - Out-of-Network $15/$20 $20/$25 15%*/15%* 40%*/40%* $20/$30 $10/$20 $10/$20 $150/day x 3 $250/day x 3 15%* 40%* $100/day x 5 $100 $100 $10 $10 $10* $10* $10 $10/$20Net $8 $25/$40 $25/$40 $25*/$40* $25*/$40* $25/$40 $20/$40 $20/$35 No No Yes* Yes* Yes Yes No f * * f f * f f * * f * f * h f * h f f * * f f * * * * * * Florida Av-Med Health Plan Capital Health Plan Humana CoverageFirst Humana CoverageFirst Humana CoverageFirst Humana Medical Plan JMH Health Plan Total Health Choice Vista Healthplan Vista Healthplan Vista Healthplan Vista Healthplan Vista Healthplan of South Florida - In-Network - Out-of-Network - In-Network - Out-of-Network - In-Network - Out-of-Network $15/$25 $10/$10 $20*/$35* 30%*/30%* $20*/$35* 30%*/30%* $20*/$35* 30%*/30%* $10/$20 $10/$10 $10/$10 $10/$20 $10/$20 $10/$20 $10/$20 $10/$20 $100/dayx5 $100 $15 $8 $30/$50 $25/$40 No No No* No* No* No* No* No* No No No Yes Yes Yes Yes Yes f f f f f f f f f f f f f f f f * f * h f h f * f * * h * h $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%* $25/$50+30%* $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%* $25/$50+30%* $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%* $25/$50+30%* $100/day x 3 None $100 $100/day x 3 $100/day x 3 $100/day x 3 $100/day x 3 $100 x 3 days $5/$20 $5 $5 $10 $10 $10 $10 $10 $20/$40 50% $15 $20/$40 $20/$40 $20/$40 $20/$40 $20/$40 * See Brochure for details on patient’s payment responsibility. 29 Customer service Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average Health Maintenance Organization (HMO) and Point of Service (POS) 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. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay 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 is the amount you pay when you are admitted into a hospital. Enrollment Code Plan Name – Location Georgia Aetna Health Inc. - Atlanta and Athens Areas Aetna HealthFund (Consumer Driven Plan) - Atlanta Area Kaiser Permanente - Atlanta area Telephone Number Self only Self & family Self Only Self & Family 800/537-9384 888/238-6240 800/611-1811 2U1 221 F81 2U2 222 F82 66.80 64.72 64.26 161.16 148.86 163.16 NCQA 2 NCQA 1 Guam PacifiCare Asia Pacific-High -Guam/N.Mariana Islands/Belau PacifiCare Asia Pacific-Std - Guam/N.Mariana Islands/Belau 671/647-3526 671/647-3526 JK1 JK4 JK2 JK5 72.28 56.98 205.66 150.50 Hawaii HMSA - All of Hawaii Kaiser Permanente-High -Islands of Hawaii/Maui/Oahu/Kauai Kaiser Permanente-Std - Islands of Hawaii/Maui/Oahu/Kauai 808/948-6499 808/432-5955 808/432-5955 871 631 634 872 632 635 67.46 80.56 64.78 150.18 173.20 139.26 NCQA 1 NCQA 1 NCQA 1 Idaho Group Health Cooperative-High -Kootenai and Latah Group Health Cooperative-Std - Kootenai and Latah 888/901-4636 888/901-4636 VR1 VR4 VR2 VR5 79.62 69.00 222.26 158.68 NCQA 1 NCQA 1 30 Accredited Twice – Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 4 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 4 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name Georgia Aetna Health Inc. Aetna HealthFund Kaiser Permanente - In-Network - Out-of-Network $20/$25 15%*/15%* 40%*/40%* $15/$15 $250/day x 3 15%* 40%* $250 $10 $10* $10* $10/$16 Com $25/$40 $25*/$40* $25*/$40* $10/$16 Yes Yes* Yes* No f * f f Customer service * h * * * h Guam PacifiCare Asia Pacific-High PacifiCare Asia Pacific-Std $10/$10 $15/$15 None $150 $5 $5 $5/$20 $5/$20 No No h h f f * * * * * * * * Hawaii HMSA Kaiser Permanente-High Kaiser Permanente-Std - In-Network - Out-of-Network $15/$15 30% sch +/30% sch + $10/$10 $15/$15 None None None None $5 $20/50% $5+20%+ $20+20%+/50%+ $10 $10 $10 $10 Yes No Yes Yes h h h h * * h * * h * * h * * h * * Idaho Group Health Cooperative-High Group Health Cooperative-Std $15/$15 $20+20%/$20+20% $200/day x 3 $200/day x 3 $15 $20 $25/$50 $30/$60 Yes Yes * * * * h h * * * * * * * See Brochure for details on patient’s payment responsibility. 31 Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average f h Health Maintenance Organization (HMO) and Point of Service (POS) 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. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay 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 is the amount you pay when you are admitted into a hospital. Enrollment Code Plan Name – Location Illinois Aetna HealthFund (Consumer Driven Plan) - Chicago Area BlueCHOICE - Madison and St. Clair counties Group Health Plan - Southern/Metro East/Central Health Alliance HMO - Central/E.Central/N.West/South/West IL Humana CoverageFirst (Consumer Driven Plan) - Chicago Humana Health Plan Inc.-High -Chicago area Humana Health Plan Inc.-Std - Chicago area John Deere Health Plan - Bloomingtn/Moline/Peoria/RockIsld Mercy Health Plans/Premier Health Plans - Southwest Illinois OSF HealthPlans - Central/Central-Northwestern Illinois PersonalCare's HMO - Central Illinois Unicare HMO - Chicagoland Area Union Health Service - Chicago area Telephone Number Self only Self & family Self Only Self & Family 888/238-6240 800/634-4395 800/755-3901 800/851-3379 888/393-6765 888/393-6765 888/393-6765 800/247-9110 800/327-0763 800/673-5222 800/431-1211 888/234-8855 312/829-4224 221 9G1 MM1 FX1 MW1 751 754 YH1 7M1 9F1 GE1 171 761 222 9G2 MM2 FX2 MW2 752 755 YH2 7M2 9F2 GE2 172 762 64.72 76.84 152.24 96.00 38.42 78.00 59.80 71.12 144.28 65.38 68.86 73.14 61.84 148.86 166.36 299.08 236.56 88.38 179.38 137.52 174.22 281.94 171.96 177.04 242.14 153.36 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 URAC 1 NCQA 1 32 Accredited Twice – Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 4 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 4 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name Illinois Aetna HealthFund BlueCHOICE Group Health Plan Health Alliance HMO Humana CoverageFirst Humana Health Plan Inc.-High Humana Health Plan Inc.-Std John Deere Health Plan Mercy Health Plans/Premier OSF HealthPlans PersonalCare's HMO Unicare HMO Union Health Service - In-Network - Out-of-Network - In-Network - Out-of-Network - In-Network - Out-of-Network 15%*/15%* 40%*/40%* $10/$10 $10/$20 $15/$15 $20*/$35* 30%*/30%* $10/$20 $15/$25 $15/$15 $10/$20 30%/30% $20/$20 $20/$20 $15/$15 $10/$10 15%* 40%* None $100 $100 $10* $10* $7 $10 $10 $25*/$40* $25*/$40* $12/$25 $20/$35 $20/$40 Yes* Yes* Yes Yes No No* No* No No Yes Yes No No No No No * * h * f f h h * * h * * * * * f f h * f f h * * * h h * * h * h * * * * * * * * h $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%* $25/$50+30%* $100/day x 3 $250/day x 3 $100/day x 5 None None $500 $100/day x 5 None None $5/$15 $10/$25 $10 $10 N/A $10 $10 $5 $15 $15/$35 $25/$45 $20/$35 $20/$35 N/A $20/$40 $20/$50 $15/$25 $15/$15 h * * * h * h h f h * * Customer service * * * * See Brochure for details on patient’s payment responsibility. 33 Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average h * f Health Maintenance Organization (HMO) and Point of Service (POS) 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. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay 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 is the amount you pay when you are admitted into a hospital. Enrollment Code Plan Name – Location Indiana Advantage Health Plan, Inc. - Most of Indiana Aetna Health Inc. - Southeastern Indiana Aetna HealthFund (Consumer Driven Plan) - Lake and Porter Counties Arnett HMO - Lafayette area Health Alliance HMO - Fountain/Vermillion/Warren Counties Humana CoverageFirst (Consumer Driven Plan) - Southern Indiana Humana CoverageFirst (Consumer Driven Plan) - Lake/Porter/LaPorte Counties Humana Health Plan - Southern Indiana Humana Health Plan Inc.-High -Lake/Porter/LaPorte Counties Humana Health Plan Inc.-Std - Lake/Porter/LaPorte Counties M*Plan - Indiana Metropolitan areas Physicians Health Plan of Northern Indiana - Northeast Indiana Unicare HMO - Lake/Porter Counties Telephone Number Self only Self & family Self Only Self & Family 800/553-8933 800/537-9384 888/238-6240 765/448-7440 800/851-3379 888/393-6765 888/393-6765 888/393-6765 888/393-6765 888/393-6765 317/571-5320 260/432-6690 888/234-8855 6Y1 RD1 221 G21 FX1 BM1 MW1 D21 751 754 IN1 DQ1 171 6Y2 RD2 222 G22 FX2 BM2 MW2 D22 752 755 IN2 DQ2 172 95.24 75.50 64.72 63.98 96.00 57.64 38.42 113.34 78.00 59.80 133.70 77.36 73.14 239.52 187.98 148.86 166.36 236.56 132.58 88.38 264.88 179.38 137.52 309.90 173.72 242.14 NCQA 6 NCQA 1 NCQA 1 NCQA 1 NCQA 2 NCQA 1 NCQA 1 Iowa Avera Health Plans - Northwestern Iowa Coventry Health Care of Iowa - Central Iowa/Cedar Rapids/Sioux City Health Alliance HMO - Central and Eastern Iowa John Deere Health Plan - Central/Eastern Iowa Sioux Valley Health Plan-High -Northwestern Iowa Sioux Valley Health Plan-Std - Northwestern Iowa 888/322-2115 800/257-4692 800/851-3379 800/247-9110 800/752-5863 800/752-5863 AV1 SV1 FX1 YH1 AU1 AU4 AV2 SV2 FX2 YH2 AU2 AU5 72.38 67.06 96.00 71.12 184.52 119.84 169.04 181.12 236.56 174.22 428.32 279.48 NCQA 1 NCQA 1 NCQA 1 34 Accredited Twice – Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 4 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 4 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name Indiana Advantage Health Plan, Inc. Aetna Health Inc. Aetna HealthFund Arnett HMO Health Alliance HMO Humana CoverageFirst Humana CoverageFirst Humana Health Plan Humana Health Plan Inc.-High Humana Health Plan Inc.-Std M*Plan Physicians Health Plan of Northern Indiana Unicare HMO - In-Network - Out-of-Network - In-Network - Out-of-Network - In-Network - Out-of-Network $15/$30 $20/$25 15%*/15%* 40%*/40%* $10/$10 $15/$15 $20*/$35* 30%*/30%* $20*/$35* 30%*/30%* $15/$25 $10/$20 $15/$25 $15/$30 $15/$15 $15/$15 $400x2/Yr $250/day x 3 15%* 40%* None $100 $10 $10 $10* $10* $10 $10 $30/$50 $25/$40 $25*/$40* $25*/$40* $20/$40 $20/$40 Yes Yes Yes* Yes* No No No* No* No* No* No No No Yes No No f * * * * h h * Customer service * * h h h * h h * * h * $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%* $25/$50+30%* $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%* $25/$50+30%* $250/day x 3 $100/day x 3 $250/day x 3 $250 20% None $10/$25 $5/$15 $10/$25 $10/$20 $10 $5 $25/$45 $15/$35 $25/$45 $30/$50 $20/$40 $15/$25 * * * * h * * f f * h f * * * * h f * * * * h * * f f f h f Iowa Avera Health Plans Coventry Health Care of Iowa Health Alliance HMO John Deere Health Plan Sioux Valley Health Plan Sioux Valley Health Plan - In-Network - Out-of-Network - In-Network - Out-of-Network $10/$15 $10/$10 $15/$15 $15/$15 $20/$30 40%/40% $25/$25 40%/40% $100/dayx3 None $100 $100/day x 5 $100/day x 5 40% $100/day x 5 40% $10 $5 $10 $10 $15 N/A $15 N/A $20 $15/$30 $20/$40 $20/$35 $30/$50 N/A $30/$50 N/A No No No Yes No No No No f h h h * h h h h * * * f * h f h h * See Brochure for details on patient’s payment responsibility. 35 Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average * f h h * f f * h f Health Maintenance Organization (HMO) and Point of Service (POS) 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. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay 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 is the amount you pay when you are admitted into a hospital. Enrollment Code Plan Name – Location Kansas Coventry Health Care of Kansas - Wichita/Salina areas Coventry Health Care of Kansas - Kansas City - Kansas City area Humana CoverageFirst (Consumer Driven Plan) - Kansas City Humana Health Plan, Inc.-High -Kansas City area Humana Health Plan, Inc.-Std - Kansas City area Preferred Plus of Kansas - S. Central Area Telephone Number Self only Self & family Self Only Self & Family 800/664-9251 800/969-3343 888/393-6765 888/393-6765 888/393-6765 800/660-8114 7W1 HA1 PH1 MS1 MS4 VA1 7W2 HA2 PH2 MS2 MS5 VA2 75.46 66.18 38.42 98.62 61.44 181.74 215.50 170.76 88.38 231.10 141.32 575.10 URAC 1 URAC 1 JCAHO 1 Kentucky Humana CoverageFirst (Consumer Driven Plan) - Louisville Humana Health Plan - Louisville area United Healthcare of Ohio, Inc. - Northern Kentucky 888/393-6765 888/393-6765 800/231-2918 BM1 D21 3U1 BM2 D22 3U2 57.64 113.34 152.18 132.58 264.88 354.28 NCQA 2 NCQA 1 Louisiana Coventry Healthcare Louisiana - New Orleans area Coventry Healthcare Louisiana - Baton Rouge area Vantage Health Plan - Monroe/Shreveport/Alexandria Areas 800/341-6613 800/341-6613 888/823-1910 BJ1 JA1 MV1 BJ2 JA2 MV2 61.16 98.18 113.26 142.04 237.72 371.56 Maryland Aetna Health Inc.-High -Northern/Central/Southern Maryland Aetna Health Inc.-Std - Northern/Central/Southern Maryland Aetna HealthFund (Consumer Driven Plan) - All of Maryland CareFirst BlueChoice - All of Maryland Kaiser Permanente - Baltimore/Washington, DC areas M.D. IPA - All of Maryland 800/537-9384 800/537-9384 888/238-6240 866/520-6099 301/468-6000 800/251-0956 JN1 JN4 221 2G1 E31 JP1 JN2 JN5 222 2G2 E32 JP2 80.48 52.88 64.72 120.48 72.98 73.40 181.26 123.74 148.86 263.08 173.72 176.18 NCQA 2 NCQA 2 NCQA 1 NCQA 1 NCQA 1 36 Accredited Twice – Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 4 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 4 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name Kansas Coventry Health Care of Kansas Coventry Health Care of Kansas - Kansas City Humana CoverageFirst Humana Health Plan, Inc.-High Humana Health Plan, Inc.-Std Preferred Plus of Kansas - In-Network - Out-of-Network $15/$15 $15/$15 $20*/$35* 30%*/30%* $10/$20 $15/$25 $10/$10 $100/day x 3 $100/day x 3 $5 $10 $15/$45 $20/$50 Yes Yes No* No* No No Yes f f * * * * h h Customer service f f $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%* $25/$50+30%* $100/day x 3 $250/day x 3 $50/day x 10 $5/$20 $10/$25 $5 $20/$40 $25/$45 $15 f f * * * * f f * * Kentucky Humana CoverageFirst Humana Health Plan United Healthcare of Ohio, Inc. - In-Network - Out-of-Network $20*/$35* 30%*/30%* $15/$25 $15/$15 $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%* $25/$50+30%* $250/day x 3 $250 $10/$25 $10 $25/$45 $15/$30 No* No* No Yes * * * h * * * h * * * * Louisiana Coventry Healthcare Louisiana Coventry Healthcare Louisiana Vantage Health Plan $15/$15 $15/$15 $15/$15 $100/day x 3 $100/day x 3 $250 $10 $10 $10 $20/$45 $20/$45 $20/$35 Yes Yes Yes f f * * * * h h * * * * Maryland Aetna Health Inc.-High Aetna Health Inc.-Std Aetna HealthFund CareFirst BlueChoice Kaiser Permanente M.D. IPA - In-Network - Out-of-Network $15/$20 $20/$25 15%*/15%* 40%*/40%* $20/$30 $10/$20 $10/$20 $150/day x 3 $250/day x 3 15%* 40%* $100/day x 5 $100 $100 $10 $10 $10* $10* $10 $10/$20Net $8 $25/$40 $25/$40 $25*/$40* $25*/$40* $25/$40 $20/$40 $20/$35 No No Yes* Yes* Yes Yes No f * * f f * f f * * f * f * h f * h f f * * f f * * * * * * * See Brochure for details on patient’s payment responsibility. 37 Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average * * f f Health Maintenance Organization (HMO) and Point of Service (POS) 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. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay 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 is the amount you pay when you are admitted into a hospital. Enrollment Code Plan Name – Location Massachusetts Blue Chip, Coord Hlth Partners - Southeastern Massachusetts ConnectiCare - Counties Hampden, Hampshire, Franklin Fallon Community Health Plan - Central/Eastern Massachusetts Telephone Number Self only Self & family Self Only Self & Family 401/459-5500 800/251-7722 800/868-5200 DA1 TE1 JV1 DA2 TE2 JV2 122.88 76.18 114.52 382.16 243.86 314.28 NCQA 1 NCQA 1 NCQA 1 Michigan Bluecare Network of MI - Midland County Area Bluecare Network of MI - Kalamazoo County Area Bluecare Network of MI - Genesee County Area Bluecare Network of MI - Kent County Area Bluecare Network of MI - Mid Michigan Bluecare Network of MI - Southeast MI Grand Valley Health Plan - Grand Rapids area Health Alliance Plan - Southeastern Michigan/Flint area HealthPlus MI - Flint/Saginaw areas M-Care - Southeastern Michigan and Flint area OmniCare - Southeastern Michigan Total Health Care - Greater Detroit/Flint areas 800/662-6667 800/662-6667 800/662-6667 800/662-6667 800/662-6667 800/662-6667 616/949-2410 800/422-4641 800/332-9161 800/658-8878 800/477-6664 800/826-2862 K51 KF1 KN1 KR1 LN1 LX1 RL1 521 X51 EG1 KA1 N21 K52 KF2 KN2 KR2 LN2 LX2 RL2 522 X52 EG2 KA2 N22 79.24 155.84 94.22 142.92 176.26 59.78 74.90 67.24 110.98 63.32 63.26 57.84 333.00 561.26 388.00 560.06 454.94 178.80 286.90 178.16 253.74 167.80 155.62 142.10 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 3 Minnesota Avera Health Plans - Southwestern Minnesota HealthPartners Classic-High -Minneapolis/St. Paul/St.Cloud HealthPartners Open Access-Basic - Minneapolis/St. Paul/St.Cloud HealthPartners Primary Clinic Plan - Minneapolis/St. Paul/St. Cloud 888/322-2115 952-883-5000 952-883-5000 952-883-5000 AV1 531 534 HQ1 AV2 532 535 HQ2 72.38 144.06 85.12 236.98 169.04 374.26 232.78 597.26 NCQA 1 NCQA 1 NCQA 1 38 Accredited Twice – Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 4 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 4 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name Massachusetts Blue Chip, Coord Hlth Partners ConnectiCare Fallon Community Health Plan - In-Network - Out-of-Network $15/$25 30%/30% $10/$10 $10/$10 $500 None None $100 $7 $25/$40 $40+20% $40+20%/$40+20% $10 $5 $20/$35 $20/$40 Yes No Yes Yes f h * h h * h h h h h * Customer service * h * Michigan Bluecare Network of MI Bluecare Network of MI Bluecare Network of MI Bluecare Network of MI Bluecare Network of MI Bluecare Network of MI Grand Valley Health Plan Health Alliance Plan HealthPlus MI M-Care OmniCare Total Health Care $10/$10 $10/$10 $10/$10 $10/$10 $10/$10 $10/$10 $10/$10 $10/$10 $10/$10 $10/$10 $10/$10 $10/$10 Nothing Nothing Nothing Nothing Nothing Nothing None None None None None None $5 $5 $5 $5 $5 $5 $5 $10 $10 $10 $5 Nothing $20 $20 $20 $20 $20 $20 $5 $20 $20 $20/$30 $10/$25 Nothing Yes Yes Yes Yes Yes Yes No Yes Yes No Yes No * * * * * * h * h * f f f f f f f f * * h * f f * * * * * * h f h * f f f f f f f f * * h * f * f f f f f f h f h * * * * * * * * * h * h * * f Minnesota Avera Health Plans HealthPartners Classic-High HealthPartners Open Access-Basic HealthPartners Primary Clinic Plan $10/$15 $15/$15 $15/$15 $20/$20 $100/dayx3 $100 $100 $200 $10 $12 $10 $12 $20 $12/$24 $10/$35 $12/$24 Yes No No No f f f * * * * * * * * * f f f * * * 39 Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average * h * Health Maintenance Organization (HMO) and Point of Service (POS) 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. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay 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 is the amount you pay when you are admitted into a hospital. Enrollment Code Plan Name – Location Missouri BlueCHOICE - St Louis/Central/SW areas Coventry Health Care of Kansas - Kansas City - Kansas City area Group Health Plan - St. Louis area Humana CoverageFirst (Consumer Driven Plan) - Kansas City Humana Health Plan, Inc.-High -Kansas City area Humana Health Plan, Inc.-Std - Kansas City area Mercy Health Plans/Premier Health Plans - East/Central/Southwest Missouri Telephone Number Self only Self & family Self Only Self & Family 800/634-4395 800-969-3343 800/755-3901 888/393-6765 888/393-6765 888/393-6765 800/327-0763 9G1 HA1 MM1 PH1 MS1 MS4 7M1 9G2 HA2 MM2 PH2 MS2 MS5 7M2 76.84 66.18 152.24 38.42 98.62 61.44 144.28 166.36 170.76 299.08 88.38 231.10 141.32 281.94 NCQA 1 URAC 1 URAC 1 URAC 1 Montana New West Health Services - Most of Montana 800/290-3657 NV1 NV2 76.62 170.48 Nevada Aetna Health Inc. - Las Vegas Area Health Plan of Nevada - Las Vegas area PacifiCare Desert Region (NV) - Las Vegas/Clark County 800/537-9384 800/777-1840 800-531-3341 Y11 NM1 K91 Y12 NM2 K92 67.24 45.98 62.54 167.44 117.72 141.98 NCQA 2 NCQA 2 New Jersey Aetna Health Inc. - All of New Jersey Aetna HealthFund (Consumer Driven Plan) - All of New Jersey AmeriHealth HMO - All of New Jersey GHI Health Plan-High -Northern New Jersey 800/537-9384 888/238-6240 888/238-6240 212/501-4444 P31 221 221 801 P32 222 222 802 79.44 64.72 64.72 127.54 212.68 148.86 148.86 371.66 NCQA 1 URAC 1 NCQA 1 New Mexico Cimarron Health Plan - All of New Mexico Lovelace Health Plan - All of New Mexico Presbyterian Health Plan - All NM counties except Otero & S. Eddy 800/473-0391 800/244-6224 800/356-2219 PX1 Q11 P21 PX2 Q12 P22 80.12 76.96 72.18 287.48 201.20 198.72 NCQA 2 NCQA 1 NCQA 2 40 Accredited Twice – Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 4 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 4 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name Missouri BlueCHOICE Coventry Health Care of Kansas - Kansas City Group Health Plan Humana CoverageFirst Humana Health Plan, Inc.-High Humana Health Plan, Inc.-Std Mercy Health Plans/Premier - In-Network - Out-of-Network - In-Network - Out-of-Network $10/$10 $15/$15 $10/$20 $20*/$35* 30%*/30%* $10/$20 $15/$25 $10/$20 30%/30% None $100/day x 3 $100 $7 $10 $10 $12/$25 $20/$50 $20/$35 Yes Yes Yes No* No* No No Yes No * f * h * * h * * * h * Customer service * f * $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%* $25/$50+30%* $100/day x 3 $250/day x 3 None None $5/$20 $10/$25 $10 N/A $20/$40 $25/$45 $20/$35 N/A f f * * * h * * h f f h * * h Montana New West Health Plan $15/$15 $100 $10 $20/$40 Yes Nevada Aetna Health Inc. Health Plan of Nevada PacifiCare Desert Region (AZ & NV) $20/$25 $10/$10 $15/$30 $250/day x 3 $100 $200/ day x 5 $10 $5 $15 $25/$40 $20/$35 $35/$50 Yes Yes Yes f * f f f f f f f * f * New Jersey Aetna Health Inc. Aetna HealthFund AmeriHealth HMO GHI Health Plan - In-Network - Out-of-Network $30/$35 - In-Network - Out-of-Network $20/$25 15%*/15%* 40%*/40%* $200/day x 3 $15/$15 50% of sch./50% of sch. $250/day x 3 15%* 40%* $15 None None $10 $10* $10* $40/50% $10 N/A $25/$40 $25*/$40* $25*/$40* Yes $20/$50 N/A Yes Yes* Yes* f Yes No * * * * * * * * * f f * * * * * * * New Mexico Cimarron Health Plan Lovelace Health Plan Presbyterian Health Plan $10/$10 $15/$25 $10/$10 $100 $250 None $5 $7 $7 $15/$30 $15/$35 $17/$34 Yes Yes Yes f * * f f f f f f f * * f * * f * * * See Brochure for details on patient’s payment responsibility. 41 Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average * * * f f h Health Maintenance Organization (HMO) and Point of Service (POS) 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. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay 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 is the amount you pay when you are admitted into a hospital. Enrollment Code Plan Name – Location New York Aetna Health Inc. - NYC Area and Dutchess/Sullivan/Ulster Aetna HealthFund (Consumer Driven Plan) - New York City Area Blue Choice - Rochester area Capital District Physicians' Health Plan - North/Central New York Capital District Physicians' Health Plan - Hudson Valley area Capital District Physicians' Health Plan - Capital District area GHI Health Plan-High -All of New York GHI Health Plan-Std - NYC/Brnx/Kings/Queen/Rich/Nass/Suff/Rock/Westche GHI HMO Select - Brnx/Brklyn/Manhat/Queen/Richmon/Westche GHI HMO Select - Capital/Hudson Valley Regions HIP of Greater New York-High -New York City area HIP of Greater New York-Std - New York City area HMO Blue - Utica/Rome/Central New York areas HMOBlue-CNY - Syracuse/Binghamton/Elmira areas Independent Health Assoc - Western New York MVP Health Care - Eastern Region MVP Health Care - Central Region MVP Health Care - Mid-Hudson Region Preferred Care - Rochester area Univera Healthcare - Western New York (Southern Counties) Univera Healthcare - Western New York (Northern Counties) Vytra Health Plans - Queens/Nassau/Suffolk Counties Telephone Number Self only Self & family Self Only Self & Family 800/537-9384 888/238-6240 800/462-0108 518/641-3700 518/641-3700 518/641-3700 212/501-4444 212/501-4444 877/244-4466 877/244-4466 800/HIP-TALK 800/HIP-TALK 800/722-7884 800/828-2887 800/453-1910 888/687-6277 888/687-6277 888/687-6277 800/950-3224 716/847-0881 716/847-0881 800/406-0806 JC1 221 MK1 PW1 QB1 SG1 801 804 6V1 X41 511 514 AH1 EB1 QA1 GA1 M91 MX1 GV1 KQ1 Q81 J61 JC2 222 MK2 PW2 QB2 SG2 802 805 6V2 X42 512 515 AH2 EB2 QA2 GA2 M92 MX2 GV2 KQ2 Q82 J62 80.74 64.72 60.04 78.46 76.12 73.80 127.54 79.44 109.80 87.08 73.04 58.48 179.26 124.14 52.54 61.84 70.14 72.02 59.78 72.34 57.08 108.26 240.92 148.86 150.50 248.92 226.14 201.88 371.66 240.22 321.84 293.00 263.88 163.74 523.58 294.74 147.08 159.74 181.10 190.00 159.60 212.36 161.82 366.46 NCQA 1 NCQA 2 NCQA 1 NCQA 1 NCQA 1 URAC 1 URAC 1 NCQA 3 NCQA 3 NCQA 2 NCQA 2 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 North Dakota Heart of America HMO - Northcentral North Dakota 800-525-5661 RU1 RU2 59.20 152.16 42 Accredited Twice – Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 4 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 4 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name New York Aetna Health Inc. Aetna HealthFund Blue Choice Capital District Physicians' Health Plan Capital District Physicians' Health Plan Capital District Physicians' Health Plan GHI Health Plan GHI Health Plan-Std GHI HMO Select GHI HMO Select HIP of Greater New York-High HIP of Greater New York-Std HMO Blue HMOBlue-CNY Independent Health Assoc MVP Health Care MVP Health Care MVP Health Care Preferred Care Univera Healthcare Univera Healthcare Vytra Health Plans - In-Network - Out-of-Network - In-Network - Out-of-Network $20/$25 15%*/15%* 40%*/40%* $15/$15 $15/$15 $15/$15 $15/$15 $15/$15 50% of sch./50% of sch. $25/$25 $10/$10 $10/$10 $10/$10 $10/$20 $15/$15 $15/$15 $15/$15 $15/$15 $15/$15 $15/$15 $15/$15 $15/$15 $15/$15 $10/$10 $250/day x 3 15%* 40%* None $240 $240 $240 None None $250/day x 3 None None None $500 $240 $100 None $240 $240 $240 None $250 $250 None $10 $10* $10* $5 $10 $10 $10 $10 N/A $10 $10 $10 $10 $10 $10 $10 $10 $5 $5 $5 $10 $10 $10 $5 $25/$40 $25*/$40* $25*/$40* $20/$35 $20/$35 $20/$35 $20/$35 $20/$50 N/A $25/$50 $20/$30 $20/$30 $15/$40 $20/$40 $25/$40 $25/$40 $20/$35 $20/$40 $20/$40 $20/$40 $20/$35 $20/$45 $20/$45 $10 Yes Yes* Yes* No Yes Yes Yes Yes No Yes Yes Yes Yes Yes No No No Yes Yes Yes Yes No No Yes * f * f Customer service * h h h h * * f f * * * * * h h h h * * * h h h h * * f f * * h h h h h h h h h h h h h h * * * * f f h h h h h h h h h * h h h h * * * * f f h h h h h h h * * * * h h h f f f f * * f f h h h h h * * h North Dakota Heart of America HMO $10/Nothing None 50% 50% No * See Brochure for details on patient’s payment responsibility. 43 Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average * h h h h * * f f f f * * h * * * h h h * Health Maintenance Organization (HMO) and Point of Service (POS) 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. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay 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 is the amount you pay when you are admitted into a hospital. Enrollment Code Plan Name – Location Ohio Aetna Health Inc. - Cleveland Area Aetna Health Inc. - Greater Cincinnati Area AultCare HMO - Stark/Carroll/Holmes/Tuscarawas/Wayne Co Blue HMO - Most of Ohio HMO Health Ohio - Northeast Ohio HOMETOWN HEALTH PLAN - Massillon Humana CoverageFirst (Consumer Driven Plan) - Cincinnati Kaiser Permanente - Cleveland/Akron areas Paramount Health Care - Northwest/North Central Ohio SummaCare Health Plan - Cleveland, Akron areas SuperMed HMO - Northeast Ohio The Health Plan of the Upper Ohio Valley - Eastern Ohio United Healthcare of Ohio, Inc. - Cincinnati/Dayton/Springfield areas Telephone Number Self only Self & family Self Only Self & Family 800/537-9384 800/537-9384 330/363-6360 800/228-4375 800/522-2066 800-426-9013 888/393-6765 800/686-7100 800/462-3589 330/996-8700 800/522-2066 800/624-6961 800/231-2918 7D1 RD1 3A1 R51 L41 MZ1 L81 641 U21 5W1 5M1 U41 3U1 7D2 RD2 3A2 R52 L42 MZ2 L82 642 U22 5W2 5M2 U42 3U2 70.54 75.50 72.94 104.62 75.56 64.84 48.04 75.88 77.28 72.72 93.32 77.22 152.18 169.92 187.98 179.08 308.68 219.12 162.10 110.48 190.76 264.28 245.66 305.60 177.60 354.28 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 Oklahoma Aetna Health Inc. - Oklahoma City/Tulsa Areas PacifiCare Southwest Region (OK) - Central/Northeastern Oklahoma 800/537-9384 800-531-3341 SL1 2N1 SL2 2N2 78.52 81.48 211.98 227.40 NCQA 1 NCQA 1 Oregon Kaiser Permanente-High -Portland/Salem areas Kaiser Permanente-Std - Portland/Salem areas PacifiCare of Oregon - Metro Portland/Salem/Corvalis/Eugene 800/813-2000 800/813-2000 800-531-3341 571 574 7Z1 572 575 7Z2 98.44 74.84 91.50 228.96 171.74 198.02 NCQA 1 NCQA 1 NCQA 1 44 Accredited Twice – Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 4 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 4 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name Ohio Aetna Health Inc. Aetna Health Inc. AultCare HMO Blue HMO HMO Health Ohio HOMETOWN HEALTH PLAN Humana CoverageFirst Kaiser Permanente Paramount Health Care SummaCare Health Plan SuperMed HMO The Health Plan of the Upper Ohio Valley United Healthcare of Ohio, Inc. - In-Network - Out-of-Network $20/$25 $20/$25 $10/$10 $10/$10 $10/$10 $15/$20 $20*/$35* 30%*/30%* $10/$10 $10/$20 $10/$10 $10/$10 $10/$20 $15/$15 $250/day x 3 $250/day x 3 None None None $250 $10 $10 $10 $10 $10 $15 $25/$40 $25/$40 $20/$35 $20/$30 $20/$30 $25/$40 Yes Yes No Yes Yes No No* No* No No Yes Yes Yes Yes * * h * * * * h h * h h h h * * * * h * Customer service * * h f * $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%* $25/$50+30%* $100 $300 None None $250 $250 $10 $5 $10 $10 $15 $10 $25 $15/$25 $20/$40 $20 $30/$50 $15/$30 h h * * * * * h h * h h * * h * h * * * h * h h * h * * h * Oklahoma Aetna Health Inc. PacifiCare Southwest Region (OK & TX) $20/$25 $20/$40 $250/day x 3 $400/day x 5 $10 $20 $25/$40 $40/$50 Yes Yes * f * * * * Oregon Kaiser Permanente-High Kaiser Permanente-Std PacifiCare of Oregon $10/$10 $15/$15 $20/$45 None None $400/day x 5 $10 $15 $20 $20 $30 $40/$50 Yes Yes Yes * * * * * * f f h f f h h h * * * * * See Brochure for details on patient’s payment responsibility. 45 Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average f f h * f * h h f h * Health Maintenance Organization (HMO) and Point of Service (POS) 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. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay 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 is the amount you pay when you are admitted into a hospital. Enrollment Code Plan Name – Location Pennsylvania Aetna Health Inc. - Philadelphia and Southeastern PA Aetna Health Inc. - Pittsburgh Area Aetna HealthFund (Consumer Driven Plan) - Philadelphia and Southeastern PA HealthAmerica Pennsylvania-High -Greater Pittsburgh area HealthAmerica Pennsylvania-Std - Greater Pittsburgh area HealthAmerica Pennsylvania-High -Northeastl Pennsylvania HealthAmerica Pennsylvania-Std - Northeast Pennsylvania HealthAmerica Pennsylvania-High -Central Pennsylvania HealthAmerica Pennsylvania-Std - Central Pennsylvania HealthAmerica Pennsylvania-High -Northwestern Pennsylvania HealthAmerica Pennsylvania-Std - Northwestern Pennsylvania Keystone Health Plan Central - Harrisburg/Northern Region/Lehigh Valley Keystone Health Plan East - Philadelphia area UPMC Health Plan - Western Pennsylvania area Telephone Number Self only Self & family Self Only Self & Family 800/537-9384 800/537-9384 888/238-6240 866/351-5946 866/351-5946 866/351-5946 866/351-5946 866/351-5946 866/351-5946 866/351-5946 866/351-5946 800/622-2843 800/227-3115 888/876-2756 P31 YE1 221 261 264 4N1 4N4 SW1 SW4 VJ1 VJ4 S41 ED1 8W1 P32 YE2 222 262 265 4N2 4N5 SW2 SW5 VJ2 VJ5 S42 ED2 8W2 79.44 62.00 64.72 85.66 73.96 115.48 80.74 111.60 79.58 74.76 68.44 105.62 80.36 78.06 212.68 170.96 148.86 283.40 200.26 334.34 246.86 304.16 216.84 208.50 174.54 282.16 293.54 242.24 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 Puerto Rico Humana Health Plans of Puerto Rico - Puerto Rico Triple-S - All of Puerto Rico 800/314-3121 787/749-4777 ZJ1 891 ZJ2 892 41.74 56.46 96.02 121.28 Rhode Island Blue Chip, Coord Hlth Partners - All of Rhode Island 401/459-5500 DA1 DA2 122.88 382.16 NCQA 1 46 Accredited Twice – Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 4 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 4 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name Pennsylvania Aetna Health Inc. Aetna Health Inc. Aetna HealthFund - In-Network - Out-of-Network $20/$25 $20/$25 15%*/15%* 40%*/40%* $10/$20 $20/$30 $10/$20 $20/$30 $10/$20 $20/$30 $10/$20 $20/$30 $15/$20 $10/$15 $10/$10 $250/day x 3 $250/day x 3 15%* 40%* None $200/day x 3 None $200/day x 3 None $200/day x 3 None $200/day x 3 None None None $10 $10 $10* $10* $10 $10 $10 $10 $10 $10 $10 $10 $10 $5 $5 $25/$40 $25/$40 $25*/$40* $25*/$40* $20/$40 $35/$60 $20/$40 $35/$60 $20/$40 $35/$60 $20/$40 $35/$60 $25/$40 $15/$25 $15/$35 Yes Yes Yes* Yes* Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes f * * * Customer service * HealthAmerica Pennsylvania-High HealthAmerica Pennsylvania-Std HealthAmerica Pennsylvania-High HealthAmerica Pennsylvania-Std HealthAmerica Pennsylvania-High HealthAmerica Pennsylvania-Std HealthAmerica Pennsylvania-High HealthAmerica Pennsylvania-Std Keystone Health Plan Central Keystone Health Plan East UPMC Health Plan f f h h h h h h * * f f h h h h h h * * h f * h * h h * * h * * * h * Puerto Rico Humana Health Plans of Puerto Rico Triple-S - In-Network - Out-of-Network - In-Network - Out-of-Network $5/$5 $8/$8 $7.50/$10 $7.50 + 10%/$10 + 10% None $50 None None $2.50 N/A $5 25% $5 N/A $8/$12 25% No No Yes No h h f h h * Rhode Island Blue Chip, Coord Hlth Partners - In-Network - Out-of-Network $15/$25 30%/30% $500 None $7 $40+20% $25/$40 $40+20% Yes No f h h h * * * See Brochure for details on patient’s payment responsibility. 47 Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average * f f f f h * * Health Maintenance Organization (HMO) and Point of Service (POS) 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. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay 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 is the amount you pay when you are admitted into a hospital. Enrollment Code Plan Name – Location South Dakota Avera Health Plans - Eastern and Central South Dakota Sioux Valley Health Plan-High -Eastern/Central/Rapid City Areas Sioux Valley Health Plan-Std - Eastern/Central/Rapid City Areas Telephone Number Self only Self & family Self Only Self & Family 888/322-2115 800/752-5863 800/752-5863 AV1 AU1 AU4 AV2 AU2 AU5 72.38 184.52 119.84 169.04 428.32 279.48 NCQA 2 NCQA 2 Tennessee Aetna Health Inc. - Nashville Area Aetna Health Inc. - Memphis Area Humana CoverageFirst (Consumer Driven Plan) - Memphis 800/537-9384 800/537-9384 888/393-6765 6J1 UB1 L61 6J2 UB2 L62 69.22 66.28 48.04 166.92 177.34 110.48 NCQA 1 NCQA 1 48 Accredited Twice – Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 4 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 4 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name South Dakota Avera Health Plans Sioux Valley Health Plan Sioux Valley Health Plan - In-Network - Out-of-Network - In-Network - Out-of-Network $10/$15 $20/$30 40%/40% $25/$25 40%/40% $100/dayx3 $100/day x 5 40% $100/day x 5 40% $10 $15 N/A $15 N/A $20 $30/$50 N/A $30/$50 N/A No No No No No f * h * * f f * h * Customer service * Tennessee Aetna Health Inc. Aetna Health Inc. Humana CoverageFirst - In-Network - Out-of-Network $20/$25 $20/$25 $20*/$35* 30%*/30%* $250/day x 3 $250/day x 3 $10 $10 $25/$40 $25/$40 Yes Yes No* No* * * * * * * * * h h f f $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%* $25/$50+30%* * See Brochure for details on patient’s payment responsibility. 49 Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average f Health Maintenance Organization (HMO) and Point of Service (POS) 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. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay 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 is the amount you pay when you are admitted into a hospital. Enrollment Code Plan Name – Location Texas Aetna Health Inc. - Austin/San Antonio Areas Aetna Health Inc. - Dallas/Ft Worth/Houston Areas FIRSTCARE - Waco area FIRSTCARE - West Texas HMO Blue Texas - Houston Humana CoverageFirst (Consumer Driven Plan) - Houston Humana CoverageFirst (Consumer Driven Plan) - Dallas/Ft. Worth Humana CoverageFirst (Consumer Driven Plan) - Corpus Christi Humana CoverageFirst (Consumer Driven Plan) - San Antonio Humana CoverageFirst (Consumer Driven Plan) - Austin Humana Health Plan of Texas-High -San Antonio area Humana Health Plan of Texas-Std - San Antonio area Mercy Health Plans/Premier Health Plans - Webb/Zapata/Duval/Jim Hogg Counties PacifiCare Southwest Region (TX) - San Antonio/Dallas/Ft.Worth Telephone Number Self only Self & family Self Only Self & Family 800/537-9384 800/537-9384 800/884-4901 800/884-4901 800/833-5318 888/393-6765 888/393-6765 888/393-6765 888/393-6765 888/393-6765 888/393-6765 888/393-6765 800/617-3433 800-531-3341 P11 PU1 6U1 CK1 YM1 T21 T81 TP1 TU1 TV1 UR1 UR4 HM1 GF1 P12 PU2 6U2 CK2 YM2 T22 T82 TP2 TU2 TV2 UR2 UR5 HM2 GF2 63.90 76.78 74.92 135.38 77.40 57.64 55.24 50.44 48.04 52.84 98.44 68.50 105.42 91.40 160.98 212.66 160.94 258.16 203.68 132.58 127.06 116.00 110.48 121.52 230.70 157.56 316.40 217.72 NCQA 1 NCQA 1 NCQA 2 NCQA 1 Utah Altius Health Plans - Wasatch Front 800/377-4161 9K1 9K2 119.94 243.86 Vermont MVP Health Care - All of Vermont 888/687-6277 VW1 VW2 89.42 303.78 NCQA 1 50 Accredited Twice – Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 4 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 4 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name Texas Aetna Health Inc. Aetna Health Inc. FIRSTCARE FIRSTCARE HMO Blue Texas Humana CoverageFirst Humana CoverageFirst Humana CoverageFirst Humana CoverageFirst Humana CoverageFirst - In-Network - Out-of-Network - In-Network - Out-of-Network - In-Network - Out-of-Network - In-Network - Out-of-Network - In-Network - Out-of-Network $20/$25 $20/$25 $15/$25 $15/$25 $20/$20 $20*/$35* 30%*/30%* $20*/$35* 30%*/30%* $20*/$35* 30%*/30%* $20*/$35* 30%*/30%* $20*/$35* 30%*/30%* $10/$20 $15/$25 $10/$10 40%/40% $20/$40 $250/day x 3 $250/day x 3 $100 $100 $100/dayx4 $10 $10 $10 $10 $10 $25/$40 $25/$40 $20/$40 $20/$40 $25/$40 Yes Yes Yes Yes Yes No* No* No* No* No* No* No* No* No* No* No No Yes No Yes * * h * * * * f f f f f * * h f h h h * * * h f * * f h h f h * f h h * * h f * h f $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%* $25/$50+30%* $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%* $25/$50+30%* $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%* $25/$50+30%* $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%* $25/$50+30%* $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%* $25/$50+30%* $100/day x 3 $250/day x 3 None None $400/day x 5 $5/$20 $10/$25 $7 N/A $20 $20/$40 $25/$45 $12/$25 N/A $40/$50 Humana Health Plan of Texas-High Humana Health Plan of Texas-Std Mercy Health Plans/Premier - In-Network - Out-of-Network PacifiCare Southwest Region (OK & TX) Utah Altius Health Plans $10/$15 None $10 $20/$40 Yes f * f f f f Vermont MVP Health Care $15/$15 $240 $5 $20/$40 Yes h h h h h * * See Brochure for details on patient’s payment responsibility. 51 Customer service Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average Health Maintenance Organization (HMO) and Point of Service (POS) 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. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay 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 is the amount you pay when you are admitted into a hospital. Enrollment Code Plan Name – Location Virginia Aetna Health Inc.-High -Northern/Central/Richmond, Virginia Area Aetna Health Inc.-Std - Northern/Central/Richmond, Virginia Area Aetna HealthFund (Consumer Driven Plan) - Northern/Central/Richmond VA Areas CareFirst BlueChoice - Northern Virginia Kaiser Permanente - Washington, DC area M.D. IPA - N.VA/Cntrl VA/Richmond/Tidewater/Roanoke Optima Health Plan - Peninsula/Southside Hampton Roads Piedmont Community Healthcare - Lynchburg area Telephone Number Self only Self & family Self Only Self & Family 800/537-9384 800/537-9384 888/238-6240 866/520-6099 301/468-6000 800/251-0956 800/206-1060 888/674-3368 JN1 JN4 221 2G1 E31 JP1 9R1 2C1 JN2 JN5 222 2G2 E32 JP2 9R2 2C2 80.48 52.88 64.72 120.48 72.98 73.40 90.70 81.50 181.26 123.74 148.86 263.08 173.72 176.18 234.98 188.42 NCQA 1 NCQA 1 NCQA 2 NCQA 2 NCQA 1 NCQA 1 Washington Aetna Health Inc. - Western/Southeast Washington Aetna HealthFund (Consumer Driven Plan) - Seattle/Western Washington Group Health Cooperative-High -Most of Western Washington Group Health Cooperative-Std - Most of Western Washington Group Health Cooperative-High -Central WA/Spokane/Pullman Group Health Cooperative-Std - Central WA/Spokane/Pullman Kaiser Permanente-High -Vancouver/Longview Kaiser Permanente-Std - Vancouver/Longview KPS Health Plans - High -All of Western Washington KPS Health Plans - Std - All of Western Washington PacifiCare of Oregon - Clark County 800/537-9384 888/238-6240 888/901-4636 888/901-4636 888/901-4636 888/901-4636 800/813-2000 800/813-2000 800/552-7114 800/552-7114 800-531-3341 8J1 221 541 544 VR1 VR4 571 574 VT1 L11 7Z1 8J2 222 542 545 VR2 VR5 572 575 VT2 L12 7Z2 59.46 64.72 96.24 70.96 79.62 69.00 98.44 74.84 114.94 72.00 91.50 151.20 148.86 211.18 160.18 222.26 158.68 228.96 171.74 227.50 157.32 198.02 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 52 Accredited Twice – Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 4 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 4 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name Virginia Aetna Health Inc.-High Aetna Health Inc.-Std Aetna HealthFund CareFirst BlueChoice Kaiser Permanente M.D. IPA Optima Health Plan - In-Network Piedmont Community Healthcare - Out-of-Network - In-Network - Out-of-Network $15/$20 $20/$25 15%*/15%* 40%*/40%* $20/$30 $10/$20 $10/$20 $10/$20 $25/$25 40%/30% $150/day x 3 $250/day x 3 15%* 40%* $100/day x 5 $100 $100 $250 None None $10 $10 $10* $10* $10 $10/$20Net $8 $10 $15 $15 $25/$40 $25/$40 $25*/$40* $25*/$40* $25/$40 $20/$40 $20/$35 $20/$40 $30 $30 No No Yes* Yes* Yes Yes No Yes Yes No f f * * f f * * Customer service * * f * * h f f * h f f * * * f * * f * h h Washington Aetna Health Inc. Aetna HealthFund Group Health Cooperative-High Group Health Cooperative-Std Group Health Cooperative-High Group Health Cooperative-Std Kaiser Permanente-High Kaiser Permanente-Std KPS Health Plans KPS Health Plans PacifiCare of Oregon - In-Network - Out-of-Network - In-Network - Out-of-Network - In-Network - Out-of-Network $20/$25 15%*/15%* 40%*/40%* $15/$15 $20+20%/$20+20% $15/$15 $20+20%/$20+20% $10/$10 $15/$15 $15/$25 $15+45%/$25+45% $15/x3 or 20%/20% $15/x3 or 45%/45% $20/$45 $250/day x 3 15%* 40%* $200/day x 3 $200/day x 3 $200/day x 3 $200/day x 3 None None None None $100/day x 5 $100/day x 5 $400/day x 5 $10 $10* $10* $15 $20 $15 $20 $10 $15 $5 N/A $10 N/A $20 $25/$40 $25*/$40* $25*/$40* $25/$50 $30/$60 $25/$50 $30/$60 $20 $30 $20/50% N/A $30/50% N/A $40/$50 Yes Yes* Yes* Yes Yes Yes Yes Yes Yes Yes No Yes No Yes * * * * * * h * * * * * * h h h h h f f h * * * * f f h * * * * h h h * * * * * * h f * * * f f * See Brochure for details on patient’s payment responsibility. 53 Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average * * f * h h Health Maintenance Organization (HMO) and Point of Service (POS) 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. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay 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 is the amount you pay when you are admitted into a hospital. Enrollment Code Plan Name – Location West Virginia The Health Plan of the Upper Ohio Valley - Northern/Central West Virginia Telephone Number Self only Self & family Self Only Self & Family 800/624-6961 U41 U42 77.22 177.60 NCQA 1 Wisconsin Dean Health Plan - South Central Wisconsin Group Health Cooperative - South Central Wisconsin HealthPartners Classic-High -West Central Wisconsin HealthPartners Open Access-Basic - West Central Wisconsin HealthPartners Primary Clinic Plan - West Central Wisconsin Humana CoverageFirst (Consumer Driven Plan) - Milwaukee 800/279-1301 608/251-3356 952-883-5000 952-883-5000 952-883-5000 888/393-6765 WD1 WJ1 531 534 HQ1 FB1 WD2 WJ2 532 535 HQ2 FB2 67.66 66.20 144.06 85.12 236.98 52.84 182.70 178.98 374.26 232.78 597.26 121.52 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 Wyoming WINhealth Partners - Wyoming 307/638-7700 PV1 PV2 99.72 370.58 54 Accredited Twice – Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 4 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 4 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name West Virginia The Health Plan of the Upper Ohio Valley $10/$20 $250 $15 $30/$50 Yes * h h h Customer service h Wisconsin Dean Health Plan Group Health Cooperative HealthPartners Classic-High HealthPartners Open Access-Basic HealthPartners Primary Clinic Plan Humana CoverageFirst - In-Network - Out-of-Network $10/$10 $20/$20 $15/$15 $15/$15 $20/$20 $20*/$35* 30%*/30%* None None $100 $100 $200 $10 $6 $12 $10 $12 30% $12 $12/$24 $10/$35 $12/$24 No No No No No No* No* h * f f f h * * * * h h * * * * * * * * * * * f f * h * * * $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%*$25/$50+30%* Wyoming WINhealth Partners $10/$10 None $10 $15/$40 Yes * See Brochure for details on patient’s payment responsibility. 55 Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average h This page intentionally left blank 56 RETURN ADDRESS NAME STREET Place postage stamp here STATE ZIP CODE CITY OWCP/DOL DFEC Central Mail Room P.O. Box 8300 London, Connecticut 40742 Request for Registration Form or Brochures U.S. Department of Labor Employment Standards Administration Office of Worker’s Compensation Programs Washington, D.C. 20210 Official Business Penalty for Private Use $300 Forwarding and Address Correction Requested Detach Request For Registration Form Or Brochures special has ❑ Thisnot use itpostcard otherbeen prepared to speed the return of health benefits open season information to you. Do for any purpose. want to make change open season and know what plan I have ❑ Ibrochure of thataplan andduringneed brochures. Please send me a or option I wish to enroll in.only. the don’t registration form (SF 2809) I am considering making a change during open season but would like more information. Please send me a registration form (SF 2809) and a brochure for each of the plans I have listed below. CODE CODE Name Print or type your full name , OWCP claim number, and mailing address here. Address the other side and add a stamp. Then drop card in mail box. List enrollment codes of the plans for the brochures you want. Codes for each FEHB plan appear in the plan comparison chart. CODE CODE CODE CODE IMPORTANT HMOs and Plans with a Point of Service product are open to compensationers in the plan’s area. Fee-for Service plans sponsored by employee organizations have specific membership requirements. Some are restricted and open only to compensationers who are already members of the sponsoring organization. Do not send this card to OPM. Keep a record of the date you mail this. OWCP claim number Street address City, state, and ZIP code Check here if we need to change your mailing (home) address in our records. Signature Date