FEHB Guide - OPM.gov

The 2014

FEHB Guide

Healthcare and Insurance RI 70-16Revised November 2013

For Tribal Employees

Visit us at wwwopmgovhealthcare-insuranceindian-tribeshealth-insurance

The information contained in this FEHB Guide for Tribal Employees

is only a summary of the benefits available under each plan

Before you select a plan or option please read the Planrsquos Federal

brochure as it is the official statement of benefits

All benefits are subject to the definitions limitations and

exclusions set forth in the Planrsquos Federal brochure

This page intentionally left blank

Table of Contents

Introduction to the Federal Employees Health Benefits (FEHB) Program and this Guide 2

Federal Employees Health Benefits (FEHB) Program 3

Temporary Continuation of Coverage (TCC) 5

FEHB Program Health Information Technology and PriceCost Transparency 8

Appendix A FEHB Program Features 9

Appendix B Choosing an FEHB Plan 10

Appendix C Qualifying Life Events 13

Appendix D Member Survey Results 14

Appendix E FEHB Plan Comparison Charts 15

bull Nationwide FeeshyforshyService Plans 16

bull Health Maintenance Organization Plans and Plans Offering a PointshyofshyService Product 21

bull High Deductible and ConsumershyDriven 60

Medicaid and the Childrenrsquos Health Insurance Program (CHIP) 84

Introduction to the Federal Employees Health Benefits (FEHB) Program and this Guide

The Indian Health Care Improvement Act (IHCIA) section 409 ldquoAccess to Federal Insurancerdquo under the Patient Protection and Affordable Care Act (ACA) extends entitlement to purchase coverage in the FEHB Program to the following groups (hereinafter tribal employer)

1) Indian tribes or tribal organizations carrying out programs under the Indian SelfshyDetermination and Education Assistance Act and

2) Urban Indian organizations carrying out programs under title V of the Indian Health Care Improvement Act

The purpose of this Guide is to provide you basic information about the benefits offered to you as the tribal employee of a tribal employer that has chosen to participate in the FEHB Program This Guide will assist you with the process of selecting and enrolling in a plan that meets your health care needs during any of the following events

bull Initial Enrollment Opportunity bull Annual Open Season bull Qualifying Life Events bull Becoming eligible for Temporary Continuation of Coverage

Things to consider

1) See pages 3 and 4 for general information on FEHB (including eligibility) and Appendix B for guidance on choosing a plan

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

3) Contact your tribal employer for information on how to enroll

How do I get more information about this Program

Visit the FEHB Program online at wwwopmgovhealthcareshyinsuranceindianshytribeshealthshyinsurance for information including

bull How to compare health plans and choose the one that meets your needs bull Health plan websites and plan brochures bull Getting quality healthcare bull Medicare and FEHB

Federal Employees Health Benefits (FEHB) Program

What does this Program offer

The FEHB Program offers a wide variety of plans and coverage to help you meet your health care needs It is group coverage available to eligible tribal employers that have chosen to participate in the FEHB Program for their eligible tribal employees It also covers eligible family members of those tribal employees If you leave tribal employment the FEHB Program offers Temporary Continuation of Coverage (TCC) as well as an opportunity to convert your enrollment to nonshygroup (private) coverage Please refer to the TCC section in this Guide for more details

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

Key FEHB Program facts

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

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

bull All nationwide FEHB plans offer international coverage

bull There are separate andor different provider networks for each plan Utilizing an inshynetwork provider may reduce your outshyofshypocket costs

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

bull The FEHB Open Season for Tribal Employees begins on the Monday of the second full work week in November and ends on the Monday of the second full week in December This yearrsquos Open Season is from Monday November 11 2013 through Monday December 9 2013

bull If your tribal employer participates in premium conversion FEHB enrollment changes can only be made during the annual Open Season or if you experience a Qualifying Life Event (QLE) Premium conversion allows tribal employees to use preshytax dollars to pay their FEHB premiums Check with your tribal employer to see if they participate in premium conversion

bull If your tribal employer does not participate in premium conversion or you choose not to participate in premium conversion you may change your FEHB enrollment from Self and Family to Self Only or cancel coverage at any time Other FEHB enrollment changes must be made during the annual Open Season or if you experience a QLE

What enrollment types are available

bull Self Only which covers only the enrolled tribal employee or

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

Am I eligible to enroll

You may be eligible if you are employed by a tribal employer that participates in the FEHB Program If your tribal employer has not provided you with information about FEHB enrollment you should contact them for information

Which family members are eligible

Family members covered under your Self and Family enrollment are

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

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

ndash Foster children are included if they meet certain requirements

ndash A child age 26 or over who is incapable of selfshysupport because of a mental or physical disability that

existed before age 26 is also an eligible family member

Contact your tribal employer for additional information In determining whether the child is a covered

family member your tribal employer will look at the childrsquos relationship to you as an FEHB enrollee

How much does it cost

The premiums for your FEHB enrollment are shared by you and your tribal employer Your tribal employer pays at a minimum the lesser of 72 of the average total premium of all plans weighted by the number of enrollees in each or 75 of the premium for the specific plan you choose If you are a tribal employee of a tribal employer that participates in premium conversion and you have chosen to participate you automatically pay your share of premium through a payroll deduction using preshytax dollars

The charts in Appendix E provide cost information for all plans in the FEHB Program

Please note that the provided rates are the maximum amount you will be required to pay for your premium Your tribal employer may choose to pay a higher portion of your premium Check with your tribal employer for exact rates You may have other outshyofshypocket costs in addition to your premium such as copays coinsurance and deductibles

When can I enroll or change my FEHB enrollment

If you are employed by a tribal employer that has recently elected to purchase health insurance through the FEHB Program you now have an opportunity to enroll in coverage Your tribal employer will provide you with the exact dates of your Initial Enrollment Opportunity and your effective date of coverage

If you chose not to enroll during the Initial Enrollment Opportunity you may also enroll 1) during the annual Open Season held from the Monday of the second full work week in November through the Monday of the second full work week in December (this yearrsquos Open Season is from November 11 through December 9 2013) or 2) if you have a qualifying life event (QLE)

If you participate in premium conversion you may enroll change your enrollment type change plans or cancel outside of Open Season only if you experience a QLE such as a change in family or other insurance coverage status Appendix C contains more specific information about QLEs that permit tribal employees to enroll or change enrollment in the FEHB Program However if you do not participate in premium conversion you may change your enrollment type from Self and Family to Self Only or cancel coverage at any time

How do I enroll or change my FEHB enrollment

You must enroll or change your FEHB enrollment by completing the Health Benefits Election Form (SF 2809) This form is available on our website at wwwopmgovformspdf_fillsf2809pdf You can find information and guidance on the SF 2809 at wwwopmgovhealthcareshyinsuranceindianshytribesreferenceshymaterialsenrollmentshyformshy2809shyemployeeshyguidancepdf Contact your tribal employer for details

Temporary Continuation of Coverage (TCC)

This section provides basic information about the Temporary Continuation of Coverage (TCC) provisions of the FEHB Program

What does TCC offer

TCC allows former tribal employees and formerly eligible family members to continue their FEHB Program coverage for a limited period TCC offers the same FEHB coverage and benefits that are available to tribal employees

Who is Eligible for TCC

Individuals eligible for TCC include

bull Former tribal employees whose FEHB coverage ended because they separated from tribal employment (including retirement) unless they were separated for gross misconduct

bull Children who lose coverage under a Self and Family FEHB enrollment of a current or former tribal employee because they are no longer considered eligible family members and

bull Former (divorced) spouses who lose coverage under a Self and Family FEHB enrollment of a current or former tribal employee

Family members covered under your Self and Family TCC enrollment include

bull Your spouse (including a valid common law marriage)

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

stepchildren Foster children are included if they meet certain requirements

bull Your child age 26 or over who is incapable of selfshysupport because of a mental or physical

disability that existed before age 26

Note In determining whether the child is a covered family member your tribal employer will look at the childrsquos relationship to you as an FEHB enrollee

What TCC enrollment types are available

bull Self Only which only covers the TCC enrollee or

bull Self and Family which covers the TCC enrollee and all eligible family members

Note A former (divorced) spousersquos eligible family members are limited to children of both the tribal employee and the former spouse

How much does it cost Under TCC you pay the total monthly premium (enrolleersquos share plus the tribal employerrsquos share) plus a 2 percent administrative charge The charts in Appendix E provide cost information for all plans in the FEHB Program

When can I enroll

Individuals eligible for TCC generally must enroll within 60 days after the qualifying event permitting enrollment or after receiving notice of eligibility from the tribal employer whichever is later The opportunity to elect TCC ends 60 days after the qualifying event if (1) you do not notify your tribal employer within 60 days of your childrsquos loss of coverage or (2) you or your former (divorced) spouse do not notify your tribal employer within 60 days of your divorce

How do I enroll

You must enroll by completing the Health Benefits Election Form (SF 2809) This form is available on our website at wwwopmgovformspdf_fillsf2809pdf You can find information and guidance on the SF 2809 at wwwopmgovhealthcareshyinsuranceindianshytribesreferenceshymaterialsenrollmentshyformshy2809shyemployeeshyguidancepdf

If you are a former tribal employee contact your tribal employer If you are a child contact the tribal employer of your parent who is the FEHB enrollee If you are a former (divorced) spouse contact the tribal employer of your former spouse

When can I change my TCC enrollment Former tribal employees children andor former (divorced) spouses with an existing TCC enrollment may change their enrollment during the annual Open Season or based upon a qualifying life event (QLE) A QLE is a term defined by OPM to describe events that may allow you to change your FEHB enrollment

A complete listing of QLEs can be found in Table 4 of the Tables of Permissible Changes of the SF 2809 at wwwopmgovformspdf_fillsf2809pdf

Be aware this information only applies to individuals with an existing TCC enrollment and that time limits apply for requesting changes

When does my TCC coverage end

If you are a former tribal employee TCC ends on the date that is 18 months after the date of your separation from tribal employment

If you are a child TCC ends on the date that is 36 months from the date you cease being an eligible family member for FEHB purposes

If you are a former (divorced) spouse TCC ends on the date that is 36 months from the date you cease being an eligible family member for FEHB purposes

Note As a TCC enrollee you may voluntarily cancel your TCC enrollment at any time However once your cancellation takes effect you cannot reenroll in the FEHB Program You will not be entitled to a 31shyday extension of coverage for conversion to a nonshygroup (private) policy Family members who lose coverage upon your cancellation may enroll only if they are eligible for FEHB in their own right as tribal employees

If your TCC enrollment terminates because you acquire other FEHB coverage and that coverage ends before your original TCC eligibility period ends you may reenroll for the time remaining until your original TCC ending date

How do I get more information about TCC

Visit FEHB online at wwwopmgovhealthcareshyinsuranceindianshytribeshealthshyinsurance for more information about Temporary Continuation of Coverage

FEHB Program Health Information Technology and PriceCost Transparency

Did You Knowhellip Health Information Technology can improve your health

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

What are examples of HIT at work

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

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

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

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

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

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

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

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

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

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

Appendix A FEHB Program Features

No waiting periods You can use your benefits as soon as your coverage becomes effective There are no preshyexisting condition limitations

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

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

Employing office contributions Your tribal employer pays at a minimum 72 percent of the average premium of all plans toward the total cost of your premium Please check with your tribal employer for exact rates

Salary deductions You pay your share of the premium through a payroll deduction If your tribal employer participates in premium conversion you may choose to pay your share of the FEHB premium with preshytax dollars

Enrollment opportunities Each year you can enroll or change your health plan enrollment during the annual Open Season Open Season runs from the Monday of the second full work week in November to the Monday of the second full work week in December This year Open Season will run from November 11 through December 9 2013 Also certain qualifying life events (QLEs) allow for certain types of changes throughout the year see your tribal employer for details

Continued group coverage The FEHB Program offers continued FEHB coverage bull For you or your family when you move transfer or go on leave without pay or enter military service (certain rules about coverage and premium amounts apply see your tribal employer)

Coverage after FEHB ends The FEHB Program offers temporary continuation of coverage (TCC) and conversion to nonshygroup (private) coverage bull For you and your family if you leave your job or retire bull For your covered child if he or she turns age 26 or bull For your former spouse when you divorce

Coverage for family members if you die Your surviving family members may be eligible to continue coverage as described below bull If you have a Self and Family FEHB enrollment with only a spouse your spouse is eligible for conversion to nonshygroup (private) coverage bull If you have a Self and Family FEHB enrollment with a child or children the child(ren) are eligible for Temporary Continuation of Coverage (TCC) and may cover your spouse Eligible family members may convert to nonshygroup (private) coverage when TCC expires at the end of 36 months

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

Appendix B Choosing an FEHB Plan

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

Types of Plans Choice of doctors hospitals pharmacies and other providers

Specialty care Outshyofshypocket costs Paperwork

FeeshyforshyService wPPO (Preferred Provider Organization)

You must use the planrsquos network to reduce your outshyofshypocket costs For BCBS Basic Option you must use Preferred providers for your care to be eligible for benefits

Referral not required to get benefits

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

Some if you donrsquot use network providers

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

to reduce your outshyofshypocket costs

required from primary care doctor to get benefits

costs are generally limited to copayments

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

Referral generally required to get maximum benefits

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

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

ConsumershyDriven You may use network Referral not required You will pay an Some if you donrsquot use Health Plans and nonshynetwork

providers You will pay more by not using the network

to get maximum benefits from PPOs

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

network providers You file a claim to obtain reimbursement from your HRA

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

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

Referral not required to get maximum benefits from PPOs

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

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

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

Ask yourself these questions

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

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

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

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

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

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

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

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

Definitions

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

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

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

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

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

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

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

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

Premium Conversion shy Premium conversion allows tribal employees who are eligible for FEHB the opportunity to pay their share of FEHB premiums with preshytax dollars In order for tribal employees to participate in premium conversion their tribal employer must have a premium conversion plan Premium conversion plans are governed by the Internal Revenue Code and IRS rules govern when participants may change their enrollment or cancel outside of the annual Open Season

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

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

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

Appendix C Qualifying Life Events

Note This information does not apply to individuals who have a Temporary Continuation of Coverage (TCC) FEHB enrollment Please see the TCC section of this Guide if you are a current TCC enrollee

Qualifying Life Events

A qualifying life event (QLE) is a term defined by OPM to describe events that may allow a tribal employee to enroll in the FEHB Program make changes to hisher FEHB enrollment or make changes to hisher premium conversion participation if applicable

Outside of Open Season you can make changes to your FEHB enrollment if you experience certain QLEs The most common QLEs for changing FEHB enrollment type or plan are marriage acquiring a child moving away from the service area of your Health Maintenance Organization (HMO) losing health insurance coverage or changing employment status Your eligibility to make certain changes to your FEHB enrollment will depend upon whether or not you participate in premium conversion

Tribal Employees who Participate in Premium Conversion

Premium conversion allows tribal employees who are eligible for FEHB the opportunity to pay their share of FEHB premiums with preshytax dollars Your tribal employer may choose whether or not to have a premium conversion plan If your tribal employer has a premium conversion plan you may choose to participate or not participate If your tribal employer does not have a premium conversion plan you may not participate

Premium conversion plans are governed by the Internal Revenue Code and IRS rules govern when you may change your FEHB enrollment or premium conversion status outside of the annual Open Season If you experience a QLE you may change your FEHB enrollment (including a change to Self Only or cancellation) provided the action is consistent with the QLE

If you participate in premium conversion please refer to QLE Table 1 of the Standard Form (SF) 2809 at wwwopmgovformspdf_fillsf2809pdf for detailed information If you need assistance in accessing the SF 2809 or have additional questions please contact your tribal employer

Tribal Employees who do not Participate in Premium Conversion

If your tribal employer does not have a premium conversion plan or if they have a plan and you choose not to participate you are not subject to IRS rules for when you can make certain changes to your FEHB enrollment However you are subject to OPM rules for employees who do not participate in premium conversion

An important difference is that a tribal employee who does not participate in premium conversion may cancel hisher FEHB enrollment or change from a Self and Family to a Self Only enrollment at any time

If you do not participate in premium conversion please refer to QLE Table 5 of the SF 2809 at wwwopmgovformspdf_fillsf2809pdf for detailed information If you need assistance in accessing the SF 2809 or have additional questions please contact your tribal employer

Appendix D FEHB Member Survey Results

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

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

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

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

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

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

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

bull Customer Service ndash How often did your health planrsquos customer service department give you the information or help you needed How often did your health planrsquos customer service staff treat you with courtesy and respect How often were the forms from your health plan easy to fill out

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

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

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

Appendix E FEHB Plan Comparison Charts

Nationwide FeeshyforshyService Plans (Pages 16 through 19)

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

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

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

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

The Health Maintenance Organization (HMO) and PointshyofshyService (POS) section begins on page 21

The High Deductible Health Plan (HDHP) and ConsumershyDriven Health Plan (CDHP) section begins on page 60

Please note that the premium rates provided are the maximum amount you will be expected to pay for your premium Your tribal employer may choose to pay a higher portion of your premium Please check with your tribal employer for exact rates

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

Nationwide FeeshyforshyService Plans

How to read this chart

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

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

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

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

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

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

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

Your Maximum Monthly Premium is the maximum amount you will pay for your premium Your tribal employer may choose to pay a higher portion of your premium Check with your tribal employer for exact rates

Temporary Continuation of Coverage (TCC) allows former tribal employees and formerly eligible family members to continue their FEHB coverage for a limited period Under TCC you pay the total monthly premium (enrolleersquos share plus the tribal employerrsquos share) plus a 2 administrative charge which equals 102 of Total Monthly Premium

Plan Name Open to All Telephone Number

Enrollment Code

Your Maximum Monthly Premium

TCC 102 of your

Total Monthly Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

APWU Health Plan (APWU) shyhigh

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

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

GEHA Benefit Plan (GEHA) shyhigh

GEHA Benefit Plan (GEHA) shystd

MHBP shystd

MHBP shyValue Plan

NALC shyhigh

NALC Value Option

SAMBA shyhigh

SAMBA shystd

800shy222shy2798

Local phone

800shy821shy6136

800shy410shy7778

888shy636shy6252

800shy638shy6589

126114

142015

126195

145991

148291

109939

130096

168477

122733

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

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

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

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

MedicalshySurgical ndash You Pay

Copay ($)Coinsurance ()

APWU shyhigh

BCBS shystd

BCBS shybasic

GEHA shyhigh

GEHA shystd

MHBP shystd

MHBP shyvalue

NALC shyhigh

NALC shyValue

SAMBA shyhigh

SAMBA shystd

Benefit Type

Per Person

Calendar Year

Prescription Drug

Hospital Inpatient

Office Visits

Inpatient Surgical Services

Hospital Inpatient

RampB Level I

Prescription Drugs

Level II Level III

PPO $275 None None $18 10 10 $8 2525 Yes NonshyPPO $500 None $300 30+diff 30+diff 30 50 5050 Yes

PPO $350 None $250 $20 15 Nothing 2015 Medicare B T2 30$80 T3 45$105 Yes NonshyPPO $350 None $350 + 35+ 35+ 35+ Nothing 45+ T1shyT5 T4 30$35$95 T5 30$55$155 Yes

PPO None None $175day $875 Max $25 $200 Nothing $1030day $3090day T2 $45 T3 50($55Min) T4 $50to$140 T5 $70to$195

PPO $350 None $100 $20 10 Nothing $10 25 Max $150NA Yes NonshyPPO $350 None $300 25 25 Nothing $10 25 Max $150 +NA Yes

PPO $350 None None $10 15 15 $10 50 Max $200NA Yes NonshyPPO $350 None None 35 35 35 $10 50 Max $200 +NA Yes

PPO $400 None $200 $20 10 Nothing $5 30($200 max)50($200 max) Yes NonshyPPO $600 None $500 30 30 30 50 5050 Yes

PPO $600 None None $30 20 20 $10 4575 Yes NonshyPPO $900 Not Covered None 40 40 40 Not Covered Not Covered Yes

PPO $300 None $200 $20 15 Nothing 20 3045 Yes NonshyPPO $300 None $350 30 30 30 45+ 45+45+ Yes

NonshyPPO $4000 None 50 50 50 50 50 5050+ No PPO $2000 None 20 20 20 20 $10 $40$60 No

PPO $300 None $200 $20 10 Nothing $8 20($55 max)35($100 max) Yes NonshyPPO $300 None $300 30 30 30 $8 20($55 max)35($100 max) Yes

PPO $350 None $150 up to $450 $20 15 Nothing $8 30($70 max)40($110 max) Yes NonshyPPO $350 None $200 up to $600 35 35 35 $8 30($70 max)40($110 max) Yes

Deductible

Mail Order Discounts

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

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

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

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

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

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

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

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

APWU Health Plan shyhigh

Blue Cross and Blue Shield Service Benefit Plan shystd

Blue Cross and Blue Shield Service Benefit Plan shybasic

GEHA Benefit Plan shyhigh

GEHA Benefit Plan shystd

MHBP shystd

MHBP shyValue Plan

NALC shyhigh

NALC shyValue Option

SAMBA shyhigh

SAMBA shystd

Plan Name Open to All

FFS National A

Member Survey Results

Plan Code

verage 805

Overall plan satisfaction

Getting needed care

Getting care quickly

How well doctors

communicate

Customer service

Claims processing

Plan Information on Costs

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

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

Plan Name Location

Plan Code

Getting needed care

How well doctors

communicate Customer service

Claims processing

Plan Inforshymation on Costs

FFS National Average 805 927 917 951 911 934 716

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

Arizona 10 11

851 747

905 898

919 884

933 923

938 914

969 928

724 680

California 10 11

809 705

915 873

897 840

954 943

881 910

937 912

677 616

District of Columbia 10 11

768 691

935 893

930 874

951 940

882 881

898 922

657 622

Florida 10 11

864 806

942 916

922 894

952 947

934 916

954 937

733 660

Illinois 10 11

861 796

933 912

934 881

955 950

901 936

972 938

712 653

Maryland 10 11

857 770

931 897

917 898

954 940

897 921

956 967

713 666

Texas 10 11

887 825

934 898

931 883

950 955

936 910

957 967

721 617

Virginia 10 11

871 782

924 901

929 894

966 962

914 917

959 960

708 681

Health Maintenance Organization Plans and Plans Offering a PointshyofshyService Product

(Pages 22 through 59)

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

HMOs charge a copayment for primary physician and specialist visits and sometimes a copayment for inshyhospital care bull Most HMOs ask you to choose a doctor or medical group as your primary care physician (PCP) Your PCP provides your

general medical care In many HMOs you must get authorization or a ldquoreferralrdquo from your PCP to see other providers The referral is a recommendation by your physician for you to be evaluated andor treated by a different physician or medical professional The referral ensures that you see the right provider for the care appropriate to your condition

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

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

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

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

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

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

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

Member Survey Results ndash See Appendix D for a description

Temporary Continuation of Coverage (TCC) ndash Allows former tribal employees and formerly eligible family members to continue their FEHB coverage for a limited period Under TCC you pay the total monthly premium (enrolleersquos share plus the tribal employerrsquos share) plus a 2 administrative charge which equals 102 of Your Total Monthly Premium

Your maximum monthly premium is the maximum amount you will be expected to pay for your premium Your tribal employer may choose to pay a higher portion of your premium Please check with your tribal employer for exact rates

Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 21 for an explanation of the columns on these pages

Plan Name ndash Location Telephone

Number

Enrollment Code

TCC 102 of your Total Monthly

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Alabama

Aetna Value Planshy Most of Alabama 877shy459shy6604

Alaska

Aetna Value Planshy Most of Alaska 877shy459shy6604

Arizona

Aetna Value Planshy All of Arizona 877shy459shy6604

Aetna Open Access shyHighshy Phoenix and Tucson Areas 877shy459shy6604

Health Net of Arizona Inc shyHighshy MaricopaPimaOther AZ counties 800shy289shy2818

Health Net of Arizona Inc shyStdshy MaricopaPimaOther AZ counties 800shy289shy2818

Humana Health Plan Inc shyHighshy Phoenix 888shy393shy6765

Humana Health Plan Inc shyStdshy Phoenix 888shy393shy6765

Humana Health Plan Inc shyHighshy Tucson 888shy393shy6765

Humana Health Plan Inc shyStdshy Tucson 888shy393shy6765

Arkansas

Aetna Value Planshy Most of Arkansas 877shy459shy6604

QualChoice shyHighshy All of Arkansas 800shy235shy7017

QualChoice shyStdshy All of Arkansas 800shy235shy7017

F54 F55

JS4 JS5

G54 G55

WQ1 WQ2

A71 A72

A74 A75

BF1 BF2

BF4 BF5

C71 C72

C74 C75

F54 F55

DH1 DH2

DH4 DH5

13058 29656

17258 41140

12822 29119

33482 89188

26548 80303

19509 62476

13880 30882

12491 27794

15825 35210

13149 29256

13058 29656

30353 76056

14296 38452

53279 120995

61069 138677

52315 118808

77618 187686

70545 178623

63365 160440

56629 125999

50965 113400

59608 132629

53648 119367

53279 120995

74426 174291

58048 135935

Plan Name ndash Location

Primary care

Specialist office copay

Hospital per stay

deductible

Prescription Drugs

Level I Level II Level III

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Alabama

Aetna Value Plan InshyNetwork $25$40 20 $10

HMOPOS Nationa

30to$60050 to$1200 Yes

l Average 679 864 849 942 877 875 649

Aetna Value Plan OutshyNetwork

Alaska

Aetna Value Plan InshyNetwork

$25$40

50+50+

30to$60050 to$1200

Yes Aetna Value Plan OutshyNetwork

Arizona

$25$40

50+50+

30to$60050 to$1200

Aetna Open AccessshyHigh

Health Net of Arizona IncshyHigh

Health Net of Arizona IncshyStandard

Humana Health Plan IncshyHigh

Humana Health Plan IncshyStandard

Arkansas

$20$35

$20$40

$25$50

$20$35

$25$40

$20$35

$25$40

$250day x 4

$250dayx5

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+50+

$35$100

$40$60

30to$60050 to$1200

QualChoice InshyNetwork

QualChoice OutshyNetwork

$20$30

$20$40

$100max$500

$200max$1000

50+50+

$40$60

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

California

Aetna Value Planshy Most of California 877shy459shy6604

Aetna HMO shy Los Angeles and San Diego Areas 877shy459shy6604

Anthem Blue Cross Select HMO shyHighshy Southern California 800shy235shy8631

Blue Shield of CA Access+HMO shyHighshy Southern Region 800shy880shy8086

Health Net of California shyHighshy Northern Region 800shy522shy0088

Health Net of California shyStdshy Northern Region 800shy522shy0088

Health Net of California shyHighshy Southern Region 800shy522shy0088

Health Net of California shyStdshy Southern Region 800shy522shy0088

Kaiser Foundation Health Plan shy Basic Option shy Northern California 800shy464shy4000

Kaiser Foundation Health Plan of California shyHighshy Northern California 800shy464shy4000

Kaiser Foundation Health Plan of California shyStdshy Northern California 800shy464shy4000

Kaiser Foundation Health Plan of California shyHighshy Southern California 800shy464shy4000

Kaiser Foundation Health Plan of California shyStdshy Southern California 800shy464shy4000

UnitedHealthcare of California shyHighshy Central and Southern California 866shy546shy0510

UnitedHealthcare of California shyStdshy Central and Southern California 866shy546shy0510

Colorado

Aetna Value Planshy All of Colorado 877shy459shy6604

Kaiser Foundation Health Plan of Colorado shyHighshy DenverBoulderSouthern Colorado areas 800shy632shy9700

Kaiser Foundation Health Plan of Colorado shyStdshy DenverBoulderSouthern Colorado areas 800shy632shy9700

Connecticut

Aetna Value Planshy All of Connecticut 877shy459shy6604

Delaware

Aetna Value Planshy All of Delaware 877shy459shy6604

Aetna Open Access shyHighshy KentNew CastleSussex areas 877shy459shy6604

Aetna Open Access shyBasicshy KentNew CastleSussex areas 877shy459shy6604

JS4 JS5

2X1 2X2

B31 B32

SI1 SI2

LB1 LB2

LB4 LB5

LP1 LP2

LP4 LP5

KC1 KC2

591 592

594 595

621 622

624 625

CY1 CY2

CY4 CY5

G54 G55

651 652

654 655

EP4 EP5

P31 P32

P34 P35

17258 41140

15940 41769

18194 43825

18445 42566

77474 182834

71405 168807

30687 74663

27027 66198

18293 47705

35345 91275

22772 58183

14073 35293

9019 20845

22819 54699

13109 30036

12822 29119

23933 55581

9887 22345

12694 28827

64801 164359

49560 118027

61069 138677

59725 139319

62024 141416

62280 140132

122490 283205

116299 268898

74767 172871

71034 164236

62125 145373

79518 189815

66694 156061

57420 132713

36797 85048

66742 152507

53485 122549

52315 118808

67878 153407

40339 91170

51792 117616

109563 264361

94017 217102

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

California

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

Anthem Blue Cross Select HMOshyHigh

Blue Shield of CA Access+HMOshyHigh

Health Net of CaliforniashyHigh

Health Net of CaliforniashyStandard

Kaiser Foundation HP shy Basic Option

Kaiser Foundation HP of CaliforniashyHigh

Kaiser Foundation HP of CaliforniashyStandard

UnitedHealthcare of CaliforniashyHigh

UnitedHealthcare of CaliforniashyStandard

Colorado

$20$35

$25$35

$20$30

$30$50

$20$30

$30$50

$25$35

$15$25

$30$40

$15$25

$30$40

$20$35

$25$40

$250day x 4

$250max4days

$200 x 3 days

$150dayx5

$150day x 4

$5$40$60

50+50+

$35$100

$5$40$70$60

$35$60

$35$65

$35$60

$35$65

$35$35

$30$30

$35$35

$30$30

$35$35

$35$60

$25$50

30to$60050 to$1200

Kaiser Foundation HP of ColoradoshyHigh

Kaiser Foundation HP of ColoradoshyStandard

Connecticut

$20$40

$25$40

$250x3

50+50+

$35$60

$40$80

30to$60050 to$1200

Delaware

$25$40

50+50+

30to$60050 to$1200

Aetna Open AccessshyBasic

$20$35

$15$35

$250day x 4

20 Plan Allow

50+50+

$35$100

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

District of Columbia

Aetna Value Plan shy All of Washington DC

Aetna Open Access shyHighshy Washington DC Area

Aetna Open Access shyBasicshy Washington DC Area

CareFirst BlueChoice shyHighshy Washington DC Metro Area

CareFirst BlueChoice shyStdshy Washington DC Metro Area

Kaiser Foundation Health Plan MidshyAtlantic States shyHighshy Washington DC area

Kaiser Foundation Health Plan MidshyAtlantic States shyStdshy Washington DC area

MD IPA shyHighshy Washington DC area

Florida

Aetna Value Plan shy Most of Florida

AvMed Health Plans shyHighshy Broward Dade and Palm Beach

AvMed Health Plans shyStdshy Broward Dade and Palm Beach

Capital Health Plan shyHighshy Tallahassee area

Coventry Health Plan of Florida shyHighshy Southern Florida

Coventry Health Plan of Florida shyStdshy Southern Florida

Humana Value Plan shy Tampa Area

Humana Value Plan shy South Florida Area

Humana Medical Plan Inc shyHighshy Orlando

Humana Medical Plan Inc shyStdshy Orlando

Humana Medical Plan Inc shyHighshy South Florida

Humana Medical Plan Inc shyStdshy South Florida

Humana Medical Plan Inc shyHighshy Daytona

Humana Medical Plan Inc shyStdshy Daytona

Humana Medical Plan Inc shyHighshy Tampa

Humana Medical Plan Inc shyStdshy Tampa

877shy459shy6604

888shy789shy9065

877shy574shy3337

877shy835shy9861

877shy459shy6604

800shy882shy8633

850shy383shy3311

800shy441shy5501

888shy393shy6765

F54 F55

JN1 JN2

JN4 JN5

2G1 2G2

2G4 2G5

E31 E32

E34 E35

JP1 JP2

F54 F55

ML1 ML2

ML4 ML5

EA1 EA2

5E1 5E2

5E4 5E5

MJ4 MJ5

QP4 QP5

E21 E22

E24 E25

EE1 EE2

EE4 EE5

EX1 EX2

EX4 EX5

LL1 LL2

LL4 LL5

13058 29656

46867 105610

14021 31351

21177 48693

15284 35429

16926 42124

9646 22186

20245 50123

13058 29656

20336 56279

12604 30253

11679 30949

16664 47450

12501 30003

10247 22697

13149 29256

11834 26331

23153 51514

15825 35210

13880 30882

12491 27794

48720 108398

15825 35208

53279 120995

91271 204437

57208 127913

65067 146381

59056 132852

60731 139681

39358 90520

64116 147840

53279 120995

64209 154119

51424 123431

47650 126273

60464 145113

51005 122414

41809 92606

53648 119367

48282 107430

67082 149259

59608 132629

56629 125999

50965 113400

93161 207280

59608 132627

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

HMOPOS Nationa

30to$60050 to$1200 Yes

l Average 679 864 849 942 877 875 649

CareFirst BlueChoiceshyHigh

CareFirst BlueChoice InshyNetwork

$15$30

$20$35

$25$35

Nothing$35

$150day x3

10 Plan Allow

Nothing

50+50+

$35$100

$35$65

54 CareFirst BlueChoice OutshyNetwork

Kaiser Foundation HP MidshyAtlantic StatesshyHigh

Kaiser Foundation HP MidshyAtlantic StatesshyStandard

MD IPAshyHigh

Florida

$70$70

$10$20

$20$30

$25$40

$250dayx3

$150day x 3

Nothing

$7$17 Net

$12$22Net

$35$65

$30$50$45$65

$35$55$50$70

$30$60

30to$60050 to$1200

AvMed Health PlansshyHigh

AvMed Health PlansshyStandard

Capital Health PlanshyHigh

Coventry Health Plan of FloridashyHigh

Coventry Health Plan of FloridashyStandard

Humana Value Plan InshyNetwork

$15$40

$25$45

Nothing$15

$15$30

$20$50

$35$55

$250dayx3

$300dayx3

Ded + $150x3

Ded + $150x5

$15 Tier 1

50+50+

$30$5030

$40$6030

$40$6020

$50$7020

$40$60

$30 Tier 2 $50 Tier 3

Humana Value Plan OutshyNetwork

$35$55

$40+$60+

$40$60

Yes Humana Value Plan OutshyNetwork

Humana Medical Plan IncshyHigh

Humana Medical Plan IncshyStandard

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$40+$60+

$40$60

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Georgia

Aetna Value Planshy All of Georgia

Aetna Open Access shyHighshy Atlanta and Athens Areas

Humana Value Plan shy Atlanta Area

Humana Value Plan shy Macon Area

Humana Employers Health of Georgia Inc shyHighshy Columbus

Humana Employers Health of Georgia Inc shyStdshy Columbus

Humana Employers Health of Georgia Inc shyHighshy Atlanta

Humana Employers Health of Georgia Inc shyStdshy Atlanta

Humana Employers Health of Georgia Inc shyHighshy Macon

Humana Employers Health of Georgia Inc shyStdshy Macon

Kaiser Foundation Health Plan of Georgia shyHighshy Atlanta AthensColumbusMaconSavannah

Kaiser Foundation Health Plan of Georgia shyStdshy Atlanta AthensColumbusMaconSavannah

Calvos Selectcare shyHighshy Guam Northern Mariana Islands Palau

TakeCare shyHighshy GuamNMarianaIslandsBelau(Palau)

TakeCare shyStdshy GuamNMarianaIslandsBelau(Palau)

Hawaii Aetna Value Planshy All of Hawaii

HMSA shyHighshy All of Hawaii

Kaiser Foundation Health Plan of Hawaii shyHighshy HawaiiKauaiLanaiMauiMolokaiOahu

Kaiser Foundation Health Plan of Hawaii shyStdshy HawaiiKauaiLanaiMauiMolokaiOahu

877shy459shy6604

888shy393shy6765

888shy865shy5813

671 479shy7982

671shy647shy3526

877shy459shy6604

800shy776shy4672

808shy432shy5955

F54 F55

2U1 2U2

AD4 AD5

LM4 LM5

CB1 CB2

CB4 CB5

DG1 DG2

DG4 DG5

DN1 DN2

DN4 DN5

F81 F82

F84 F85

B41 B42

JK1 JK2

JK4 JK5

JS4 JS5

871 872

631 632

634 635

13058 29656

44133 104232

10247 22697

15825 35210

13880 30882

15825 35210

13149 29256

15825 35210

13880 30882

15015 36863

10047 22957

11949 31399

12447 36018

10209 26960

17258 41140

11377 25325

14515 32578

7553 16846

53279 120995

88482 203031

41809 92606

59608 132629

56629 125999

59608 132629

53648 119367

59608 132629

56629 125999

58782 134315

40991 93667

48751 128109

50786 133453

41654 109996

61069 138677

46419 103326

58272 129944

30818 68731

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Georgia

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

Humana CoverageFirst InshyNetwork

$20$35

$35$55

$250day x 4

50+50+

$35$100

$40$60

59 90 878 941 86 857 62

Humana CoverageFirst OutshyNetwork

$35$55

$40+$60+

$40$60

Yes Humana CoverageFirst OutshyNetwork

Humana Employers Health of Georgia shyHigh

Humana Employers Health of Georgia shyStandard

Kaiser Foundation HP of GeorgiashyHigh

Kaiser Foundation HP of GeorgiashyStandard

Calvos Selectcare InshyNetwork

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$30

$20$35

$15$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250dayx3

$10$20 Comm

$15$25 Comm

$40+$60+

$40$60

$2550 of AWP

$40$50 Comm $40$50 Comm

Calvos Selectcare OutshyNetwork

TakeCareshyHigh

TakeCareshyStandard

Hawaii Aetna Value Plan InshyNetwork

$5 at FHP$40

$25$40

$100day for 5

$150day for 5

$25$50

$40$80

30to$60050 to$1200

HMSA InshyNetwork

$15$15

50+50+

$30$65

Yes 842 914 884 955 878 931 628 HMSA OutshyNetwork

Kaiser Foundation HP of HawaiishyHigh

Kaiser Foundation HP of HawaiishyStandard

$20$20

$30$30

$7 + 20

$45$45

$50$50

$30 + 20 $65 + 20 No

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Aetna Value Planshy Most of Idaho 877shy459shy6604

Altius Health Plans shyHighshy Southern Region 800shy377shy4161

Altius Health Plans shyStdshy Southern Region 800shy377shy4161

Group Health Cooperative shyHighshy most of Washington StateampNorthern Idaho 888shy901shy4636

Group Health Cooperative shyStdshy most of Washington StateampNorthern Idaho 888shy901shy4636

SelectHealth shyHighshy Utah Idaho 801shy442shy7497

SelectHealth shyStdshy Utah Idaho 801shy442shy7497

Illinois

Aetna Value Planshy Most of Illinois 877shy459shy6604

Blue Cross and Blue Shield of Illinois shyHighshy Illinois 855shy676shy4482

Blue Preferred Plus POS shyHighshy Madison and St Clair counties 888shy811shy2092

Health Alliance HMO shyHighshy CentralECentralNCentSouthWest Ill 800shy851shy3379

Health Alliance HMO shyStdshy CentralECentralNCentSouthWest Ill 800shy851shy3379

Humana Benefit Plan of Illinois Inc shyHighshy Central and Northwestern Illinois 888shy393shy6765

Humana Benefit Plan of Illinois Inc shyStdshy Central and Northwestern Illinois 888shy393shy6765

Humana Value Plan shy Central Illinois 888shy393shy6765

Humana Value Plan shy Chicago Area 888shy393shy6765

Humana Health Plan Inc shyHighshy Chicago 888shy393shy6765

Humana Health Plan Inc shyStdshy Chicago 888shy393shy6765

Union Health Service shyHighshy Chicago area 312shy423shy4200

United Healthcare of the Midwest Inc shyHighshy Southwest Illinois 877shy835shy9861

UnitedHealthcare Plan of the River Valley Inc shyHighshy West Central Illinois 800shy747shy1446

H44 H45

9K1 9K2

DK4 DK5

541 542

544 545

SF1 SF2

SF4 SF5

H44 H45

A21 A22

9G1 9G2

FX1 FX2

K84 K85

9F1 9F2

AB4 AB5

GB4 GB5

MW4 MW5

751 752

754 755

761 762

B91 B92

YH1 YH2

13093 29732

19819 42542

11798 25954

27070 55009

11742 26509

19210 43095

12435 27741

13093 29732

30483 71121

32158 67069

26932 67294

20323 51891

51805 115264

15825 35210

10247 22697

40638 90413

15825 35210

14109 33787

33072 74273

14091 38330

53418 121307

63682 140107

48136 105894

71078 152824

47908 108156

63060 140671

50737 113183

53418 121307

74559 169258

76267 165125

70937 165354

64196 149643

96307 214284

59608 132629

41809 92606

84917 188936

59608 132629

57566 131177

77200 172473

57491 135811

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

Altius Health PlansshyHigh

Altius Health PlansshyStandard

Group Health CooperativeshyHigh

Group Health CooperativeshyStandard

SelectHealthshyHigh

SelectHealthshyStandard

Illinois

$20$30

$20$40

$25$25

$25$35

$15$25

$20$30

$25$40

$100 after

$5 $25$50

50+50+

$25$50

$35$60

$40$60

$25$50$50

$25$50

30to$60050 to$1200

Blue Cross and Blue Shield of IllinoisshyHigh

Blue Preferred Plus POS InshyNetwork

$20$35

$25$35

$200day x 5

$10 copay

50+50+

$40$60

$40$6025 $6025

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

Health Alliance HMOshyHigh

Health Alliance HMOshyStandard

Humana Benefit Plan of Illinois IncshyHigh

Humana Benefit Plan of Illinois IncshyStandard

30 after ded

$25$50

$20$35

$25$40

$35$55

30 after ded

$200day x 5

$250day x 3

$500day x 3

$35$70

$40$60

745 915 88 962 878 868 67

$35$55

$40+$60+

$40$60

Union Health ServiceshyHigh

United Healthcare of the Midwest IncshyHigh

UnitedHealthcare Plan of the River Valley shyHigh

$20$35

$25$40

$15$15

$25$40

$25$50

$250day x 3

$500day x 3

$40+$60+

$40$60

$35$60

$30$60

$35$50

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Indiana

Aetna Value Planshy All of Indiana 877shy459shy6604

Health Alliance HMO shyHighshy Western Indiana 800shy851shy3379

Health Alliance HMO shyStdshy Western Indiana 800shy851shy3379

Humana Value Plan shy LakePorterLaPorte Counties 888shy393shy6765

Humana Health Plan of Ohio shyHighshy Portions of Indiana 888shy393shy6765

Humana Health Plan of Ohio shyStdshy Portions of Indiana 888shy393shy6765

Humana Health Plan Inc shyHighshy LakePorterLaPorte Counties 888shy393shy6765

Humana Health Plan Inc shyStdshy LakePorterLaPorte Counties 888shy393shy6765

Humana Health Plan Inc shyHighshy Southern Indiana 888shy393shy6765

Humana Health Plan Inc shyStdshy Southern Indiana 888shy393shy6765

Physicians Health Plan of Northern Indiana shyHighshy Northeast Indiana 260shy432shy6690

Aetna Value Planshy All of Iowa 877shy459shy6604

Coventry Health Care of Iowa shyHighshy CentralEasternWestern Iowa 800shy257shy4692

Coventry Health Care of Iowa shyStdshy CentralEasternWestern Iowa 800shy257shy4692

Health Alliance HMO shyHighshy Central and Eastern Iowa 800shy851shy3379

Health Alliance HMO shyStdshy Central and Eastern Iowa 800shy851shy3379

HealthPartners High Option shyNorthern Iowa 800shy883shy2177

HealthPartners Standard Option shyNorthern Iowa 800shy883shy2177

Sanford Health Plan shyHighshy Northwestern Iowa 800shy752shy5863

Sanford Health Plan shyStdshy Northwestern Iowa 800shy752shy5863

UnitedHealthcare Plan of the River Valley Inc shyHighshy Eastern and Central Iowa 800shy747shy1446

JS4 JS5

FX1 FX2

K84 K85

MW4 MW5

A61 A62

A64 A65

751 752

754 755

MH1 MH2

MH4 MH5

DQ1 DQ2

H44 H45

SV1 SV2

SY4 SY5

FX1 FX2

K84 K85

V31 V32

V34 V35

AU1 AU2

AU4 AU5

YH1 YH2

17258 41140

26932 67294

20323 51891

10247 22697

13880 30882

12491 27794

40638 90413

15825 35210

13880 30882

30786 68557

13093 29732

13351 31376

9799 23027

26932 67294

20323 51891

26865 64982

8897 20464

26173 63455

23647 57594

14091 38330

61069 138677

70937 165354

64196 149643

41809 92606

56629 125999

50965 113400

84917 188936

59608 132629

56629 125999

74868 166643

53418 121307

54474 128016

39979 93951

70937 165354

64196 149643

70869 162996

36302 83494

70163 161438

67586 155460

57491 135811

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Indiana

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$25$50

$35$55

$200day x 5

50+50+

$35$70

$40$60

745 915 88 962 878 868 67

Humana Health Plan of OhioshyHigh

Humana Health Plan of OhioshyStandard

Physicians Health Plan of Northern IndianashyHigh

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$15

$25$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$40+$60+

$40$60

$25$50

30to$60050 to$1200

Coventry Health Care of IowashyHigh

Coventry Health Care of IowashyStandard

HealthPartners High Option

HealthPartners Standard Option

Sanford Health Plan InshyNetwork

$25$50

$25$45

$0 for 3 then 20

$20$30

$200day x 5

Nothing

20 in40 out

$100day x 5

$3 $10

50+50+

$45$70$100

30$5000 Max

$35$70

$45$90

$40$70

$30$50

558 Sanford Health Plan OutshyNetwork

$25$25

$100day x 5

40+40+

$30$50

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

40+40+

$25$50

40+40+

$35$50

Yes 577 896 86 956 914 918 623

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Kansas

Aetna Value Planshy Most of Kansas

Aetna Open Access shyHighshy Kansas City area

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

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

Humana Value Plan shy Kansas City Area

Humana Health Plan Inc shyHighshy Kansas City

Humana Health Plan Inc shyStdshy Kansas City

Kentucky

Aetna Value Planshy Most of Kentucky

Humana Health Plan of Ohio shyHighshy Portions of Kentucky

Humana Health Plan of Ohio shyStdshy Portions of Kentucky

Humana Health Plan Inc shyHighshy Louisville

Humana Health Plan Inc shyStdshy Louisville

Humana Health Plan Inc shyHighshy Lexington

Humana Health Plan Inc shyStdshy Lexington

Louisiana

Aetna Value Planshy Most of Louisiana

Coventry Health Care of Louisiana shyHighshy New Orleans Area

Coventry Health Care of Louisiana shyStdshy New Orleans Area

Humana Health Benefit Plan of Louisiana Inc shyHighshy Baton Rouge

Humana Health Benefit Plan of Louisiana Inc shyStdshy Baton Rouge

Humana Health Benefit Plan of Louisiana Inc shyHighshy New Orleans

Humana Health Benefit Plan of Louisiana Inc shyStdshy New Orleans

877shy459shy6604

800shy969shy3343

888shy393shy6765

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy341shy6613

888shy393shy6765

G54 G55

HY1 HY2

HA1 HA2

HA4 HA5

PH4 PH5

MS1 MS2

MS4 MS5

H44 H45

A61 A62

A64 A65

MH1 MH2

MH4 MH5

MI1 MI2

MI4 MI5

F54 F55

BJ1 BJ2

BJ4 BJ5

AE1 AE2

AE4 AE5

BC1 BC2

BC4 BC5

12822 29119

13777 50039

13519 32270

12568 29535

10247 22697

62521 139111

15825 35210

13093 29732

13880 30882

12491 27794

15825 35210

13880 30882

19459 43292

13880 30882

13058 29656

19208 48754

13035 30271

15825 35210

13149 29256

13880 30882

12491 27794

52315 118808

55396 147754

55160 129630

51276 120503

41809 92606

107238 238608

59608 132629

53418 121307

56629 125999

50965 113400

59608 132629

56629 125999

63314 140872

56629 125999

53279 120995

63058 146443

53182 123506

59608 132629

53648 119367

56629 125999

50965 113400

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Kansas

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

Coventry Health Care of KansasshyHigh

Coventry Health Care of KansasshyStandard

$20$35

$30$60

$35$55

$250day x 4

$3 $12

50+50+

$35$100

$50$75

$40$60

Kentucky

$20$35

$25$40

$250day x 3

$500day x 3

$40+$60+

$40$60

30to$60050 to$1200

Louisiana

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+50+

$40$60

30to$60050 to$1200

Coventry Health Care of LouisianashyHigh

Coventry Health Care of LouisianashyStandard

Humana Health Benefit Plan of LA shyHigh

Humana Health Benefit Plan of LA shyStandard

$25$45

$30$55

$20$35

$35$40

$20$35

$35$40

Ded+$100

Ded+30

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+50+

$40$100

$40$60

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Aetna Value Planshy All of Maine 877shy459shy6604

Maryland

Aetna Value Planshy All of Maryland 877shy459shy6604

Aetna Open Access shyHighshy NorthernCentralSouthern Maryland Areas 877shy459shy6604

Aetna Open Access shyBasicshy NorthernCentralSouthern Maryland Areas 877shy459shy6604

CareFirst BlueChoice shyHighshy All of Maryland 888shy789shy9065

CareFirst BlueChoice shyStdshy All of Maryland 888shy789shy9065

Coventry Health Care shyHighshy All of Maryland 800shy833shy7423

Coventry Health Care shyStdshy All of Maryland 800shy833shy7423

Kaiser Foundation Health Plan MidshyAtlantic States shyHighshy BaltimoreWashington DC areas 877shy574shy3337

Kaiser Foundation Health Plan MidshyAtlantic States shyStdshy BaltimoreWashington DC areas 877shy574shy3337

MD IPA shyHighshy All of Maryland 877shy835shy9861

Massachusetts

Aetna Value Planshy Most of Massachusetts 877shy459shy6604

Fallon Community Health Plan shyBasicshy CentralEastern Massachusetts 800shy868shy5200

EP4 EP5

F54 F55

JN1 JN2

JN4 JN5

2G1 2G2

2G4 2G5

IG1 IG2

IG4 IG5

E31 E32

E34 E35

JP1 JP2

EP4 EP5

JG1 JG2

12694 28827

13058 29656

46867 105610

14021 31351

21177 48693

15284 35429

14998 37685

13265 30509

16926 42124

9646 22186

20245 50123

12694 28827

29337 80043

51792 117616

53279 120995

91271 204437

57208 127913

65067 146381

59056 132852

58764 135153

54121 124479

60731 139681

39358 90520

64116 147840

51792 117616

73390 178358

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

Maryland

$25$40

50+50+

30to$60050 to$1200

$15$30

$20$35

$25$35

Nothing$35

$150day x3

10 Plan Allow

Nothing

50+50+

$35$100

$35$65

Coventry Health CareshyHigh

Coventry Health CareshyStandard

MD IPAshyHigh

Massachusetts

$70$70

$20$40

$10$20

$20$30

$25$40

$200day x 3

$250dayx3

$150day x 3

Nothing

$7$17 Net

$12$22Net

$35$65

$30$60

$30$50$45$65

$35$55$50$

$30$60

30to$60050 to$1200

70 Yes

Fallon Community Health PlanshyBasic

$25$35

$150to$750max

50+50+

$30$60

Yes 627 851 882 929 883 801 649

Plan Name ndash Location Telephone Number

Enrollment Code

TCC 102 of your Total Monthly Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Michigan

Aetna Value Planshy All of Michigan 877shy459shy6604

Bluecare Network of MI shyHighshy East Region 800shy662shy6667

Bluecare Network of MI shyHighshy Southeast Region 800shy662shy6667

Grand Valley Health Plan shyHighshy Grand Rapids area 616shy949shy2410

Grand Valley Health Plan shyStdshy Grand Rapids area 616shy949shy2410

Health Alliance Plan shyHighshy Southeastern MichiganFlint Area 800shy556shy9765

Health Alliance Plan shyStdshy Southeastern MichiganFlint Area 800shy556shy9765

HealthPlus of MI shyHighshy East Michigan 800shy332shy9161

Total Health Care USA shyHighshy Michigan 800shy826shy2862

Minnesota

Aetna Value Planshy Most of Minnesota 877shy459shy6604

HealthPartners High Option shy Minnesota 800shy883shy2177

HealthPartners Standard Option shy Minnesota 800shy883shy2177

Mississippi Aetna Value Planshy Most of Mississippi 877shy459shy6604

G54 G55

K51 K52

LX1 LX2

RL1 RL2

RL4 RL5

521 522

GY4 GY5

X51 X52

A51 A52

H44 H45

V31 V32

V34 V35

H44 H45

12822 29119

22055 52593

18055 50747

24184 61492

19656 50897

20111 55722

16974 48191

13915 49809

13670 50117

13093 29732

26865 64982

8897 20464

13093 29732

52315 118808

65962 150359

61882 148476

68134 159436

63515 148629

63980 153551

60780 145869

56775 147520

55776 147834

53418 121307

70869 162996

36302 83494

53418 121307

Primary care

Hospital per stay deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

Michigan

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

Bluecare Network of MIshyHigh

Grand Valley Health PlanshyHigh

Grand Valley Health PlanshyStandard

Health Alliance PlanshyHigh

Health Alliance PlanshyStandard

HealthPlus of MIshyHigh

Total Health Care USAshyHigh

Minnesota

$15$25

$10$10

$20$20

$10$20

$15$30

$10$20

$15$15

$25$40

Nothing

$500x3

Nothing

50+50+

$30$60

$15$15

$50$50

$40$60

$40$40

30to$60050 to$1200

Mississippi Aetna Value Plan InshyNetwork

$25$45

$0 for 3 then 20

$25$40

Nothing

20 in40 out

50+50+

$45$90

$40$70

30to$60050 to$1200

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

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Missouri Aetna Value Planshy Most of Missouri

Blue Preferred Plus POS shyHighshy StLouisCentralSW areas

United Healthcare of the Midwest Inc shyHighshy St Louis Area

Montana

Aetna Value Planshy SouthSoutheastWestern MT Areas

Nebraska

Aetna Value Planshy All of Nebraska

Nevada

Aetna Value Planshy Las Vegas Area

Aetna Open Access shyHighshy Clark County and Las Vegas areas

Health Plan of Nevada shyHighshy Las VegasEsmeralda and Nye counties

New Hampshire

Aetna Value Planshy All of New Hampshire

877shy459shy6604

888shy811shy2092

800shy969shy3343

888shy393shy6765

877shy835shy9861

877shy459shy6604

877shy545shy7378

877shy459shy6604

G54 G55

HY1 HY2

9G1 9G2

HA1 HA2

HA4 HA5

PH4 PH5

MS1 MS2

MS4 MS5

B91 B92

H44 H45

G54 G55

HF1 HF2

NM1 NM2

EP4 EP5

12822 29119

13577 50039

32158 67069

13519 32270

12568 29535

10247 22697

62521 139111

15825 35210

33072 74273

13093 29732

12822 29119

11267 36491

9883 23303

12694 28827

52315 118808

55396 147754

76267 165125

55160 129630

51276 120503

41809 92606

107238 238608

59608 132629

77200 172473

53418 121307

52315 118808

45970 133935

40322 95078

51792 117616

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

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

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$20$35

$250day x 4

50+50+

$35$100 $40$60

Yes 639 862 862 94 838 901 538

Blue Preferred Plus POS InshyNetwork $25$35 $500 $5 25$6025 Yes 647 891 861 961 84 864 685 Blue Preferred Plus POS OutshyNetwork Coventry Health Care of KansasshyHigh

30 after ded $30$60

$30$60

$35$55

30 after ded 25

NA $3 $12

$3 $12

NA $50$75

$40$60

NA Yes

Montana

$20$35

$25$40

$250day x 3

$500day x 3

$40+$60+

$40$60

$30$60

30to$60050 to$1200

Nebraska

$25$40

50+50+

30to$60050 to$1200

Nevada

$25$40

50+50+

30to$60050 to$1200

Health Plan of NevadashyHigh

New Hampshire

$20$35

$10$25

$25$40

$250day x 4

50+50+

$35$100

$35$55$100

30to$60050 to$1200

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

New Jersey

Aetna Value Planshy All of New Jersey 877shy459shy6604

Aetna Open Access shyHighshy Northern New Jersey 877shy459shy6604

Aetna Open Access shyBasicshy Northern New Jersey 877shy459shy6604

Aetna Open Access shyHighshy Southern NJ 877shy459shy6604

Aetna Open Access shyBasicshy Southern NJ 877shy459shy6604

GHI Health Plan shyHighshy Northern New Jersey 212shy501shy4444

GHI Health Plan shyStdshy Northern New Jersey 212shy501shy4444

New Mexico

Aetna Value Planshy AlbuquerqueDona AnaHobbs Area 877shy459shy6604

Lovelace Health Plan shyHighshy All of New Mexico 800shy808shy7363

Presbyterian Health Plan shyHighshy All counties in New Mexico 800shy356shy2219

EP4 EP5

JR1 JR2

JR4 JR5

P31 P32

P34 P35

801 802

804 805

G54 G55

Q11 Q12

P21 P22

12694 28827

52355 123641

34184 82457

64801 164359

49560 118027

32591 93212

14135 33572

12822 29119

13099 30785

23940 56335

51792 117616

96868 222828

78334 180821

109563 264361

94017 217102

76709 191791

57672 130958

52315 118808

53445 125603

67885 154176

Primary care Hospital

Prescription Drugs

Mail lan

ll icate

r ng rmation

Plan Name ndash Location Specialist

office copay per stay

deductible Level I Level II Level III

order discount

Overall p

satisfaction

Getting n

Getting c

quickly

doctors

commun

Custome

service

Claims

processi

New Jersey

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

GHI Health Plan InshyNetwork

$20$35

$15$35

$20$35

$15$35

$20$20

$250day x 4

20 Plan Allow

$250day x 4

20 Plan Allow

$150max$450

50+50+

$35$100

$45$85

642 GHI Health Plan OutshyNetwork

GHI Health PlanshyStandard

New Mexico

50 of sch

$30$30

$25$40

+50 of sch

$250day x 3

$45$85

30to$60050 to$1200

663 844 851 936 86 828 642

Lovelace Health PlanshyHigh

Presbyterian Health PlanshyHigh

$25$35

$25$40

$250 after ded

$100 x 5 days

50+50+

$35$6050

$40$7550

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

New York

Aetna Value Planshy Most of New York 877shy459shy6604

Aetna Open Access shyHighshy NYC AreaUpstate NY 877shy459shy6604

Aetna Open Access shyBasicshy NYC AreaUpstate NY 877shy459shy6604

CDPHP Universal Benefits Inc shyHighshy Upstate Hudson Valley Central NY 877shy269shy2134

CDPHP Universal Benefits Inc shyStdshy Upstate Hudson Valley Central NY 877shy269shy2134

GHI HMO Select shyHighshy BrnxBrklynManhatQueenRichmonWestche 877shy244shy4466

GHI HMO Select shyHighshy CapitalHudson Valley Regions 877shy244shy4466

GHI Health Plan shyHighshy All of New York 212shy501shy4444

GHI Health Plan shyStdshy All of New York 212shy501shy4444

HIP Health of Greater New York shyHighshy New York City area including Long Island 800shy447shy8255

HIP Health of Greater New York shyStdshy New York City area including Long Island 800shy447shy8255

Independent Health Association shyHighshy Western New York 800shy501shy3439

Independent Health Association shyStdshy Western New York 800shy501shy3439

MVP Health Care shyHighshy Eastern Region 888shy687shy6277

MVP Health Care shyStdshy Eastern Region 888shy687shy6277

MVP Health Care shyHighshy Western Region 888shy687shy6277

MVP Health Care shyStdshy Western Region 888shy687shy6277

MVP Health Care shyHighshy Central Region 888shy687shy6277

MVP Health Care shyStdshy Central Region 888shy687shy6277

MVP Health Care shyHighshy Northern Region 888shy687shy6277

MVP Health Care shyStdshy Northern Region 888shy687shy6277

MVP Health Care shyHighshy MidshyHudson Region 888shy687shy6277

MVP Health Care shyStdshy MidshyHudson Region 888shy687shy6277

EP4 EP5

JC1 JC2

JC4 JC5

SG1 SG2

SG4 SG5

6V1 6V2

X41 X42

801 802

804 805

511 512

514 515

QA1 QA2

C54 C55

GA1 GA2

GA4 GA5

GV1 GV2

GV4 GV5

M91 M92

M94 M95

MF1 MF2

MF4 MF5

MX1 MX2

MX4 MX5

12694 28827

40198 109033

26007 71920

22952 71235

12294 32053

19548 60991

14167 47634

32591 93212

14135 33572

17000 63158

12206 34562

18597 58201

14454 47853

16586 53386

13377 39674

13042 35704

11193 28006

17110 54877

13779 42651

25417 75411

22349 67734

18731 58664

13657 42345

51792 117616

84468 207928

69993 170073

66877 169374

50161 129408

63405 158925

57800 145301

76709 191791

57672 130958

60806 161136

49800 131968

62435 156079

58209 145524

60384 151168

54580 137182

53210 133132

45669 114266

60918 152689

56220 140218

69392 173634

66262 165803

62572 156552

55723 139906

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

New York

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

CDPHP Universal Benefits IncshyHigh

CDPHP Universal Benefits IncshyStandard

GHI HMO SelectshyHigh

$20$35

$15$35

$20$30

$25$40

$20$20

$250day x 4

20 Plan Allow

$100 x 5

$500+10

$150max$450

50+50+

$35$100

$30$50

$45$85

HIP Health of Greater New YorkshyHigh

HIP Health of Greater New YorkshyStandard

Independent Health Assoc InshyNetwork

50 of sch

$30$30

$20$40

$30$50

$25$25

+50 of sch

$250day x 3

$15$100Ded

$45$85

$35$75

$30$75

$35$75 $75$100Ded

755 Independent Health Assoc OutshyNetwork

Independent Health Association InshyNetwork

$30$50

Yes Independent Health Association OutshyNetwork

MVP Health CareshyHigh

MVP Health CareshyStandard

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

North Carolina

Aetna Value Planshy All of North Carolina 877shy459shy6604

North Dakota

Aetna Value Planshy Most of North Dakota 877shy459shy6604

HealthPartners High Option shy Eastern North Dakota 800shy883shy2177

HealthPartners Standard Option shyEastern North Dakota 800shy883shy2177

Sanford Heart of America Health Plan shyHighshy Northcentral North Dakota 800shy525shy5661

Sanford Health Plan shyHighshy North Dakota 800shy752shy5863

Sanford Health Plan shyStdshy North Dakota 800shy752shy5863

Aetna Value Planshy All of Ohio 877shy459shy6604

AultCare HMO shyHighshy StarkCarrollHolmesTuscarawasWayne Co 330shy363shy6360

Humana Health Plan of Ohio shyHighshy Greater Cincinnati Area 888shy393shy6765

Humana Health Plan of Ohio shyStdshy Greater Cincinnati Area 888shy393shy6765

HealthSpan Integrated CareshyClevelandAkron areas 800shy686shy7100

HealthSpan Integrated CareshyStdshyClevelandAkron areas 800shy686shy7100

The Health Plan of the Upper Ohio Valley shyHighshy Eastern Ohio 800shy624shy6961

Oklahoma

Aetna Value Planshy All of Oklahoma 877shy459shy6604

Globalhealth Inc shyHighshy Oklahoma 877shy280shy5600

F54 F55

H44 H45

V31 V32

V34 V35

RU1 RU2

C91 C92

C94 C95

JS4 JS5

3A1 3A2

A61 A62

A64 A65

641 642

644 645

U41 U42

JS4 JS5

IM1 IM2

13058 29656

13093 29732

26865 64982

8897 20464

13803 47086

20976 51441

14143 45836

17258 41140

14204 44676

13880 30882

12491 27794

28758 69344

13114 30163

26271 60855

17258 41140

11810 28460

53279 120995

53418 121307

70869 162996

36302 83494

56317 144742

64862 149184

57705 143467

61069 138677

57953 142284

56629 125999

50965 113400

72799 167445

53504 123066

70263 158786

61069 138677

48185 116118

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

North Carolina

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

North Dakota

$25$40

50+50+

30to$60050 to$1200

Sanford Heart of America Health Plan InshyNetwork

$25$45

$0 for 3 then 20

$15$25

Nothing

20 in40 out

50$600ded

50+50+

$45$90

$40$70

50$600 ded

Sanford Heart of America Health Plan OutshyNetwork

$20$30

$100day x 5

$30$50

$25$25

$100day x 5

40+40+

$30$50

40+40+

$25$40

40+40+

30to$60050 to$1200

AultCare HMOshyHigh

HealthSpan Integrated CareshyHigh

HealthSpan Integrated CareshyStandard

The Health Plan of the Upper Ohio ValleyshyHigh

Oklahoma

$15$20

$20$35

$25$40

$20$20

$30$40

$10$20

$25$40

$250day x 3

$500day x 3

50+50+

$30$40$55

$40$60

$30$30

$40$40

$30$50

30to$60050 to$1200

Globalhealth IncshyHigh

$15$45

$250dymx1000

50+50+

$45$70

Yes 592 816 839 916 893 872 727

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Oregon

Aetna Value Planshy Most of Oregon

Kaiser Foundation Health Plan of Northwest shyHighshy PortlandSalem areas

Kaiser Foundation Health Plan of Northwest shyStdshy PortlandSalem areas

Pennsylvania

Aetna Value Planshy All of Pennsylvania

Aetna Open Access shyHighshy Philadelphia

Aetna Open Access shyBasicshy Philadelphia

Aetna Open Access shyHighshy Pittsburgh and Western PA Areas

Geisinger Health Plan shyStdshy NortheasternCentralSouth Central areas

HealthAmerica Pennsylvania shyHighshy Greater Pittsburgh Area

UPMC Health Plan shyHighshy Western Pennsylvania

UPMC Health Plan shyStdshy Western Pennsylvania

Puerto Rico

Humana Health Plans of Puerto Rico Inc shyHighshy Puerto Rico

TripleshyS Salud Inc shyHighshy All of Puerto Rico

Rhode Island

Aetna Value Planshy All of Rhode Island

South Carolina

Aetna Value Planshy All of South Carolina

877shy459shy6604

800shy813shy2000

877shy459shy6604

800shy447shy4000

866shy351shy5946

888shy876shy2756

800shy314shy3121

787shy774shy6060

877shy459shy6604

H44 H45

571 572

574 575

H44 H45

P31 P32

P34 P35

YE1 YE2

GG4 GG5

261 262

8W1 8W2

UW4 UW5

ZJ1 ZJ2

891 892

EP4 EP5

JS4 JS5

13093 29732

22672 52645

13617 31283

13093 29732

64801 164359

49560 118027

19203 59806

16820 41884

17814 47183

22135 54101

13345 30692

8026 18317

8829 19866

12694 28827

17258 41140

53418 121307

66592 150412

55557 127637

53418 121307

109563 264361

94017 217102

63053 157716

60623 139436

61637 144841

66044 151897

54448 125225

32748 74733

36023 81052

51792 117616

61069 138677

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Oregon

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

Kaiser Foundation HP of NorthwestshyHigh

Kaiser Foundation HP of NorthwestshyStandard

Pennsylvania

$20$30

$30$40

$25$40

50+50+

$40$60

30to$60050 to$1200

Geisinger Health PlanshyStandard

HealthAmerica PennsylvaniashyHigh

UPMC Health PlanshyHigh

UPMC Health PlanshyStandard

Puerto Rico

Humana Health Plans of PR InshyNetwork

$20$35

$15$35

$20$35

$25$50

10 after Deduct

20 after Deduct

$250day x 4

20 Plan Allow

$250day x 4

20aftrDeduct

15 after ded

10 after deduct

20after Deduct

30 $5$15

$5 after ded

50+50+

$35$100

$35$60

$35$75

$35$75$100

$10$15

40 $40$120 50 $85$250

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

Greater of $15 or Yes

TripleshyS Salud Inc InshyNetwork TripleshyS Salud Inc OutshyNetwork

Rhode Island

$750$10

$25$40

$750 amp 10 +$10 amp 10 +

None 10 +

$5 or $12 NA

2025 up to$100$175max

30to$60050 to$1200

Yes No

691 874 844 963 872 75 586

South Carolina

$25$40

50+50+

30to$60050 to$1200

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

Enrollment Code

TCC 102 of Your Total Monthly Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

South Dakota

Aetna Value Planshy Rapid CitySioux Falls Area 877shy459shy6604

HealthPartners High Option shy Eastern South Dakota 800shy883shy2177

HealthPartners Standard Option shyEastern South Dakota 800shy883shy2177

Sanford Health Plan shyHighshy EasternCentralRapid City Areas 800shy752shy5863

Sanford Health Plan shyStdshy EasternCentralRapid City Areas 800shy752shy5863

Tennessee

Aetna Value Planshy Most of Tennessee 877shy459shy6604

Aetna Open Access shyHighshy Memphis Area 877shy459shy6604

Humana Health Plan Inc shyHighshy Knoxville 888shy393shy6765

Humana Health Plan Inc shyStdshy Knoxville 888shy393shy6765

G54 G55

V31 V32

V34 V35

AU1 AU2

AU4 AU5

F54 F55

UB1 UB2

GJ1 GJ2

GJ4 GJ5

12822 29119

26865 64982

8897 20464

26173 63455

23647 57594

13058 29656

24581 76516

15825 35210

12491 27794

52315 118808

70869 162996

36302 83494

70163 161438

67586 155460

53279 120995

68539 174761

59608 132629

50965 113400

Primary

Prescription Drugs

ded ation

care Hospital Mail

Getting nee

How well

r ng rm

Plan Name ndash Location Specialist office copay

per stay deductible Level I

Level II Level III

order discount

Overall

satisfaction

Getting

quickly

doctors

commun

Custome

service

Claims

processi

Plan Info

on Costs

South Dakota

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$25$45

$0 for 3 then 20

$20$30

Nothing

20 in40 out

$100day x 5

50+50+

$45$90

$40$70

$30$50

$25$25

$100day x 5

40+40+

$30$50

535 903 89 977 902 912 558 Sanford Health Plan OutshyNetwork

Tennessee

40+40+

$25$40

40+40+

30to$60050 to$1200

$20$35

$25$40

$250day x 4

$250day x 3

$500day x 3

50+50+

$35$100

$40$60

66 875 868 959 889 914 69

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Aetna Value Planshy All of Texas 877shy459shy6604

Aetna Whole Health shyBasicshy Houston Area 877shy459shy6604

Firstcare shyHighshy Waco area 800shy884shy4901

Firstcare shyHighshy West Texas 800shy884shy4901

Firstcare shyHighshy TaylorCallahanEastland 800shy884shy4901

Firstcare shyHighshy Lubbock area 800shy884shy4901

Firstcare shyHighshy BryanCollege Station Area 800shy884shy4901

Humana Value Plan shy Corpus Christi Area 888shy393shy6765

Humana Value Plan shy San Antonio Area 888shy393shy6765

Humana Value Plan shy Austin Area 888shy393shy6765

Humana Health Plan of Texas shyHighshy Houston 888shy393shy6765

Humana Health Plan of Texas shyStdshy Houston 888shy393shy6765

Humana Health Plan of Texas shyHighshy Corpus Christi 888shy393shy6765

Humana Health Plan of Texas shyStdshy Corpus Christi 888shy393shy6765

Humana Health Plan of Texas shyHighshy San Antonio 888shy393shy6765

Humana Health Plan of Texas shyStdshy San Antonio 888shy393shy6765

Humana Health Plan of Texas shyHighshy Austin 888shy393shy6765

Humana Health Plan of Texas shyStdshy Austin 888shy393shy6765

Scott amp White Health Plan shyStdshy Central TX amp Some SE and SW Counties 800shy321shy7947

UnitedHealthcare Benefits of Texas Inc shyHighshy San Antonio 866shy546shy0510

JS4 JS5

ES1 ES2

B71 B72

CK1 CK2

CN1 CN2

CZ1 CZ2

ET1 ET2

TP4 TP5

TU4 TU5

TV4 TV5

EW1 EW2

EW4 EW5

UC1 UC2

UC4 UC5

UR1 UR2

UR4 UR5

UU1 UU2

UU4 UU5

A84 A85

GF1 GF2

17258 41140

12817 40332

11057 37880

10809 34896

13391 65886

13031 61566

12638 56836

10247 22697

13880 30882

12491 27794

17899 39821

13880 30882

55020 122416

13880 30882

26524 59015

15825 35210

14907 37260

32515 78160

61069 138677

52295 137853

45113 135352

44103 132308

54635 163918

53169 159512

51562 154687

41809 92606

56629 125999

50965 113400

61723 137332

56629 126001

99587 221579

56629 126001

70521 156910

59608 132629

58671 134720

76632 176438

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

Aetna Whole Health InshyNetwork

$5$25$35

50+50+

$35$60

Yes Aetna Whole Health OutshyNetwork

FirstcareshyHigh

$30$55

$35$55

$250day x 5

$35$70

$40$60

$35$55

$40+$60+

$40$60

$35$55

$40+$60+

$40$60

Humana Health Plan of TexasshyHigh

Humana Health Plan of TexasshyStandard

Scott amp White Health PlanshyStandard

UnitedHealthcare Benefits of Texas IncshyHigh

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$45

$20$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 5

$40+$60+

$40$60

$45$100

$35$60

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Aetna Value Planshy Most of Utah 877shy459shy6604

Altius Health Plans shyHighshy Wasatch Front 800shy377shy4161

Altius Health Plans shyStdshy Wasatch Front 800shy377shy4161

SelectHealth shyHighshy Urban and Suburban Utah 800shy538shy5038

SelectHealth shyStdshy Urban and Suburban Utah 800shy538shy5038

Vermont Aetna Value Planshy All of Vermont 877shy459shy6604

Virgin Islands

TripleshyS Salud Inc shyHighshy US Virgin Islands 800shy981shy3241

G54 G55

9K1 9K2

DK4 DK5

SF1 SF2

SF4 SF5

EP4 EP5

851 852

12822 29119

19819 42542

11798 25954

19210 43095

12435 27741

12694 28827

10305 23402

52315 118808

63682 140107

48136 105894

63060 140671

50737 113183

51792 117616

42043 95481

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

SelectHealthshyHigh

Vermont Aetna Value Plan InshyNetwork

$20$30

$20$40

$15$25

$20$30

$25$40

$100 after

$5$25$50

50+50+

$25$50

$35$60

$25$50$50

$25 $50$50

30to$60050 to$1200

Virgin Islands

4040 40 50+ 50+50+ No

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

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

None 10 +

$5 or $12 NA NA

2025 up to$100$175max

Yes No

691 874 844 963 872 75 586

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Virginia

Aetna Value Planshy Most of Virginia 877shy459shy6604

Aetna Open Access shyHighshy NorthernCentralRichmond Virginia Areas 877shy459shy6604

Aetna Open Access shyBasicshy NorthernCentralRichmond Virginia Areas 877shy459shy6604

Aetna Whole Health shyBasicshy Roanoke VA area 877shy459shy6604

Aetna Whole Health shyBasicshy Newport News VA area 877shy459shy6604

CareFirst BlueChoice shyHighshy Northern Virginia 888shy789shy9065

CareFirst BlueChoice shyStdshy Northern Virginia 888shy789shy9065

HealthKeepers Inc shyHighshy Virginia 855shy580shy1200

Kaiser Foundation Health Plan MidshyAtlantic States shyHighshy Northern VirginiaFredericksburg area 877shy574shy3337

Kaiser Foundation Health Plan MidshyAtlantic States shyStdshy Northern VirginiaFredericksburg area 877shy574shy3337

MD IPA shyHighshy Northern Viginia 877shy835shy9861

Optima Health Plan shyHighshy Hampton Roads and Richmond areas 800shy206shy1060

Optima Health Plan shyStdshy Hampton Roads and Richmond areas 800shy206shy1060

Piedmont Community Healthcare shyHighshy Lynchburg area 888shy674shy3368

Washington

Aetna Value Planshy Most of Washington 877shy459shy6604

Aetna Open Access shyHighshy Seattle and Spokane areas 877shy459shy6604

Group Health Cooperative shyHighshy Western WACentral WASpokanePullman 888shy901shy4636

Group Health Cooperative shyStdshy Western WACentral WASpokanePullman 888shy901shy4636

KPS Health Plans shyStdshy All of Washington 800shy552shy7114

KPS Health Plans shyHighshy All of Washington 800shy552shy7114

Kaiser Foundation Health Plan of Northwest shyHighshy VancouverLongview 800shy813shy2000

Kaiser Foundation Health Plan of Northwest shyStdshy VancouverLongview 800shy813shy2000

F54 F55

JN1 JN2

JN4 JN5

D91 D92

J91 J92

2G1 2G2

2G4 2G5

A91 A92

E31 E32

E34 E35

JP1 JP2

9R1 9R2

9R4 9R5

2C1 2C2

G54 G55

C31 C32

541 542

544 545

L11 L12

VT1 VT2

571 572

574 575

13058 29656

46867 105610

14021 31351

12138 40332

11280 29365

21177 48693

15284 35429

20427 47008

16926 42124

9646 22186

20245 50123

26858 69565

11269 26665

12235 28017

12822 29119

14933 62274

27070 55009

11742 26509

12426 26823

31651 67459

22672 52645

13617 31283

53279 120995

91271 204437

57208 127913

49524 137853

46023 119808

65067 146381

59056 132852

64302 144663

60731 139681

39358 90520

64116 147840

70861 167671

45977 108794

49920 114308

52315 118808

58698 160234

71078 152824

47908 108156

50700 109437

75750 165523

66592 150412

55557 127637

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

Virginia

Aetna Value Plan InshyNetwork Aetna Value Plan OutshyNetwork

Aetna Whole Health InshyNetwork Aetna Whole Health OutshyNetwork

$25$40 4040

$15$30

$20$35

$25$35 4040

$5$25$35 4040

$25$35

Nothing$35

$150day x3

10 Plan Allow

$10 50+

Nothing

50+50+

$35$100

$35$60 4040

$35$65

30to$60050 to$1200

POS National

Yes No

Average

CareFirst BlueChoice OutshyNetwork

HealthKeepers IncshyHigh

MD IPAshyHigh

Optima Health PlanshyHigh

Optima Health PlanshyStandard

Piedmont Community HealthcareshyHigh

Washington

KPS Health Plans InshyNetwork KPS Health Plans OutshyNetwork

$70$70

$10$20

$20$30

$25$40

$25$30

$35$35

$25$40 4040

$20$35

$25$25

$25$35

$154 or 2020

$30$30 $30+40+diff

$20$30

$30$40

$0$3530NonshyNetwork

$20$0childlt22$30

$154+40+diff 40+diff

$200 x3 days

$250dayx3

$150day x 3

$150max$750

$20020

$250day x 4

Nothing Nothing

None None

Nothing

$7$17 Net

$12$22Net

$10 50+

$10 Not Covered

$5 Not Covered

$35$65

$30$50$50

$30$50$45$65

$35$55$50$70

$30$60

$40$55

50+50+

$35$100

$40$60

Not Covered

$40$60

$353050up to $3000

$355050 up to $3000

$35$50 30day$100 90day

$25$50 30day$100 90day

30to$60050 to$1200

Yes No

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

West Virginia

Aetna Value Planshy Most of West Virginia 877shy459shy6604

The Health Plan of the Upper Ohio Valley shyHighshy NorthernCentral West Virginia 800shy624shy6961

Wisconsin

Aetna Value Planshy All of Wisconsin 877shy459shy6604

Aetna Whole Health shyBasicshy Milwaukee WI Area 877shy459shy6604

Dean Health Plan shyHighshy South Central Wisconsin 800shy279shy1301

Group Health Cooperative shyHighshy South Central Wisconsin 800shy605shy4327

HealthPartners High Option shy Western Wisconsin 800shy883shy2177

HealthPartners Standard Option shy Western Wisconsin 800shy883shy2177

MercyCare HMO shyHighshy South Central Wisconsin 800shy895shy2421

Physicians Plus shyHighshy All of WI 800shy545shy5015

Wyoming

Aetna Value Plan shyBasicshy All of Wyoming 877shy459shy6604

Altius Health Plans shyHighshy Uinta County 800shy377shy4161

Altius Health Plans shyStdshy Uinta County 800shy377shy4161

F54 F55

U41 U42

JS4 JS5

F71 F72

WD1 WD2

WJ1 WJ2

V31 V32

V34 V35

EY1 EY2

LW1 LW2

H44 H45

9K1 9K2

DK4 DK5

13058 29656

26271 60855

17258 41140

10600 29208

24382 72670

15910 51534

26865 64982

8897 20464

14597 48275

16556 55954

13093 29732

19819 42542

11798 25954

53279 120995

70263 158786

61069 138677

43250 119170

68336 170838

59694 149279

70869 162996

36302 83494

58355 145955

60353 153787

53418 121307

63682 140107

48136 105894

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Claims

processing

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Plan Inform

on Costs

West Virginia

Wisconsin

Dean Health PlanshyHigh

MercyCare HMOshyHigh

Physicians PlusshyHigh

Wyoming

$25$40 4040

$10$20

$25$40 4040

$25$35 4040

$25$25

$10$10

$25$45

$0 for 3 then 20

$10$10

$25$40 4040

$20$30

$20$40

Nothing

20 in40 out

Nothing

$10 Yes 50+ 50+50+ No

$15 $30$50 Yes

$10 Yes 50+ 50+50+ No

$5 $35$60 Yes 40 4040 No

$10 Yes

$5 $20$20 Yes

$12 $45$90 Yes

$9 $40$70 Yes

$10 $20$50 Yes

$10 3050 No

$10 Yes 50+ 50+50+ No

$7 $25$50 No

$7 $35$60 None

HMOPOS National Average

30$75max 50 wmin$50

30to$60050 to$1200

909 876 951 929 944

909 90 97 834 879

834 834 953 929 932

893 875 951 92 911

888 854 938 888 87

857 822 96 863 866

852 813 948 883 895

864 849 942 877 875

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

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

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

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

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

Health Savings Account (HSA)

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

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

Features of an HSA include

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

bull Taxshydeferred interest earned on the account

bull Taxshyfree withdrawals for qualified medical expenses

bull Carryover of unused funds and interest from year to year

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

Health Reimbursement Arrangement (HRA)

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

bull An enrollee cannot make deposits into an HRA

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

bull Interest is not earned on an HRA and

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

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

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

Features of an HRA include

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

Please note that the premium rates provided are the maximum amount you are expected to pay for your premium Your tribal employer may choose to pay a higher portion of your premium Please check with your tribal employer for exact rates

ELIGIBILITY

FUNDING

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

The plan deposits a monthly ldquopremium pass throughrdquo into your account

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

The plan deposits the credit amount directly into your account

CONTRIBUTIONS

DISTRIBUTIONS

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

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

See IRS Publication 502 for a complete list of eligible expenses

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

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

ANNUAL ROLLOVER

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

Yes funds accumulate without a maximum cap

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

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

Yes credits accumulate without a maximum cap

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

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

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

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

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

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

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

Inpatient Hospital shows what you pay after the deductible is met for hospital services when an inpatient The amount could be a daily copayment up to a specified amount (eg $50 a day up to three days) a coinsurance amount such as 20 or a flat deductible amount (eg $200 per admission) This amount does not include charges from physicians or for services that may not be charged by the hospital such as laboratory or radiology

Temporary Continuation of Coverage (TCC) allows former tribal employees and formerly eligible family members to continue their FEHB coverage for a limited period Under TCC you pay the total monthly premium (enrolleersquos share plus the tribal employerrsquos share) plus a 2 administrative charge which equals 102 of Your Total Monthly Premium

Plan Name Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

APWU Health Plan shyCDHPshy Nationwide

GEHA High Deductible Health Plan shyHDHPshy Nationwide

MHBP shy Consumer Option shyHDHPshy Nationwide

NALC shyCDHPshy Nationwide

800shy718shy1299

800shy821shy6136

800shy694shy9901

888shy636shy6252

474 475

341 342

481 482

324 325

9742 21915

11021 25172

13642 30912

10454 22700

39747 89414

44967 102703

55661 126120

42653 92617

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

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

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

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

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

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

SelfFamily Levels I II III

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

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

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

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

High Deductible Health Plans and ConsumershyDriven Health Plan Member Survey Results

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

as soon as you thought you needed

Aetna HealthFund shy Nationwide 22

GEHA High Deductible Health Plan shy Nationwide 34

Mail Handlers Benefit Plan Consumer Option shy Nationwide 48

APWU Health Plan shy Nationwide 47

Humana CoverageFirst shy TX TP TU TV

Humana Coverage First shy IN MW

High Deductible Health Plans Plan Name

Plan Code

ConsumershyDriven Health Plans Plan Name

Plan Code

HDHP National Average

CDHP National Average

885 866 929 860

891 888 952 830

873 851 923 863

891 859 912 887

881 865 939 850

891 888 952 830

909 907 925 871

849 864 932 843

875 801 948 856

Getting needed care

How well doctors

Getting needed care

How well doctors

Claims processing

High Deductible and ConsumershyDriven Health Plans See pages 64shy65 for an explanation of the columns on these pages

Plan Name

Telephone Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Aetna HealthFund shyHDHPshy All 50 States and DC 877shy459shy6604 224 225 11856 25965 48372 105938

Premium

Alabama

Aetna HealthFund shyCDHPshy Most of Alabama

Alaska

Aetna HealthFund shyCDHPshy Most of Alaska

Arizona

Aetna HealthFund shyCDHPshy All of Arizona

Arkansas

Aetna HealthFund shyCDHPshy Most of Arkansas

California

Aetna HealthFund shyCDHPshy Most of California

Colorado

Aetna HealthFund shyCDHPshy All of Colorado

Plan Name

877shy459shy6604

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

136516

151489

149613

136516

151489

149613

Self amp family

Plan Name

Benefit Type

Premium Contribution to HSAHRA

CY Ded SelfFamily

Cat Limit SelfFamily

Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

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

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

Alabama

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

Alaska

Aetna HealthFund CDHP InshyNetwork $8333$16666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFund CDHP OutshyNetwork $8333$16666 $1000$2000 $5000$10000 40 40 40 FundDed4040+40+40+

Arizona

Arkansas

California

Colorado

Premium

Connecticut

Aetna HealthFund shyCDHPshy All of Connecticut

Delaware

Aetna HealthFund shyCDHPshy All of Delaware

Aetna HealthFund shyCDHPshy All of Washington DC

CareFirst BlueChoice shyHDHPshy Washington DC Metro Area

Florida

Aetna HealthFund shyCDHPshy Most of Florida

Coventry Health Plan of Florida shyHDHPshy Southern Florida

Humana CoverageFirst shyCDHPshy Tampa Area

Humana CoverageFirst shyCDHPshy South Florida Area

Georgia

Aetna HealthFund shyCDHPshy All of Georgia

Humana CoverageFirst shyCDHPshy Atlanta Area

Humana CoverageFirst shyCDHPshy Macon Area

TakeCare shyHDHPshy GuamN Mariana IslandsBelau (Palau)

Plan Name

877shy459shy6604

888shy789shy9065

877shy459shy6604

800shy441shy5501

888shy393shy6765

877shy459shy6604

888shy393shy6765

671shy647shy3526

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

145440

136516

127574

136516

141522

116366

136516

105282

110827

Self amp family

Connecticut

Delaware

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

Florida

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

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

Georgia

TakeCare InshyNetwork $8666$22208 $3000$6000 $5000$10000 20 after Ded 20 after Ded 20 after Ded Nothing $20$40$150 30 after Ded30 after Ded TakeCare OutshyNetWork $8666$22208 $3000$6000 $10000$20000 30 after Ded 30 after Ded 30 after Ded 1st $300ded 30 after Ded

Premium

Hawaii Aetna HealthFund shyCDHPshy All of Hawaii

Aetna HealthFund shyCDHPshy Most of Idaho

Altius Health Plans shyHDHPshy Southern Region

Illinois

Aetna HealthFund shyCDHPshy Most of Illinois

Humana CoverageFirst shyCDHPshy Central Illinois

Humana CoverageFirst shyCDHPshy Chicago Area

Indiana

Aetna HealthFund shyCDHPshy All of Indiana

Humana CoverageFirst shyCDHPshy LakePorterLaPorte Counties

Aetna HealthFund shyCDHPshy All of Iowa

Coventry Health Care of Iowa shyHDHPshy CentralEasternWestern Iowa

Kansas

Aetna HealthFund shyCDHPshy Most of Kansas

Humana CoverageFirst shyCDHPshy Kansas City Area

Plan Name

877shy459shy6604

800shy377shy4161

877shy459shy6604

888shy393shy6765

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy257shy4692

877shy459shy6604

800shy969shy3343

888shy393shy6765

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

151489

136317

110827

110823

151489

110823

136317

149613

122219

Self amp family

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

Altius Health Plans $4583$9166 $1250$2500 $5000$10000 $20 10 10 Nothing $7$25$50

Illinois

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

Indiana

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

Kansas

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

Premium

Kentucky

Aetna HealthFund shyCDHPshy Most of Kentucky

Humana CoverageFirst shyCDHPshy Lexington Area

Louisiana

Aetna HealthFund shyCDHPshy Most of Louisiana

Aetna HealthFund shyCDHPshy All of Maine

Maryland

Aetna HealthFund shyCDHPshy All of Maryland

CareFirst BlueChoice shyHDHPshy All of Maryland

Coventry Health Care HDHP shy All of Maryland

Massachusetts

Aetna HealthFund shyCDHPshy Most of Massachusetts

Michigan

Aetna HealthFund shyCDHPshy All of Michigan

Minnesota

Aetna HealthFund shyCDHPshy Most of Minnesota

Mississippi Aetna HealthFund shyCDHPshy Most of Mississippi

Plan Name

877shy459shy6604

888shy393shy6765

877shy459shy6604

888shy789shy9065

800shy833shy7423

877shy459shy6604

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

136317

136516

145440

136516

127574

109488

145440

149613

136317

Self amp family

Kentucky

Louisiana

Maryland

CareFirst BlueChoice InshyNetwork $3750$7500 $1500$3000 $4000$8000 Nothing $300 Nothing Nothing Nothing$30$60 CareFirst BlueChoice

Coventry Health Care HDHP

OutshyNetWork

InshyNetwork

$3750$7500

$4167$8334

$3000$6000

$2000$4000

$6000$12000

$4000$8000

Nothing

Nothing$30$60

$3$15$30$60 Coventry Health Care HDHP OutshyNetWork $4167$8334 $2000$4000 $4000$8000 30 30 30 30 NA

Massachusetts

Michigan

Minnesota

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

Premium

Missouri Aetna HealthFund shyCDHPshy Most of Missouri

Montana

Aetna HealthFund CDHP shy SouthSoutheastWestern MT Areas

Nebraska

Aetna HealthFund shyCDHPshy All of Nebraska

Nevada

Aetna HealthFund shyCDHPshy Las Vegas Area

New Hampshire

Aetna HealthFund shyCDHPshy All of New Hampshire

New Jersey

Aetna HealthFund shyCDHPshy All of New Jersey

New Mexico

Aetna HealthFund shyCDHPshy AlbuquerqueDona AnaHobbs Area

New York

Aetna HealthFund shyCDHPshy Most of New York

Independent Health Assoc shyHDHPshy Western New York

Plan Name

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

877shy459shy6604

800shy969shy3343

888shy393shy6765

877shy459shy6604

800shy501shy3439

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

149613

122219

136317

149613

145440

149613

145440

101669

Self amp family

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

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

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

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

Premium

North Carolina

Aetna HealthFund shyCDHPshy All of North Carolina

North Dakota

Aetna HealthFund shyCDHPshy Most of North Dakota

Ohio Aetna HealthFund shyCDHPshy All of Ohio

AultCare HMO shyHDHPshy StarkCarrollHolmesTuscarawasWayne Co

Oklahoma Aetna HealthFund shyCDHPshy All of Oklahoma

Oregon Aetna HealthFund shyCDHPshy Most of Oregon

Pennsylvania

Aetna HealthFund shyCDHPshy All of Pennsylvania

HealthAmerica Pennsylvania shy HDHP shy Greater Pittsburgh Area

UPMC Health Plan shyHDHPshy Western Pennsylvania

Rhode Island

Aetna HealthFund shyCDHPshy All of Rhode Island

South Carolina

Aetna HealthFund shyCDHPshy All of South Carolina

Plan Name

877shy459shy6604

330shy363shy6360

877shy459shy6604

866shy351shy5946

888shy876shy2756

877shy459shy6604

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

136516

136317

151489

136317

115650

114458

145440

151489

Self amp family

North Carolina

North Dakota

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

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

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

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

Pennsylvania

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

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

Rhode Island

South Carolina

Plan Name

CY Ded SelfFamily

Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

20 Plan Allow20 Plan Allow 20 Plan Allow

$5 after deduct$35 after deduct

10After Deduct

10 after deduct

30After Deduct

30 after deduct

Premium

South Dakota

Aetna HealthFund shyCDHPshy Rapid CitySioux Falls Area

Tennessee

Aetna HealthFund shyCDHPshy Most of Tennessee

Texas Aetna HealthFund shyCDHPshy All of Texas

Humana CoverageFirst shyCDHPshy Corpus Christi Area

Humana CoverageFirst shyCDHPshy San Antonio Area

Humana CoverageFirst shyCDHPshy Austin Area

Utah Aetna HealthFund shyCDHPshy Most of Utah

Altius Health Plans shyHDHPshy Wasatch Front

Vermont

Aetna HealthFund shyCDHPshy All of Vermont

Virginia Aetna HealthFund shyCDHPshy Most of Virginia

CareFirst BlueChoice shyHDHPshy Northern Virginia

Plan Name

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy377shy4161

877shy459shy6604

888shy789shy9065

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

149613

136516

151489

110827

110823

121906

149613

145440

136516

127574

Self amp family

South Dakota

Tennessee

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

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

Vermont

Aetna HealthFund CDHP InshyNetwork $8333$16666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60

Aetna HealthFund CDHP OutshyNetwork $8333$16666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+

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

Premium

Washington Aetna HealthFund shyCDHPshy Most of Washington

KPS Health Plans shyHDHPshy All of Washington

West Virginia Aetna HealthFund shyCDHPshy Most of West Virginia

Wisconsin Aetna HealthFund shyCDHPshy All of Wisconsin

Wyoming

Aetna HealthFund shyCDHPshy All of Wyoming

Altius Health Plans shyHDHPshy Uinta County

Plan Name

877shy459shy6604

800shy552shy7114

877shy459shy6604

800shy377shy4161

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

149613

136516

151489

136317

Self amp family

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

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

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

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

Wyoming

Plan Name

CY Ded SelfFamily

Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

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

______________________________________________________________________________________________________________

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

If you or your children are eligible for Medicaid or CHIP and you are eligible for health coverage from your employer your State may have a premium assistance program that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for these programs but also have access to health insurance through their employer If you or your children are not eligible for Medicaid or CHIP you will not be eligible for these premium assistance programs

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below you can contact your State Medicaid or CHIP office to find out if premium assistance is available

If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1shy877shyKIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can ask the State if it has a program that might help you pay the premiums for an employershysponsored plan

Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP as well as eligible under your employer plan your employer must permit you to enroll in your employer plan if you are not already enrolled This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance If you have questions about enrolling in your employer plan you can contact the Department of Labor electronically at wwwaskebsadolgov or by calling tollshyfree 1shy866shy444shyEBSA (3272)

If you live in one of the following States you may be eligible for assistance paying your employer health plan premiums The following list of States is current as of January 31 2013 You should contact your State for further information on eligibility ndash

ALABAMA ndash Medicaid KANSAS ndash Medicaid Website httpwwwmedicaidalabamagov Phone 1shy855shy692shy5447

Website httpwwwkdheksgovhcf Phone 1shy800shy792shy4884

ALASKA ndash Medicaid KENTUCKY ndash Medicaid Website httphealthhssstateakusdpaprogramsmedicaid Phone (Outside of Anchorage) 1shy888shy318shy8890 Phone (Anchorage) 907shy269shy6529

Website httpchfskygovdmsdefaulthtm Phone 1shy800shy635shy2570

ARIZONA ndash CHIP LOUISIANA ndash Medicaid Website httpwwwazahcccsgovapplicants Phone (Outside of Maricopa County) 1shy877shy764shy5437 Phone (Maricopa County) 602shy417shy5437

Website httpwwwlahippdhhlouisianagov Phone 1shy888shy695shy2447

COLORADO ndash Medicaid MAINE ndash Medicaid Medicaid Website httpwwwcoloradogov Medicaid Phone (In state) 1shy800shy866shy3513 Medicaid Phone (Out of state) 1shy800shy221shy3943

Website httpwwwmainegovdhhsofipublicshyassistanceindexhtml Phone 1shy800shy977shy6740 TTY 1shy800shy977shy6741

FLORIDA ndash Medicaid MASSACHUSETTS ndash Medicaid and CHIP Website httpswwwflmedicaidtplrecoverycom Phone 1shy877shy357shy3268

Website httpwwwmassgovMassHealth Phone 1shy800shy462shy1120

GEORGIA ndash Medicaid MINNESOTA ndash Medicaid Website httpdchgeorgiagov Click on Programs then Medicaid then Health Insurance Premium Payent (HIPP) Phone 1shy800shy869shy1150

Website httpwwwdhsstatemnus Click on Health Care then Medical Assistance Phone 1shy800shy657shy3629

IDAHO ndash Medicaid and CHIP MISSOURI ndash Medicaid Medicaid Website wwwaccesstohealthinsuranceidahogov Medicaid Phone 1shy800shy926shy2588 CHIP Website wwwmedicaididahogov CHIP Phone 1shy800shy926shy2588

Website httpwwwdssmogovmhdparticipantspageshipphtm Phone 573shy751shy2005

INDIANA ndash Medicaid MONTANA ndash Medicaid Website httpwwwingovfssa Phone 1shy800shy889shy9949

Website httpmedicaidproviderhhsmtgovclientpages clientindexshtml Phone 1shy800shy694shy3084

IOWA ndash Medicaid NEBRASKA ndash Medicaid Website wwwdhsstateiaushipp Phone 1shy888shy346shy9562

Website wwwACCESSNebraskanegov Phone 1shy877shy383shy4278

NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid Medicaid Website httpdwssnvgov Medicaid Phone 1shy800shy992shy0900

Website httpwwwscdhhsgov Phone 1shy888shy549shy0820

NEW HAMPSHIRE ndash Medicaid SOUTH DAKOTA ndash Medicaid Website httpwwwdhhsnhgovoiidocumentshippapppdf Phone 603shy271shy5218

Website httpdsssdgov Phone 1shy888shy828shy0059

NEW JERSEY ndash Medicaid and CHIP TEXAS ndash Medicaid Medicaid Website httpwwwstatenjushumanservices dmahsclientsmedicaid Medicaid Phone 609shy631shy2392 CHIP Website httpwwwnjfamilycareorgindexhtml CHIP Phone 1shy800shy701shy0710

Website httpswwwgethipptexascom Phone 1shy800shy440shy0493

NEW YORK ndash Medicaid UTAH ndash Medicaid and CHIP Website httpwwwnyhealthgovhealth_caremedicaid Phone 1shy800shy541shy2831

Website httphealthutahgovupp Phone 1shy866shy435shy7414

NORTH CAROLINA ndash Medicaid VERMONTndash Medicaid Website httpwwwncdhhsgovdma Phone 919shy855shy4100

Website httpwwwgreenmountaincareorg Phone 1shy800shy250shy8427

NORTH DAKOTA ndash Medicaid VIRGINIA ndash Medicaid and CHIP Website httpwwwndgovdhsservicesmedicalservmedicaid Phone 1shy800shy755shy2604

Medicaid Website httpwwwdmasvirginiagovrcpshyHIPPhtm Medicaid Phone 1shy800shy432shy5924 CHIP Website httpwwwfamisorg CHIP Phone 1shy866shy873shy2647

OKLAHOMA ndash Medicaid and CHIP WASHINGTON ndash Medicaid Website httpwwwinsureoklahomaorg Phone 1shy888shy365shy3742

Website httphrsadshswagovpremiumpymtApplyshtm Phone 1shy800shy562shy3022 ext 15473

OREGON ndash Medicaid and CHIP WEST VIRGINIA ndash Medicaid Website httpwwworegonhealthykidsgov httpwwwhijossaludablesoregongov Phone 1shy877shy314shy5678

Website wwwdhhrwvgovbms Phone 1shy877shy598shy5820 HMS Third Party Liability

PENNSYLVANIA ndash Medicaid WISCONSIN ndash Medicaid Website httpwwwdpwstatepaushipp Phone 1shy800shy692shy7462

Website httpwwwbadgercareplusorgpubspshy10095htm Phone 1shy800shy362shy3002

RHODE ISLAND ndash Medicaid WYOMING ndash Medicaid Website wwwohhsrigov Phone 401shy462shy5300

Website httphealthwyogovhealthcarefinequalitycare Phone 307shy777shy7531

To see if any more States have added a premium assistance program since January 31 2013 or for more information on special enrollment rights you can contact either

US Department of Labor Employee Benefits Security Administration wwwdolgovebsa 1shy866shy444shyEBSA (3272)

US Department of Health and Human Services Centers for Medicare amp Medicaid Services wwwcmshhsgov 1shy877shy267shy2323 Ext 61565

OMB Control Number 1210shy0137 (expires 09302013)

19122-1-14 (70-16)_20 pages

19122-15-20 (70-16)_6 pages

19122-21-86 (70-16)_0

This page intentionally left blank

Table of Contents

Things to consider

What does TCC offer

When can I enroll

How do I enroll

Definitions

Enrollment Code

TCC 102 of your

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

MHBP shystd

MHBP shyValue Plan

NALC shyhigh

NALC Value Option

SAMBA shyhigh

SAMBA shystd

800shy222shy2798

Local phone

800shy821shy6136

800shy410shy7778

888shy636shy6252

800shy638shy6589

126114

142015

126195

145991

148291

109939

130096

168477

122733

APWU shyhigh

BCBS shystd

BCBS shybasic

GEHA shyhigh

GEHA shystd

MHBP shystd

MHBP shyvalue

NALC shyhigh

NALC shyValue

SAMBA shyhigh

SAMBA shystd

Benefit Type

Per Person

Calendar Year

Prescription Drug

Hospital Inpatient

Office Visits

Hospital Inpatient

RampB Level I

Prescription Drugs

Level II Level III

Deductible

MHBP shystd

MHBP shyValue Plan

NALC shyhigh

SAMBA shyhigh

SAMBA shystd

FFS National A

Plan Code

verage 805

Getting needed care

How well doctors

communicate

Customer service

Claims processing

Plan Name Location

Plan Code

Getting needed care

How well doctors

Claims processing

Arizona 10 11

851 747

905 898

919 884

933 923

938 914

969 928

724 680

California 10 11

809 705

915 873

897 840

954 943

881 910

937 912

677 616

768 691

935 893

930 874

951 940

882 881

898 922

657 622

Florida 10 11

864 806

942 916

922 894

952 947

934 916

954 937

733 660

Illinois 10 11

861 796

933 912

934 881

955 950

901 936

972 938

712 653

Maryland 10 11

857 770

931 897

917 898

954 940

897 921

956 967

713 666

Texas 10 11

887 825

934 898

931 883

950 955

936 910

957 967

721 617

Virginia 10 11

871 782

924 901

929 894

966 962

914 917

959 960

708 681

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Alabama

Alaska

Arizona

Arkansas

F54 F55

JS4 JS5

G54 G55

WQ1 WQ2

A71 A72

A74 A75

BF1 BF2

BF4 BF5

C71 C72

C74 C75

F54 F55

DH1 DH2

DH4 DH5

13058 29656

17258 41140

12822 29119

33482 89188

26548 80303

19509 62476

13880 30882

12491 27794

15825 35210

13149 29256

13058 29656

30353 76056

14296 38452

53279 120995

61069 138677

52315 118808

77618 187686

70545 178623

63365 160440

56629 125999

50965 113400

59608 132629

53648 119367

53279 120995

74426 174291

58048 135935

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Alabama

HMOPOS Nationa

30to$60050 to$1200 Yes

l Average 679 864 849 942 877 875 649

Alaska

$25$40

50+50+

30to$60050 to$1200

Arizona

$25$40

50+50+

30to$60050 to$1200

Arkansas

$20$35

$20$40

$25$50

$20$35

$25$40

$20$35

$25$40

$250day x 4

$250dayx5

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+50+

$35$100

$40$60

30to$60050 to$1200

$20$30

$20$40

$100max$500

$200max$1000

50+50+

$40$60

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

California

Colorado

Connecticut

Delaware

JS4 JS5

2X1 2X2

B31 B32

SI1 SI2

LB1 LB2

LB4 LB5

LP1 LP2

LP4 LP5

KC1 KC2

591 592

594 595

621 622

624 625

CY1 CY2

CY4 CY5

G54 G55

651 652

654 655

EP4 EP5

P31 P32

P34 P35

17258 41140

15940 41769

18194 43825

18445 42566

77474 182834

71405 168807

30687 74663

27027 66198

18293 47705

35345 91275

22772 58183

14073 35293

9019 20845

22819 54699

13109 30036

12822 29119

23933 55581

9887 22345

12694 28827

64801 164359

49560 118027

61069 138677

59725 139319

62024 141416

62280 140132

122490 283205

116299 268898

74767 172871

71034 164236

62125 145373

79518 189815

66694 156061

57420 132713

36797 85048

66742 152507

53485 122549

52315 118808

67878 153407

40339 91170

51792 117616

109563 264361

94017 217102

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

California

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

Colorado

$20$35

$25$35

$20$30

$30$50

$20$30

$30$50

$25$35

$15$25

$30$40

$15$25

$30$40

$20$35

$25$40

$250day x 4

$250max4days

$200 x 3 days

$150dayx5

$150day x 4

$5$40$60

50+50+

$35$100

$5$40$70$60

$35$60

$35$65

$35$60

$35$65

$35$35

$30$30

$35$35

$30$30

$35$35

$35$60

$25$50

30to$60050 to$1200

Connecticut

$20$40

$25$40

$250x3

50+50+

$35$60

$40$80

30to$60050 to$1200

Delaware

$25$40

50+50+

30to$60050 to$1200

$20$35

$15$35

$250day x 4

20 Plan Allow

50+50+

$35$100

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Florida

877shy459shy6604

888shy789shy9065

877shy574shy3337

877shy835shy9861

877shy459shy6604

800shy882shy8633

850shy383shy3311

800shy441shy5501

888shy393shy6765

F54 F55

JN1 JN2

JN4 JN5

2G1 2G2

2G4 2G5

E31 E32

E34 E35

JP1 JP2

F54 F55

ML1 ML2

ML4 ML5

EA1 EA2

5E1 5E2

5E4 5E5

MJ4 MJ5

QP4 QP5

E21 E22

E24 E25

EE1 EE2

EE4 EE5

EX1 EX2

EX4 EX5

LL1 LL2

LL4 LL5

13058 29656

46867 105610

14021 31351

21177 48693

15284 35429

16926 42124

9646 22186

20245 50123

13058 29656

20336 56279

12604 30253

11679 30949

16664 47450

12501 30003

10247 22697

13149 29256

11834 26331

23153 51514

15825 35210

13880 30882

12491 27794

48720 108398

15825 35208

53279 120995

91271 204437

57208 127913

65067 146381

59056 132852

60731 139681

39358 90520

64116 147840

53279 120995

64209 154119

51424 123431

47650 126273

60464 145113

51005 122414

41809 92606

53648 119367

48282 107430

67082 149259

59608 132629

56629 125999

50965 113400

93161 207280

59608 132627

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

HMOPOS Nationa

30to$60050 to$1200 Yes

l Average 679 864 849 942 877 875 649

$15$30

$20$35

$25$35

Nothing$35

$150day x3

10 Plan Allow

Nothing

50+50+

$35$100

$35$65

MD IPAshyHigh

Florida

$70$70

$10$20

$20$30

$25$40

$250dayx3

$150day x 3

Nothing

$7$17 Net

$12$22Net

$35$65

$30$50$45$65

$35$55$50$70

$30$60

30to$60050 to$1200

$15$40

$25$45

Nothing$15

$15$30

$20$50

$35$55

$250dayx3

$300dayx3

Ded + $150x3

Ded + $150x5

$15 Tier 1

50+50+

$30$5030

$40$6030

$40$6020

$50$7020

$40$60

$30 Tier 2 $50 Tier 3

$35$55

$40+$60+

$40$60

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$40+$60+

$40$60

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Georgia

877shy459shy6604

888shy393shy6765

888shy865shy5813

671 479shy7982

671shy647shy3526

877shy459shy6604

800shy776shy4672

808shy432shy5955

F54 F55

2U1 2U2

AD4 AD5

LM4 LM5

CB1 CB2

CB4 CB5

DG1 DG2

DG4 DG5

DN1 DN2

DN4 DN5

F81 F82

F84 F85

B41 B42

JK1 JK2

JK4 JK5

JS4 JS5

871 872

631 632

634 635

13058 29656

44133 104232

10247 22697

15825 35210

13880 30882

15825 35210

13149 29256

15825 35210

13880 30882

15015 36863

10047 22957

11949 31399

12447 36018

10209 26960

17258 41140

11377 25325

14515 32578

7553 16846

53279 120995

88482 203031

41809 92606

59608 132629

56629 125999

59608 132629

53648 119367

59608 132629

56629 125999

58782 134315

40991 93667

48751 128109

50786 133453

41654 109996

61069 138677

46419 103326

58272 129944

30818 68731

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Georgia

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$20$35

$35$55

$250day x 4

50+50+

$35$100

$40$60

59 90 878 941 86 857 62

$35$55

$40+$60+

$40$60

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$30

$20$35

$15$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250dayx3

$10$20 Comm

$15$25 Comm

$40+$60+

$40$60

$2550 of AWP

$40$50 Comm $40$50 Comm

TakeCareshyHigh

TakeCareshyStandard

$5 at FHP$40

$25$40

$100day for 5

$150day for 5

$25$50

$40$80

30to$60050 to$1200

HMSA InshyNetwork

$15$15

50+50+

$30$65

$20$20

$30$30

$7 + 20

$45$45

$50$50

$30 + 20 $65 + 20 No

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Illinois

H44 H45

9K1 9K2

DK4 DK5

541 542

544 545

SF1 SF2

SF4 SF5

H44 H45

A21 A22

9G1 9G2

FX1 FX2

K84 K85

9F1 9F2

AB4 AB5

GB4 GB5

MW4 MW5

751 752

754 755

761 762

B91 B92

YH1 YH2

13093 29732

19819 42542

11798 25954

27070 55009

11742 26509

19210 43095

12435 27741

13093 29732

30483 71121

32158 67069

26932 67294

20323 51891

51805 115264

15825 35210

10247 22697

40638 90413

15825 35210

14109 33787

33072 74273

14091 38330

53418 121307

63682 140107

48136 105894

71078 152824

47908 108156

63060 140671

50737 113183

53418 121307

74559 169258

76267 165125

70937 165354

64196 149643

96307 214284

59608 132629

41809 92606

84917 188936

59608 132629

57566 131177

77200 172473

57491 135811

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

SelectHealthshyHigh

Illinois

$20$30

$20$40

$25$25

$25$35

$15$25

$20$30

$25$40

$100 after

$5 $25$50

50+50+

$25$50

$35$60

$40$60

$25$50$50

$25$50

30to$60050 to$1200

$20$35

$25$35

$200day x 5

$10 copay

50+50+

$40$60

$40$6025 $6025

30 after ded

$25$50

$20$35

$25$40

$35$55

30 after ded

$200day x 5

$250day x 3

$500day x 3

$35$70

$40$60

745 915 88 962 878 868 67

$35$55

$40+$60+

$40$60

$20$35

$25$40

$15$15

$25$40

$25$50

$250day x 3

$500day x 3

$40+$60+

$40$60

$35$60

$30$60

$35$50

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Indiana

JS4 JS5

FX1 FX2

K84 K85

MW4 MW5

A61 A62

A64 A65

751 752

754 755

MH1 MH2

MH4 MH5

DQ1 DQ2

H44 H45

SV1 SV2

SY4 SY5

FX1 FX2

K84 K85

V31 V32

V34 V35

AU1 AU2

AU4 AU5

YH1 YH2

17258 41140

26932 67294

20323 51891

10247 22697

13880 30882

12491 27794

40638 90413

15825 35210

13880 30882

30786 68557

13093 29732

13351 31376

9799 23027

26932 67294

20323 51891

26865 64982

8897 20464

26173 63455

23647 57594

14091 38330

61069 138677

70937 165354

64196 149643

41809 92606

56629 125999

50965 113400

84917 188936

59608 132629

56629 125999

74868 166643

53418 121307

54474 128016

39979 93951

70937 165354

64196 149643

70869 162996

36302 83494

70163 161438

67586 155460

57491 135811

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Indiana

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$25$50

$35$55

$200day x 5

50+50+

$35$70

$40$60

745 915 88 962 878 868 67

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$15

$25$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$40+$60+

$40$60

$25$50

30to$60050 to$1200

$25$50

$25$45

$0 for 3 then 20

$20$30

$200day x 5

Nothing

20 in40 out

$100day x 5

$3 $10

50+50+

$45$70$100

30$5000 Max

$35$70

$45$90

$40$70

$30$50

$25$25

$100day x 5

40+40+

$30$50

40+40+

$25$50

40+40+

$35$50

Yes 577 896 86 956 914 918 623

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Kansas

Kentucky

Louisiana

877shy459shy6604

800shy969shy3343

888shy393shy6765

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy341shy6613

888shy393shy6765

G54 G55

HY1 HY2

HA1 HA2

HA4 HA5

PH4 PH5

MS1 MS2

MS4 MS5

H44 H45

A61 A62

A64 A65

MH1 MH2

MH4 MH5

MI1 MI2

MI4 MI5

F54 F55

BJ1 BJ2

BJ4 BJ5

AE1 AE2

AE4 AE5

BC1 BC2

BC4 BC5

12822 29119

13777 50039

13519 32270

12568 29535

10247 22697

62521 139111

15825 35210

13093 29732

13880 30882

12491 27794

15825 35210

13880 30882

19459 43292

13880 30882

13058 29656

19208 48754

13035 30271

15825 35210

13149 29256

13880 30882

12491 27794

52315 118808

55396 147754

55160 129630

51276 120503

41809 92606

107238 238608

59608 132629

53418 121307

56629 125999

50965 113400

59608 132629

56629 125999

63314 140872

56629 125999

53279 120995

63058 146443

53182 123506

59608 132629

53648 119367

56629 125999

50965 113400

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Kansas

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$20$35

$30$60

$35$55

$250day x 4

$3 $12

50+50+

$35$100

$50$75

$40$60

Kentucky

$20$35

$25$40

$250day x 3

$500day x 3

$40+$60+

$40$60

30to$60050 to$1200

Louisiana

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+50+

$40$60

30to$60050 to$1200

$25$45

$30$55

$20$35

$35$40

$20$35

$35$40

Ded+$100

Ded+30

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+50+

$40$100

$40$60

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Maryland

Massachusetts

EP4 EP5

F54 F55

JN1 JN2

JN4 JN5

2G1 2G2

2G4 2G5

IG1 IG2

IG4 IG5

E31 E32

E34 E35

JP1 JP2

EP4 EP5

JG1 JG2

12694 28827

13058 29656

46867 105610

14021 31351

21177 48693

15284 35429

14998 37685

13265 30509

16926 42124

9646 22186

20245 50123

12694 28827

29337 80043

51792 117616

53279 120995

91271 204437

57208 127913

65067 146381

59056 132852

58764 135153

54121 124479

60731 139681

39358 90520

64116 147840

51792 117616

73390 178358

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

Maryland

$25$40

50+50+

30to$60050 to$1200

$15$30

$20$35

$25$35

Nothing$35

$150day x3

10 Plan Allow

Nothing

50+50+

$35$100

$35$65

MD IPAshyHigh

Massachusetts

$70$70

$20$40

$10$20

$20$30

$25$40

$200day x 3

$250dayx3

$150day x 3

Nothing

$7$17 Net

$12$22Net

$35$65

$30$60

$30$50$45$65

$35$55$50$

$30$60

30to$60050 to$1200

70 Yes

$25$35

$150to$750max

50+50+

$30$60

Yes 627 851 882 929 883 801 649

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Michigan

Minnesota

G54 G55

K51 K52

LX1 LX2

RL1 RL2

RL4 RL5

521 522

GY4 GY5

X51 X52

A51 A52

H44 H45

V31 V32

V34 V35

H44 H45

12822 29119

22055 52593

18055 50747

24184 61492

19656 50897

20111 55722

16974 48191

13915 49809

13670 50117

13093 29732

26865 64982

8897 20464

13093 29732

52315 118808

65962 150359

61882 148476

68134 159436

63515 148629

63980 153551

60780 145869

56775 147520

55776 147834

53418 121307

70869 162996

36302 83494

53418 121307

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

Michigan

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

Minnesota

$15$25

$10$10

$20$20

$10$20

$15$30

$10$20

$15$15

$25$40

Nothing

$500x3

Nothing

50+50+

$30$60

$15$15

$50$50

$40$60

$40$40

30to$60050 to$1200

$25$45

$0 for 3 then 20

$25$40

Nothing

20 in40 out

50+50+

$45$90

$40$70

30to$60050 to$1200

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Montana

Nebraska

Nevada

New Hampshire

877shy459shy6604

888shy811shy2092

800shy969shy3343

888shy393shy6765

877shy835shy9861

877shy459shy6604

877shy545shy7378

877shy459shy6604

G54 G55

HY1 HY2

9G1 9G2

HA1 HA2

HA4 HA5

PH4 PH5

MS1 MS2

MS4 MS5

B91 B92

H44 H45

G54 G55

HF1 HF2

NM1 NM2

EP4 EP5

12822 29119

13577 50039

32158 67069

13519 32270

12568 29535

10247 22697

62521 139111

15825 35210

33072 74273

13093 29732

12822 29119

11267 36491

9883 23303

12694 28827

52315 118808

55396 147754

76267 165125

55160 129630

51276 120503

41809 92606

107238 238608

59608 132629

77200 172473

53418 121307

52315 118808

45970 133935

40322 95078

51792 117616

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$20$35

$250day x 4

50+50+

$35$100 $40$60

Yes 639 862 862 94 838 901 538

30 after ded $30$60

$30$60

$35$55

30 after ded 25

NA $3 $12

$3 $12

NA $50$75

$40$60

NA Yes

Montana

$20$35

$25$40

$250day x 3

$500day x 3

$40+$60+

$40$60

$30$60

30to$60050 to$1200

Nebraska

$25$40

50+50+

30to$60050 to$1200

Nevada

$25$40

50+50+

30to$60050 to$1200

New Hampshire

$20$35

$10$25

$25$40

$250day x 4

50+50+

$35$100

$35$55$100

30to$60050 to$1200

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

New Jersey

New Mexico

EP4 EP5

JR1 JR2

JR4 JR5

P31 P32

P34 P35

801 802

804 805

G54 G55

Q11 Q12

P21 P22

12694 28827

52355 123641

34184 82457

64801 164359

49560 118027

32591 93212

14135 33572

12822 29119

13099 30785

23940 56335

51792 117616

96868 222828

78334 180821

109563 264361

94017 217102

76709 191791

57672 130958

52315 118808

53445 125603

67885 154176

Prescription Drugs

Mail lan

ll icate

r ng rmation

order discount

Overall p

satisfaction

Getting n

Getting c

quickly

doctors

commun

Custome

service

Claims

processi

New Jersey

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$20$35

$15$35

$20$35

$15$35

$20$20

$250day x 4

20 Plan Allow

$250day x 4

20 Plan Allow

$150max$450

50+50+

$35$100

$45$85

New Mexico

50 of sch

$30$30

$25$40

+50 of sch

$250day x 3

$45$85

30to$60050 to$1200

663 844 851 936 86 828 642

$25$35

$25$40

$250 after ded

$100 x 5 days

50+50+

$35$6050

$40$7550

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

New York

EP4 EP5

JC1 JC2

JC4 JC5

SG1 SG2

SG4 SG5

6V1 6V2

X41 X42

801 802

804 805

511 512

514 515

QA1 QA2

C54 C55

GA1 GA2

GA4 GA5

GV1 GV2

GV4 GV5

M91 M92

M94 M95

MF1 MF2

MF4 MF5

MX1 MX2

MX4 MX5

12694 28827

40198 109033

26007 71920

22952 71235

12294 32053

19548 60991

14167 47634

32591 93212

14135 33572

17000 63158

12206 34562

18597 58201

14454 47853

16586 53386

13377 39674

13042 35704

11193 28006

17110 54877

13779 42651

25417 75411

22349 67734

18731 58664

13657 42345

51792 117616

84468 207928

69993 170073

66877 169374

50161 129408

63405 158925

57800 145301

76709 191791

57672 130958

60806 161136

49800 131968

62435 156079

58209 145524

60384 151168

54580 137182

53210 133132

45669 114266

60918 152689

56220 140218

69392 173634

66262 165803

62572 156552

55723 139906

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

New York

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$20$35

$15$35

$20$30

$25$40

$20$20

$250day x 4

20 Plan Allow

$100 x 5

$500+10

$150max$450

50+50+

$35$100

$30$50

$45$85

50 of sch

$30$30

$20$40

$30$50

$25$25

+50 of sch

$250day x 3

$15$100Ded

$45$85

$35$75

$30$75

$35$75 $75$100Ded

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

North Carolina

North Dakota

Oklahoma

F54 F55

H44 H45

V31 V32

V34 V35

RU1 RU2

C91 C92

C94 C95

JS4 JS5

3A1 3A2

A61 A62

A64 A65

641 642

644 645

U41 U42

JS4 JS5

IM1 IM2

13058 29656

13093 29732

26865 64982

8897 20464

13803 47086

20976 51441

14143 45836

17258 41140

14204 44676

13880 30882

12491 27794

28758 69344

13114 30163

26271 60855

17258 41140

11810 28460

53279 120995

53418 121307

70869 162996

36302 83494

56317 144742

64862 149184

57705 143467

61069 138677

57953 142284

56629 125999

50965 113400

72799 167445

53504 123066

70263 158786

61069 138677

48185 116118

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

North Carolina

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

North Dakota

$25$40

50+50+

30to$60050 to$1200

$25$45

$0 for 3 then 20

$15$25

Nothing

20 in40 out

50$600ded

50+50+

$45$90

$40$70

50$600 ded

$20$30

$100day x 5

$30$50

$25$25

$100day x 5

40+40+

$30$50

40+40+

$25$40

40+40+

30to$60050 to$1200

AultCare HMOshyHigh

Oklahoma

$15$20

$20$35

$25$40

$20$20

$30$40

$10$20

$25$40

$250day x 3

$500day x 3

50+50+

$30$40$55

$40$60

$30$30

$40$40

$30$50

30to$60050 to$1200

$15$45

$250dymx1000

50+50+

$45$70

Yes 592 816 839 916 893 872 727

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Oregon

Pennsylvania

Puerto Rico

Rhode Island

South Carolina

877shy459shy6604

800shy813shy2000

877shy459shy6604

800shy447shy4000

866shy351shy5946

888shy876shy2756

800shy314shy3121

787shy774shy6060

877shy459shy6604

H44 H45

571 572

574 575

H44 H45

P31 P32

P34 P35

YE1 YE2

GG4 GG5

261 262

8W1 8W2

UW4 UW5

ZJ1 ZJ2

891 892

EP4 EP5

JS4 JS5

13093 29732

22672 52645

13617 31283

13093 29732

64801 164359

49560 118027

19203 59806

16820 41884

17814 47183

22135 54101

13345 30692

8026 18317

8829 19866

12694 28827

17258 41140

53418 121307

66592 150412

55557 127637

53418 121307

109563 264361

94017 217102

63053 157716

60623 139436

61637 144841

66044 151897

54448 125225

32748 74733

36023 81052

51792 117616

61069 138677

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Oregon

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

Pennsylvania

$20$30

$30$40

$25$40

50+50+

$40$60

30to$60050 to$1200

Puerto Rico

$20$35

$15$35

$20$35

$25$50

10 after Deduct

20 after Deduct

$250day x 4

20 Plan Allow

$250day x 4

20aftrDeduct

15 after ded

10 after deduct

20after Deduct

30 $5$15

$5 after ded

50+50+

$35$100

$35$60

$35$75

$35$75$100

$10$15

40 $40$120 50 $85$250

Rhode Island

$750$10

$25$40

$750 amp 10 +$10 amp 10 +

None 10 +

$5 or $12 NA

2025 up to$100$175max

30to$60050 to$1200

Yes No

691 874 844 963 872 75 586

South Carolina

$25$40

50+50+

30to$60050 to$1200

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

South Dakota

Tennessee

G54 G55

V31 V32

V34 V35

AU1 AU2

AU4 AU5

F54 F55

UB1 UB2

GJ1 GJ2

GJ4 GJ5

12822 29119

26865 64982

8897 20464

26173 63455

23647 57594

13058 29656

24581 76516

15825 35210

12491 27794

52315 118808

70869 162996

36302 83494

70163 161438

67586 155460

53279 120995

68539 174761

59608 132629

50965 113400

Primary

Prescription Drugs

ded ation

care Hospital Mail

Getting nee

How well

r ng rm

Level II Level III

order discount

Overall

satisfaction

Getting

quickly

doctors

commun

Custome

service

Claims

processi

Plan Info

on Costs

South Dakota

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$25$45

$0 for 3 then 20

$20$30

Nothing

20 in40 out

$100day x 5

50+50+

$45$90

$40$70

$30$50

$25$25

$100day x 5

40+40+

$30$50

Tennessee

40+40+

$25$40

40+40+

30to$60050 to$1200

$20$35

$25$40

$250day x 4

$250day x 3

$500day x 3

50+50+

$35$100

$40$60

66 875 868 959 889 914 69

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

JS4 JS5

ES1 ES2

B71 B72

CK1 CK2

CN1 CN2

CZ1 CZ2

ET1 ET2

TP4 TP5

TU4 TU5

TV4 TV5

EW1 EW2

EW4 EW5

UC1 UC2

UC4 UC5

UR1 UR2

UR4 UR5

UU1 UU2

UU4 UU5

A84 A85

GF1 GF2

17258 41140

12817 40332

11057 37880

10809 34896

13391 65886

13031 61566

12638 56836

10247 22697

13880 30882

12491 27794

17899 39821

13880 30882

55020 122416

13880 30882

26524 59015

15825 35210

14907 37260

32515 78160

61069 138677

52295 137853

45113 135352

44103 132308

54635 163918

53169 159512

51562 154687

41809 92606

56629 125999

50965 113400

61723 137332

56629 126001

99587 221579

56629 126001

70521 156910

59608 132629

58671 134720

76632 176438

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$5$25$35

50+50+

$35$60

FirstcareshyHigh

$30$55

$35$55

$250day x 5

$35$70

$40$60

$35$55

$40+$60+

$40$60

$35$55

$40+$60+

$40$60

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$45

$20$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 5

$40+$60+

$40$60

$45$100

$35$60

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Virgin Islands

G54 G55

9K1 9K2

DK4 DK5

SF1 SF2

SF4 SF5

EP4 EP5

851 852

12822 29119

19819 42542

11798 25954

19210 43095

12435 27741

12694 28827

10305 23402

52315 118808

63682 140107

48136 105894

63060 140671

50737 113183

51792 117616

42043 95481

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

SelectHealthshyHigh

$20$30

$20$40

$15$25

$20$30

$25$40

$100 after

$5$25$50

50+50+

$25$50

$35$60

$25$50$50

$25 $50$50

30to$60050 to$1200

Virgin Islands

4040 40 50+ 50+50+ No

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

None 10 +

$5 or $12 NA NA

2025 up to$100$175max

Yes No

691 874 844 963 872 75 586

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Virginia

Washington

F54 F55

JN1 JN2

JN4 JN5

D91 D92

J91 J92

2G1 2G2

2G4 2G5

A91 A92

E31 E32

E34 E35

JP1 JP2

9R1 9R2

9R4 9R5

2C1 2C2

G54 G55

C31 C32

541 542

544 545

L11 L12

VT1 VT2

571 572

574 575

13058 29656

46867 105610

14021 31351

12138 40332

11280 29365

21177 48693

15284 35429

20427 47008

16926 42124

9646 22186

20245 50123

26858 69565

11269 26665

12235 28017

12822 29119

14933 62274

27070 55009

11742 26509

12426 26823

31651 67459

22672 52645

13617 31283

53279 120995

91271 204437

57208 127913

49524 137853

46023 119808

65067 146381

59056 132852

64302 144663

60731 139681

39358 90520

64116 147840

70861 167671

45977 108794

49920 114308

52315 118808

58698 160234

71078 152824

47908 108156

50700 109437

75750 165523

66592 150412

55557 127637

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

Virginia

$25$40 4040

$15$30

$20$35

$25$35 4040

$5$25$35 4040

$25$35

Nothing$35

$150day x3

10 Plan Allow

$10 50+

Nothing

50+50+

$35$100

$35$60 4040

$35$65

30to$60050 to$1200

POS National

Yes No

Average

MD IPAshyHigh

Washington

$70$70

$10$20

$20$30

$25$40

$25$30

$35$35

$25$40 4040

$20$35

$25$25

$25$35

$154 or 2020

$30$30 $30+40+diff

$20$30

$30$40

$20$0childlt22$30

$200 x3 days

$250dayx3

$150day x 3

$150max$750

$20020

$250day x 4

Nothing Nothing

None None

Nothing

$7$17 Net

$12$22Net

$10 50+

$10 Not Covered

$5 Not Covered

$35$65

$30$50$50

$30$50$45$65

$35$55$50$70

$30$60

$40$55

50+50+

$35$100

$40$60

Not Covered

$40$60

$353050up to $3000

$355050 up to $3000

$35$50 30day$100 90day

$25$50 30day$100 90day

30to$60050 to$1200

Yes No

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

West Virginia

Wisconsin

Wyoming

F54 F55

U41 U42

JS4 JS5

F71 F72

WD1 WD2

WJ1 WJ2

V31 V32

V34 V35

EY1 EY2

LW1 LW2

H44 H45

9K1 9K2

DK4 DK5

13058 29656

26271 60855

17258 41140

10600 29208

24382 72670

15910 51534

26865 64982

8897 20464

14597 48275

16556 55954

13093 29732

19819 42542

11798 25954

53279 120995

70263 158786

61069 138677

43250 119170

68336 170838

59694 149279

70869 162996

36302 83494

58355 145955

60353 153787

53418 121307

63682 140107

48136 105894

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Claims

processing

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Plan Inform

on Costs

West Virginia

Wisconsin

Wyoming

$25$40 4040

$10$20

$25$40 4040

$25$35 4040

$25$25

$10$10

$25$45

$0 for 3 then 20

$10$10

$25$40 4040

$20$30

$20$40

Nothing

20 in40 out

Nothing

$10 Yes 50+ 50+50+ No

$15 $30$50 Yes

$10 Yes 50+ 50+50+ No

$5 $35$60 Yes 40 4040 No

$10 Yes

$5 $20$20 Yes

$12 $45$90 Yes

$9 $40$70 Yes

$10 $20$50 Yes

$10 3050 No

$10 Yes 50+ 50+50+ No

$7 $25$50 No

$7 $35$60 None

30$75max 50 wmin$50

30to$60050 to$1200

909 876 951 929 944

909 90 97 834 879

834 834 953 929 932

893 875 951 92 911

888 854 938 888 87

857 822 96 863 866

852 813 948 883 895

864 849 942 877 875

ELIGIBILITY

FUNDING

CONTRIBUTIONS

DISTRIBUTIONS

ANNUAL ROLLOVER

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

800shy718shy1299

800shy821shy6136

800shy694shy9901

888shy636shy6252

474 475

341 342

481 482

324 325

9742 21915

11021 25172

13642 30912

10454 22700

39747 89414

44967 102703

55661 126120

42653 92617

Plan Code

885 866 929 860

891 888 952 830

873 851 923 863

891 859 912 887

881 865 939 850

891 888 952 830

909 907 925 871

849 864 932 843

875 801 948 856

Getting needed care

How well doctors

Getting needed care

How well doctors

Claims processing

Plan Name

Telephone Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Premium

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Plan Name

877shy459shy6604

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

136516

151489

149613

136516

151489

149613

Self amp family

Plan Name

Benefit Type

CY Ded SelfFamily

Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Premium

Connecticut

Delaware

Florida

Georgia

Plan Name

877shy459shy6604

888shy789shy9065

877shy459shy6604

800shy441shy5501

888shy393shy6765

877shy459shy6604

888shy393shy6765

671shy647shy3526

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

145440

136516

127574

136516

141522

116366

136516

105282

110827

Self amp family

Connecticut

Delaware

Florida

Georgia

Premium

Illinois

Indiana

Kansas

Plan Name

877shy459shy6604

800shy377shy4161

877shy459shy6604

888shy393shy6765

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy257shy4692

877shy459shy6604

800shy969shy3343

888shy393shy6765

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

151489

136317

110827

110823

151489

110823

136317

149613

122219

Self amp family

Illinois

Indiana

Kansas

Premium

Kentucky

Louisiana

Maryland

Massachusetts

Michigan

Minnesota

Plan Name

877shy459shy6604

888shy393shy6765

877shy459shy6604

888shy789shy9065

800shy833shy7423

877shy459shy6604

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

136317

136516

145440

136516

127574

109488

145440

149613

136317

Self amp family

Kentucky

Louisiana

Maryland

OutshyNetWork

InshyNetwork

$3750$7500

$4167$8334

$3000$6000

$2000$4000

$6000$12000

$4000$8000

Nothing

Nothing$30$60

Massachusetts

Michigan

Minnesota

Premium

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

Plan Name

877shy459shy6604

800shy969shy3343

888shy393shy6765

877shy459shy6604

800shy501shy3439

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

149613

122219

136317

149613

145440

149613

145440

101669

Self amp family

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

Premium

North Carolina

North Dakota

Pennsylvania

Rhode Island

South Carolina

Plan Name

877shy459shy6604

330shy363shy6360

877shy459shy6604

866shy351shy5946

888shy876shy2756

877shy459shy6604

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

136516

136317

151489

136317

115650

114458

145440

151489

Self amp family

North Carolina

North Dakota

Pennsylvania

Rhode Island

South Carolina

Plan Name

CY Ded SelfFamily

Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

10After Deduct

10 after deduct

30After Deduct

30 after deduct

Premium

South Dakota

Tennessee

Vermont

Plan Name

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy377shy4161

877shy459shy6604

888shy789shy9065

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

149613

136516

151489

110827

110823

121906

149613

145440

136516

127574

Self amp family

South Dakota

Tennessee

Vermont

Premium

Wyoming

Plan Name

877shy459shy6604

800shy552shy7114

877shy459shy6604

800shy377shy4161

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

149613

136516

151489

136317

Self amp family

Wyoming

Plan Name

CY Ded SelfFamily

Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

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

______________________________________________________________________________________________________________

19122-1-14 (70-16)_20 pages

19122-15-20 (70-16)_6 pages

19122-21-86 (70-16)_0

Table of Contents

Things to consider

What does TCC offer

When can I enroll

How do I enroll

Definitions

Enrollment Code

TCC 102 of your

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

MHBP shystd

MHBP shyValue Plan

NALC shyhigh

NALC Value Option

SAMBA shyhigh

SAMBA shystd

800shy222shy2798

Local phone

800shy821shy6136

800shy410shy7778

888shy636shy6252

800shy638shy6589

126114

142015

126195

145991

148291

109939

130096

168477

122733

APWU shyhigh

BCBS shystd

BCBS shybasic

GEHA shyhigh

GEHA shystd

MHBP shystd

MHBP shyvalue

NALC shyhigh

NALC shyValue

SAMBA shyhigh

SAMBA shystd

Benefit Type

Per Person

Calendar Year

Prescription Drug

Hospital Inpatient

Office Visits

Hospital Inpatient

RampB Level I

Prescription Drugs

Level II Level III

Deductible

MHBP shystd

MHBP shyValue Plan

NALC shyhigh

SAMBA shyhigh

SAMBA shystd

FFS National A

Plan Code

verage 805

Getting needed care

How well doctors

communicate

Customer service

Claims processing

Plan Name Location

Plan Code

Getting needed care

How well doctors

Claims processing

Arizona 10 11

851 747

905 898

919 884

933 923

938 914

969 928

724 680

California 10 11

809 705

915 873

897 840

954 943

881 910

937 912

677 616

768 691

935 893

930 874

951 940

882 881

898 922

657 622

Florida 10 11

864 806

942 916

922 894

952 947

934 916

954 937

733 660

Illinois 10 11

861 796

933 912

934 881

955 950

901 936

972 938

712 653

Maryland 10 11

857 770

931 897

917 898

954 940

897 921

956 967

713 666

Texas 10 11

887 825

934 898

931 883

950 955

936 910

957 967

721 617

Virginia 10 11

871 782

924 901

929 894

966 962

914 917

959 960

708 681

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Alabama

Alaska

Arizona

Arkansas

F54 F55

JS4 JS5

G54 G55

WQ1 WQ2

A71 A72

A74 A75

BF1 BF2

BF4 BF5

C71 C72

C74 C75

F54 F55

DH1 DH2

DH4 DH5

13058 29656

17258 41140

12822 29119

33482 89188

26548 80303

19509 62476

13880 30882

12491 27794

15825 35210

13149 29256

13058 29656

30353 76056

14296 38452

53279 120995

61069 138677

52315 118808

77618 187686

70545 178623

63365 160440

56629 125999

50965 113400

59608 132629

53648 119367

53279 120995

74426 174291

58048 135935

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Alabama

HMOPOS Nationa

30to$60050 to$1200 Yes

l Average 679 864 849 942 877 875 649

Alaska

$25$40

50+50+

30to$60050 to$1200

Arizona

$25$40

50+50+

30to$60050 to$1200

Arkansas

$20$35

$20$40

$25$50

$20$35

$25$40

$20$35

$25$40

$250day x 4

$250dayx5

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+50+

$35$100

$40$60

30to$60050 to$1200

$20$30

$20$40

$100max$500

$200max$1000

50+50+

$40$60

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

California

Colorado

Connecticut

Delaware

JS4 JS5

2X1 2X2

B31 B32

SI1 SI2

LB1 LB2

LB4 LB5

LP1 LP2

LP4 LP5

KC1 KC2

591 592

594 595

621 622

624 625

CY1 CY2

CY4 CY5

G54 G55

651 652

654 655

EP4 EP5

P31 P32

P34 P35

17258 41140

15940 41769

18194 43825

18445 42566

77474 182834

71405 168807

30687 74663

27027 66198

18293 47705

35345 91275

22772 58183

14073 35293

9019 20845

22819 54699

13109 30036

12822 29119

23933 55581

9887 22345

12694 28827

64801 164359

49560 118027

61069 138677

59725 139319

62024 141416

62280 140132

122490 283205

116299 268898

74767 172871

71034 164236

62125 145373

79518 189815

66694 156061

57420 132713

36797 85048

66742 152507

53485 122549

52315 118808

67878 153407

40339 91170

51792 117616

109563 264361

94017 217102

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

California

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

Colorado

$20$35

$25$35

$20$30

$30$50

$20$30

$30$50

$25$35

$15$25

$30$40

$15$25

$30$40

$20$35

$25$40

$250day x 4

$250max4days

$200 x 3 days

$150dayx5

$150day x 4

$5$40$60

50+50+

$35$100

$5$40$70$60

$35$60

$35$65

$35$60

$35$65

$35$35

$30$30

$35$35

$30$30

$35$35

$35$60

$25$50

30to$60050 to$1200

Connecticut

$20$40

$25$40

$250x3

50+50+

$35$60

$40$80

30to$60050 to$1200

Delaware

$25$40

50+50+

30to$60050 to$1200

$20$35

$15$35

$250day x 4

20 Plan Allow

50+50+

$35$100

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Florida

877shy459shy6604

888shy789shy9065

877shy574shy3337

877shy835shy9861

877shy459shy6604

800shy882shy8633

850shy383shy3311

800shy441shy5501

888shy393shy6765

F54 F55

JN1 JN2

JN4 JN5

2G1 2G2

2G4 2G5

E31 E32

E34 E35

JP1 JP2

F54 F55

ML1 ML2

ML4 ML5

EA1 EA2

5E1 5E2

5E4 5E5

MJ4 MJ5

QP4 QP5

E21 E22

E24 E25

EE1 EE2

EE4 EE5

EX1 EX2

EX4 EX5

LL1 LL2

LL4 LL5

13058 29656

46867 105610

14021 31351

21177 48693

15284 35429

16926 42124

9646 22186

20245 50123

13058 29656

20336 56279

12604 30253

11679 30949

16664 47450

12501 30003

10247 22697

13149 29256

11834 26331

23153 51514

15825 35210

13880 30882

12491 27794

48720 108398

15825 35208

53279 120995

91271 204437

57208 127913

65067 146381

59056 132852

60731 139681

39358 90520

64116 147840

53279 120995

64209 154119

51424 123431

47650 126273

60464 145113

51005 122414

41809 92606

53648 119367

48282 107430

67082 149259

59608 132629

56629 125999

50965 113400

93161 207280

59608 132627

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

HMOPOS Nationa

30to$60050 to$1200 Yes

l Average 679 864 849 942 877 875 649

$15$30

$20$35

$25$35

Nothing$35

$150day x3

10 Plan Allow

Nothing

50+50+

$35$100

$35$65

MD IPAshyHigh

Florida

$70$70

$10$20

$20$30

$25$40

$250dayx3

$150day x 3

Nothing

$7$17 Net

$12$22Net

$35$65

$30$50$45$65

$35$55$50$70

$30$60

30to$60050 to$1200

$15$40

$25$45

Nothing$15

$15$30

$20$50

$35$55

$250dayx3

$300dayx3

Ded + $150x3

Ded + $150x5

$15 Tier 1

50+50+

$30$5030

$40$6030

$40$6020

$50$7020

$40$60

$30 Tier 2 $50 Tier 3

$35$55

$40+$60+

$40$60

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$40+$60+

$40$60

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Georgia

877shy459shy6604

888shy393shy6765

888shy865shy5813

671 479shy7982

671shy647shy3526

877shy459shy6604

800shy776shy4672

808shy432shy5955

F54 F55

2U1 2U2

AD4 AD5

LM4 LM5

CB1 CB2

CB4 CB5

DG1 DG2

DG4 DG5

DN1 DN2

DN4 DN5

F81 F82

F84 F85

B41 B42

JK1 JK2

JK4 JK5

JS4 JS5

871 872

631 632

634 635

13058 29656

44133 104232

10247 22697

15825 35210

13880 30882

15825 35210

13149 29256

15825 35210

13880 30882

15015 36863

10047 22957

11949 31399

12447 36018

10209 26960

17258 41140

11377 25325

14515 32578

7553 16846

53279 120995

88482 203031

41809 92606

59608 132629

56629 125999

59608 132629

53648 119367

59608 132629

56629 125999

58782 134315

40991 93667

48751 128109

50786 133453

41654 109996

61069 138677

46419 103326

58272 129944

30818 68731

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Georgia

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$20$35

$35$55

$250day x 4

50+50+

$35$100

$40$60

59 90 878 941 86 857 62

$35$55

$40+$60+

$40$60

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$30

$20$35

$15$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250dayx3

$10$20 Comm

$15$25 Comm

$40+$60+

$40$60

$2550 of AWP

$40$50 Comm $40$50 Comm

TakeCareshyHigh

TakeCareshyStandard

$5 at FHP$40

$25$40

$100day for 5

$150day for 5

$25$50

$40$80

30to$60050 to$1200

HMSA InshyNetwork

$15$15

50+50+

$30$65

$20$20

$30$30

$7 + 20

$45$45

$50$50

$30 + 20 $65 + 20 No

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Illinois

H44 H45

9K1 9K2

DK4 DK5

541 542

544 545

SF1 SF2

SF4 SF5

H44 H45

A21 A22

9G1 9G2

FX1 FX2

K84 K85

9F1 9F2

AB4 AB5

GB4 GB5

MW4 MW5

751 752

754 755

761 762

B91 B92

YH1 YH2

13093 29732

19819 42542

11798 25954

27070 55009

11742 26509

19210 43095

12435 27741

13093 29732

30483 71121

32158 67069

26932 67294

20323 51891

51805 115264

15825 35210

10247 22697

40638 90413

15825 35210

14109 33787

33072 74273

14091 38330

53418 121307

63682 140107

48136 105894

71078 152824

47908 108156

63060 140671

50737 113183

53418 121307

74559 169258

76267 165125

70937 165354

64196 149643

96307 214284

59608 132629

41809 92606

84917 188936

59608 132629

57566 131177

77200 172473

57491 135811

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

SelectHealthshyHigh

Illinois

$20$30

$20$40

$25$25

$25$35

$15$25

$20$30

$25$40

$100 after

$5 $25$50

50+50+

$25$50

$35$60

$40$60

$25$50$50

$25$50

30to$60050 to$1200

$20$35

$25$35

$200day x 5

$10 copay

50+50+

$40$60

$40$6025 $6025

30 after ded

$25$50

$20$35

$25$40

$35$55

30 after ded

$200day x 5

$250day x 3

$500day x 3

$35$70

$40$60

745 915 88 962 878 868 67

$35$55

$40+$60+

$40$60

$20$35

$25$40

$15$15

$25$40

$25$50

$250day x 3

$500day x 3

$40+$60+

$40$60

$35$60

$30$60

$35$50

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Indiana

JS4 JS5

FX1 FX2

K84 K85

MW4 MW5

A61 A62

A64 A65

751 752

754 755

MH1 MH2

MH4 MH5

DQ1 DQ2

H44 H45

SV1 SV2

SY4 SY5

FX1 FX2

K84 K85

V31 V32

V34 V35

AU1 AU2

AU4 AU5

YH1 YH2

17258 41140

26932 67294

20323 51891

10247 22697

13880 30882

12491 27794

40638 90413

15825 35210

13880 30882

30786 68557

13093 29732

13351 31376

9799 23027

26932 67294

20323 51891

26865 64982

8897 20464

26173 63455

23647 57594

14091 38330

61069 138677

70937 165354

64196 149643

41809 92606

56629 125999

50965 113400

84917 188936

59608 132629

56629 125999

74868 166643

53418 121307

54474 128016

39979 93951

70937 165354

64196 149643

70869 162996

36302 83494

70163 161438

67586 155460

57491 135811

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Indiana

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$25$50

$35$55

$200day x 5

50+50+

$35$70

$40$60

745 915 88 962 878 868 67

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$15

$25$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$40+$60+

$40$60

$25$50

30to$60050 to$1200

$25$50

$25$45

$0 for 3 then 20

$20$30

$200day x 5

Nothing

20 in40 out

$100day x 5

$3 $10

50+50+

$45$70$100

30$5000 Max

$35$70

$45$90

$40$70

$30$50

$25$25

$100day x 5

40+40+

$30$50

40+40+

$25$50

40+40+

$35$50

Yes 577 896 86 956 914 918 623

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Kansas

Kentucky

Louisiana

877shy459shy6604

800shy969shy3343

888shy393shy6765

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy341shy6613

888shy393shy6765

G54 G55

HY1 HY2

HA1 HA2

HA4 HA5

PH4 PH5

MS1 MS2

MS4 MS5

H44 H45

A61 A62

A64 A65

MH1 MH2

MH4 MH5

MI1 MI2

MI4 MI5

F54 F55

BJ1 BJ2

BJ4 BJ5

AE1 AE2

AE4 AE5

BC1 BC2

BC4 BC5

12822 29119

13777 50039

13519 32270

12568 29535

10247 22697

62521 139111

15825 35210

13093 29732

13880 30882

12491 27794

15825 35210

13880 30882

19459 43292

13880 30882

13058 29656

19208 48754

13035 30271

15825 35210

13149 29256

13880 30882

12491 27794

52315 118808

55396 147754

55160 129630

51276 120503

41809 92606

107238 238608

59608 132629

53418 121307

56629 125999

50965 113400

59608 132629

56629 125999

63314 140872

56629 125999

53279 120995

63058 146443

53182 123506

59608 132629

53648 119367

56629 125999

50965 113400

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Kansas

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$20$35

$30$60

$35$55

$250day x 4

$3 $12

50+50+

$35$100

$50$75

$40$60

Kentucky

$20$35

$25$40

$250day x 3

$500day x 3

$40+$60+

$40$60

30to$60050 to$1200

Louisiana

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+50+

$40$60

30to$60050 to$1200

$25$45

$30$55

$20$35

$35$40

$20$35

$35$40

Ded+$100

Ded+30

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+50+

$40$100

$40$60

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Maryland

Massachusetts

EP4 EP5

F54 F55

JN1 JN2

JN4 JN5

2G1 2G2

2G4 2G5

IG1 IG2

IG4 IG5

E31 E32

E34 E35

JP1 JP2

EP4 EP5

JG1 JG2

12694 28827

13058 29656

46867 105610

14021 31351

21177 48693

15284 35429

14998 37685

13265 30509

16926 42124

9646 22186

20245 50123

12694 28827

29337 80043

51792 117616

53279 120995

91271 204437

57208 127913

65067 146381

59056 132852

58764 135153

54121 124479

60731 139681

39358 90520

64116 147840

51792 117616

73390 178358

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

Maryland

$25$40

50+50+

30to$60050 to$1200

$15$30

$20$35

$25$35

Nothing$35

$150day x3

10 Plan Allow

Nothing

50+50+

$35$100

$35$65

MD IPAshyHigh

Massachusetts

$70$70

$20$40

$10$20

$20$30

$25$40

$200day x 3

$250dayx3

$150day x 3

Nothing

$7$17 Net

$12$22Net

$35$65

$30$60

$30$50$45$65

$35$55$50$

$30$60

30to$60050 to$1200

70 Yes

$25$35

$150to$750max

50+50+

$30$60

Yes 627 851 882 929 883 801 649

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Michigan

Minnesota

G54 G55

K51 K52

LX1 LX2

RL1 RL2

RL4 RL5

521 522

GY4 GY5

X51 X52

A51 A52

H44 H45

V31 V32

V34 V35

H44 H45

12822 29119

22055 52593

18055 50747

24184 61492

19656 50897

20111 55722

16974 48191

13915 49809

13670 50117

13093 29732

26865 64982

8897 20464

13093 29732

52315 118808

65962 150359

61882 148476

68134 159436

63515 148629

63980 153551

60780 145869

56775 147520

55776 147834

53418 121307

70869 162996

36302 83494

53418 121307

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

Michigan

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

Minnesota

$15$25

$10$10

$20$20

$10$20

$15$30

$10$20

$15$15

$25$40

Nothing

$500x3

Nothing

50+50+

$30$60

$15$15

$50$50

$40$60

$40$40

30to$60050 to$1200

$25$45

$0 for 3 then 20

$25$40

Nothing

20 in40 out

50+50+

$45$90

$40$70

30to$60050 to$1200

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Montana

Nebraska

Nevada

New Hampshire

877shy459shy6604

888shy811shy2092

800shy969shy3343

888shy393shy6765

877shy835shy9861

877shy459shy6604

877shy545shy7378

877shy459shy6604

G54 G55

HY1 HY2

9G1 9G2

HA1 HA2

HA4 HA5

PH4 PH5

MS1 MS2

MS4 MS5

B91 B92

H44 H45

G54 G55

HF1 HF2

NM1 NM2

EP4 EP5

12822 29119

13577 50039

32158 67069

13519 32270

12568 29535

10247 22697

62521 139111

15825 35210

33072 74273

13093 29732

12822 29119

11267 36491

9883 23303

12694 28827

52315 118808

55396 147754

76267 165125

55160 129630

51276 120503

41809 92606

107238 238608

59608 132629

77200 172473

53418 121307

52315 118808

45970 133935

40322 95078

51792 117616

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$20$35

$250day x 4

50+50+

$35$100 $40$60

Yes 639 862 862 94 838 901 538

30 after ded $30$60

$30$60

$35$55

30 after ded 25

NA $3 $12

$3 $12

NA $50$75

$40$60

NA Yes

Montana

$20$35

$25$40

$250day x 3

$500day x 3

$40+$60+

$40$60

$30$60

30to$60050 to$1200

Nebraska

$25$40

50+50+

30to$60050 to$1200

Nevada

$25$40

50+50+

30to$60050 to$1200

New Hampshire

$20$35

$10$25

$25$40

$250day x 4

50+50+

$35$100

$35$55$100

30to$60050 to$1200

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

New Jersey

New Mexico

EP4 EP5

JR1 JR2

JR4 JR5

P31 P32

P34 P35

801 802

804 805

G54 G55

Q11 Q12

P21 P22

12694 28827

52355 123641

34184 82457

64801 164359

49560 118027

32591 93212

14135 33572

12822 29119

13099 30785

23940 56335

51792 117616

96868 222828

78334 180821

109563 264361

94017 217102

76709 191791

57672 130958

52315 118808

53445 125603

67885 154176

Prescription Drugs

Mail lan

ll icate

r ng rmation

order discount

Overall p

satisfaction

Getting n

Getting c

quickly

doctors

commun

Custome

service

Claims

processi

New Jersey

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$20$35

$15$35

$20$35

$15$35

$20$20

$250day x 4

20 Plan Allow

$250day x 4

20 Plan Allow

$150max$450

50+50+

$35$100

$45$85

New Mexico

50 of sch

$30$30

$25$40

+50 of sch

$250day x 3

$45$85

30to$60050 to$1200

663 844 851 936 86 828 642

$25$35

$25$40

$250 after ded

$100 x 5 days

50+50+

$35$6050

$40$7550

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

New York

EP4 EP5

JC1 JC2

JC4 JC5

SG1 SG2

SG4 SG5

6V1 6V2

X41 X42

801 802

804 805

511 512

514 515

QA1 QA2

C54 C55

GA1 GA2

GA4 GA5

GV1 GV2

GV4 GV5

M91 M92

M94 M95

MF1 MF2

MF4 MF5

MX1 MX2

MX4 MX5

12694 28827

40198 109033

26007 71920

22952 71235

12294 32053

19548 60991

14167 47634

32591 93212

14135 33572

17000 63158

12206 34562

18597 58201

14454 47853

16586 53386

13377 39674

13042 35704

11193 28006

17110 54877

13779 42651

25417 75411

22349 67734

18731 58664

13657 42345

51792 117616

84468 207928

69993 170073

66877 169374

50161 129408

63405 158925

57800 145301

76709 191791

57672 130958

60806 161136

49800 131968

62435 156079

58209 145524

60384 151168

54580 137182

53210 133132

45669 114266

60918 152689

56220 140218

69392 173634

66262 165803

62572 156552

55723 139906

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

New York

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$20$35

$15$35

$20$30

$25$40

$20$20

$250day x 4

20 Plan Allow

$100 x 5

$500+10

$150max$450

50+50+

$35$100

$30$50

$45$85

50 of sch

$30$30

$20$40

$30$50

$25$25

+50 of sch

$250day x 3

$15$100Ded

$45$85

$35$75

$30$75

$35$75 $75$100Ded

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

North Carolina

North Dakota

Oklahoma

F54 F55

H44 H45

V31 V32

V34 V35

RU1 RU2

C91 C92

C94 C95

JS4 JS5

3A1 3A2

A61 A62

A64 A65

641 642

644 645

U41 U42

JS4 JS5

IM1 IM2

13058 29656

13093 29732

26865 64982

8897 20464

13803 47086

20976 51441

14143 45836

17258 41140

14204 44676

13880 30882

12491 27794

28758 69344

13114 30163

26271 60855

17258 41140

11810 28460

53279 120995

53418 121307

70869 162996

36302 83494

56317 144742

64862 149184

57705 143467

61069 138677

57953 142284

56629 125999

50965 113400

72799 167445

53504 123066

70263 158786

61069 138677

48185 116118

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

North Carolina

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

North Dakota

$25$40

50+50+

30to$60050 to$1200

$25$45

$0 for 3 then 20

$15$25

Nothing

20 in40 out

50$600ded

50+50+

$45$90

$40$70

50$600 ded

$20$30

$100day x 5

$30$50

$25$25

$100day x 5

40+40+

$30$50

40+40+

$25$40

40+40+

30to$60050 to$1200

AultCare HMOshyHigh

Oklahoma

$15$20

$20$35

$25$40

$20$20

$30$40

$10$20

$25$40

$250day x 3

$500day x 3

50+50+

$30$40$55

$40$60

$30$30

$40$40

$30$50

30to$60050 to$1200

$15$45

$250dymx1000

50+50+

$45$70

Yes 592 816 839 916 893 872 727

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Oregon

Pennsylvania

Puerto Rico

Rhode Island

South Carolina

877shy459shy6604

800shy813shy2000

877shy459shy6604

800shy447shy4000

866shy351shy5946

888shy876shy2756

800shy314shy3121

787shy774shy6060

877shy459shy6604

H44 H45

571 572

574 575

H44 H45

P31 P32

P34 P35

YE1 YE2

GG4 GG5

261 262

8W1 8W2

UW4 UW5

ZJ1 ZJ2

891 892

EP4 EP5

JS4 JS5

13093 29732

22672 52645

13617 31283

13093 29732

64801 164359

49560 118027

19203 59806

16820 41884

17814 47183

22135 54101

13345 30692

8026 18317

8829 19866

12694 28827

17258 41140

53418 121307

66592 150412

55557 127637

53418 121307

109563 264361

94017 217102

63053 157716

60623 139436

61637 144841

66044 151897

54448 125225

32748 74733

36023 81052

51792 117616

61069 138677

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Oregon

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

Pennsylvania

$20$30

$30$40

$25$40

50+50+

$40$60

30to$60050 to$1200

Puerto Rico

$20$35

$15$35

$20$35

$25$50

10 after Deduct

20 after Deduct

$250day x 4

20 Plan Allow

$250day x 4

20aftrDeduct

15 after ded

10 after deduct

20after Deduct

30 $5$15

$5 after ded

50+50+

$35$100

$35$60

$35$75

$35$75$100

$10$15

40 $40$120 50 $85$250

Rhode Island

$750$10

$25$40

$750 amp 10 +$10 amp 10 +

None 10 +

$5 or $12 NA

2025 up to$100$175max

30to$60050 to$1200

Yes No

691 874 844 963 872 75 586

South Carolina

$25$40

50+50+

30to$60050 to$1200

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

South Dakota

Tennessee

G54 G55

V31 V32

V34 V35

AU1 AU2

AU4 AU5

F54 F55

UB1 UB2

GJ1 GJ2

GJ4 GJ5

12822 29119

26865 64982

8897 20464

26173 63455

23647 57594

13058 29656

24581 76516

15825 35210

12491 27794

52315 118808

70869 162996

36302 83494

70163 161438

67586 155460

53279 120995

68539 174761

59608 132629

50965 113400

Primary

Prescription Drugs

ded ation

care Hospital Mail

Getting nee

How well

r ng rm

Level II Level III

order discount

Overall

satisfaction

Getting

quickly

doctors

commun

Custome

service

Claims

processi

Plan Info

on Costs

South Dakota

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$25$45

$0 for 3 then 20

$20$30

Nothing

20 in40 out

$100day x 5

50+50+

$45$90

$40$70

$30$50

$25$25

$100day x 5

40+40+

$30$50

Tennessee

40+40+

$25$40

40+40+

30to$60050 to$1200

$20$35

$25$40

$250day x 4

$250day x 3

$500day x 3

50+50+

$35$100

$40$60

66 875 868 959 889 914 69

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

JS4 JS5

ES1 ES2

B71 B72

CK1 CK2

CN1 CN2

CZ1 CZ2

ET1 ET2

TP4 TP5

TU4 TU5

TV4 TV5

EW1 EW2

EW4 EW5

UC1 UC2

UC4 UC5

UR1 UR2

UR4 UR5

UU1 UU2

UU4 UU5

A84 A85

GF1 GF2

17258 41140

12817 40332

11057 37880

10809 34896

13391 65886

13031 61566

12638 56836

10247 22697

13880 30882

12491 27794

17899 39821

13880 30882

55020 122416

13880 30882

26524 59015

15825 35210

14907 37260

32515 78160

61069 138677

52295 137853

45113 135352

44103 132308

54635 163918

53169 159512

51562 154687

41809 92606

56629 125999

50965 113400

61723 137332

56629 126001

99587 221579

56629 126001

70521 156910

59608 132629

58671 134720

76632 176438

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$5$25$35

50+50+

$35$60

FirstcareshyHigh

$30$55

$35$55

$250day x 5

$35$70

$40$60

$35$55

$40+$60+

$40$60

$35$55

$40+$60+

$40$60

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$45

$20$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 5

$40+$60+

$40$60

$45$100

$35$60

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Virgin Islands

G54 G55

9K1 9K2

DK4 DK5

SF1 SF2

SF4 SF5

EP4 EP5

851 852

12822 29119

19819 42542

11798 25954

19210 43095

12435 27741

12694 28827

10305 23402

52315 118808

63682 140107

48136 105894

63060 140671

50737 113183

51792 117616

42043 95481

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

SelectHealthshyHigh

$20$30

$20$40

$15$25

$20$30

$25$40

$100 after

$5$25$50

50+50+

$25$50

$35$60

$25$50$50

$25 $50$50

30to$60050 to$1200

Virgin Islands

4040 40 50+ 50+50+ No

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

None 10 +

$5 or $12 NA NA

2025 up to$100$175max

Yes No

691 874 844 963 872 75 586

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Virginia

Washington

F54 F55

JN1 JN2

JN4 JN5

D91 D92

J91 J92

2G1 2G2

2G4 2G5

A91 A92

E31 E32

E34 E35

JP1 JP2

9R1 9R2

9R4 9R5

2C1 2C2

G54 G55

C31 C32

541 542

544 545

L11 L12

VT1 VT2

571 572

574 575

13058 29656

46867 105610

14021 31351

12138 40332

11280 29365

21177 48693

15284 35429

20427 47008

16926 42124

9646 22186

20245 50123

26858 69565

11269 26665

12235 28017

12822 29119

14933 62274

27070 55009

11742 26509

12426 26823

31651 67459

22672 52645

13617 31283

53279 120995

91271 204437

57208 127913

49524 137853

46023 119808

65067 146381

59056 132852

64302 144663

60731 139681

39358 90520

64116 147840

70861 167671

45977 108794

49920 114308

52315 118808

58698 160234

71078 152824

47908 108156

50700 109437

75750 165523

66592 150412

55557 127637

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

Virginia

$25$40 4040

$15$30

$20$35

$25$35 4040

$5$25$35 4040

$25$35

Nothing$35

$150day x3

10 Plan Allow

$10 50+

Nothing

50+50+

$35$100

$35$60 4040

$35$65

30to$60050 to$1200

POS National

Yes No

Average

MD IPAshyHigh

Washington

$70$70

$10$20

$20$30

$25$40

$25$30

$35$35

$25$40 4040

$20$35

$25$25

$25$35

$154 or 2020

$30$30 $30+40+diff

$20$30

$30$40

$20$0childlt22$30

$200 x3 days

$250dayx3

$150day x 3

$150max$750

$20020

$250day x 4

Nothing Nothing

None None

Nothing

$7$17 Net

$12$22Net

$10 50+

$10 Not Covered

$5 Not Covered

$35$65

$30$50$50

$30$50$45$65

$35$55$50$70

$30$60

$40$55

50+50+

$35$100

$40$60

Not Covered

$40$60

$353050up to $3000

$355050 up to $3000

$35$50 30day$100 90day

$25$50 30day$100 90day

30to$60050 to$1200

Yes No

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

West Virginia

Wisconsin

Wyoming

F54 F55

U41 U42

JS4 JS5

F71 F72

WD1 WD2

WJ1 WJ2

V31 V32

V34 V35

EY1 EY2

LW1 LW2

H44 H45

9K1 9K2

DK4 DK5

13058 29656

26271 60855

17258 41140

10600 29208

24382 72670

15910 51534

26865 64982

8897 20464

14597 48275

16556 55954

13093 29732

19819 42542

11798 25954

53279 120995

70263 158786

61069 138677

43250 119170

68336 170838

59694 149279

70869 162996

36302 83494

58355 145955

60353 153787

53418 121307

63682 140107

48136 105894

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Claims

processing

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Plan Inform

on Costs

West Virginia

Wisconsin

Wyoming

$25$40 4040

$10$20

$25$40 4040

$25$35 4040

$25$25

$10$10

$25$45

$0 for 3 then 20

$10$10

$25$40 4040

$20$30

$20$40

Nothing

20 in40 out

Nothing

$10 Yes 50+ 50+50+ No

$15 $30$50 Yes

$10 Yes 50+ 50+50+ No

$5 $35$60 Yes 40 4040 No

$10 Yes

$5 $20$20 Yes

$12 $45$90 Yes

$9 $40$70 Yes

$10 $20$50 Yes

$10 3050 No

$10 Yes 50+ 50+50+ No

$7 $25$50 No

$7 $35$60 None

30$75max 50 wmin$50

30to$60050 to$1200

909 876 951 929 944

909 90 97 834 879

834 834 953 929 932

893 875 951 92 911

888 854 938 888 87

857 822 96 863 866

852 813 948 883 895

864 849 942 877 875

ELIGIBILITY

FUNDING

CONTRIBUTIONS

DISTRIBUTIONS

ANNUAL ROLLOVER

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

800shy718shy1299

800shy821shy6136

800shy694shy9901

888shy636shy6252

474 475

341 342

481 482

324 325

9742 21915

11021 25172

13642 30912

10454 22700

39747 89414

44967 102703

55661 126120

42653 92617

Plan Code

885 866 929 860

891 888 952 830

873 851 923 863

891 859 912 887

881 865 939 850

891 888 952 830

909 907 925 871

849 864 932 843

875 801 948 856

Getting needed care

How well doctors

Getting needed care

How well doctors

Claims processing

Plan Name

Telephone Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Premium

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Plan Name

877shy459shy6604

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

136516

151489

149613

136516

151489

149613

Self amp family

Plan Name

Benefit Type

CY Ded SelfFamily

Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Premium

Connecticut

Delaware

Florida

Georgia

Plan Name

877shy459shy6604

888shy789shy9065

877shy459shy6604

800shy441shy5501

888shy393shy6765

877shy459shy6604

888shy393shy6765

671shy647shy3526

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

145440

136516

127574

136516

141522

116366

136516

105282

110827

Self amp family

Connecticut

Delaware

Florida

Georgia

Premium

Illinois

Indiana

Kansas

Plan Name

877shy459shy6604

800shy377shy4161

877shy459shy6604

888shy393shy6765

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy257shy4692

877shy459shy6604

800shy969shy3343

888shy393shy6765

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

151489

136317

110827

110823

151489

110823

136317

149613

122219

Self amp family

Illinois

Indiana

Kansas

Premium

Kentucky

Louisiana

Maryland

Massachusetts

Michigan

Minnesota

Plan Name

877shy459shy6604

888shy393shy6765

877shy459shy6604

888shy789shy9065

800shy833shy7423

877shy459shy6604

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

136317

136516

145440

136516

127574

109488

145440

149613

136317

Self amp family

Kentucky

Louisiana

Maryland

OutshyNetWork

InshyNetwork

$3750$7500

$4167$8334

$3000$6000

$2000$4000

$6000$12000

$4000$8000

Nothing

Nothing$30$60

Massachusetts

Michigan

Minnesota

Premium

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

Plan Name

877shy459shy6604

800shy969shy3343

888shy393shy6765

877shy459shy6604

800shy501shy3439

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

149613

122219

136317

149613

145440

149613

145440

101669

Self amp family

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

Premium

North Carolina

North Dakota

Pennsylvania

Rhode Island

South Carolina

Plan Name

877shy459shy6604

330shy363shy6360

877shy459shy6604

866shy351shy5946

888shy876shy2756

877shy459shy6604

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

136516

136317

151489

136317

115650

114458

145440

151489

Self amp family

North Carolina

North Dakota

Pennsylvania

Rhode Island

South Carolina

Plan Name

CY Ded SelfFamily

Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

10After Deduct

10 after deduct

30After Deduct

30 after deduct

Premium

South Dakota

Tennessee

Vermont

Plan Name

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy377shy4161

877shy459shy6604

888shy789shy9065

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

149613

136516

151489

110827

110823

121906

149613

145440

136516

127574

Self amp family

South Dakota

Tennessee

Vermont

Premium

Wyoming

Plan Name

877shy459shy6604

800shy552shy7114

877shy459shy6604

800shy377shy4161

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

149613

136516

151489

136317

Self amp family

Wyoming

Plan Name

CY Ded SelfFamily

Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

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

______________________________________________________________________________________________________________

19122-1-14 (70-16)_20 pages

19122-15-20 (70-16)_6 pages

19122-21-86 (70-16)_0

Things to consider

What does TCC offer

When can I enroll

How do I enroll

Definitions

Enrollment Code

TCC 102 of your

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

MHBP shystd

MHBP shyValue Plan

NALC shyhigh

NALC Value Option

SAMBA shyhigh

SAMBA shystd

800shy222shy2798

Local phone

800shy821shy6136

800shy410shy7778

888shy636shy6252

800shy638shy6589

126114

142015

126195

145991

148291

109939

130096

168477

122733

APWU shyhigh

BCBS shystd

BCBS shybasic

GEHA shyhigh

GEHA shystd

MHBP shystd

MHBP shyvalue

NALC shyhigh

NALC shyValue

SAMBA shyhigh

SAMBA shystd

Benefit Type

Per Person

Calendar Year

Prescription Drug

Hospital Inpatient

Office Visits

Hospital Inpatient

RampB Level I

Prescription Drugs

Level II Level III

Deductible

MHBP shystd

MHBP shyValue Plan

NALC shyhigh

SAMBA shyhigh

SAMBA shystd

FFS National A

Plan Code

verage 805

Getting needed care

How well doctors

communicate

Customer service

Claims processing

Plan Name Location

Plan Code

Getting needed care

How well doctors

Claims processing

Arizona 10 11

851 747

905 898

919 884

933 923

938 914

969 928

724 680

California 10 11

809 705

915 873

897 840

954 943

881 910

937 912

677 616

768 691

935 893

930 874

951 940

882 881

898 922

657 622

Florida 10 11

864 806

942 916

922 894

952 947

934 916

954 937

733 660

Illinois 10 11

861 796

933 912

934 881

955 950

901 936

972 938

712 653

Maryland 10 11

857 770

931 897

917 898

954 940

897 921

956 967

713 666

Texas 10 11

887 825

934 898

931 883

950 955

936 910

957 967

721 617

Virginia 10 11

871 782

924 901

929 894

966 962

914 917

959 960

708 681

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Alabama

Alaska

Arizona

Arkansas

F54 F55

JS4 JS5

G54 G55

WQ1 WQ2

A71 A72

A74 A75

BF1 BF2

BF4 BF5

C71 C72

C74 C75

F54 F55

DH1 DH2

DH4 DH5

13058 29656

17258 41140

12822 29119

33482 89188

26548 80303

19509 62476

13880 30882

12491 27794

15825 35210

13149 29256

13058 29656

30353 76056

14296 38452

53279 120995

61069 138677

52315 118808

77618 187686

70545 178623

63365 160440

56629 125999

50965 113400

59608 132629

53648 119367

53279 120995

74426 174291

58048 135935

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Alabama

HMOPOS Nationa

30to$60050 to$1200 Yes

l Average 679 864 849 942 877 875 649

Alaska

$25$40

50+50+

30to$60050 to$1200

Arizona

$25$40

50+50+

30to$60050 to$1200

Arkansas

$20$35

$20$40

$25$50

$20$35

$25$40

$20$35

$25$40

$250day x 4

$250dayx5

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+50+

$35$100

$40$60

30to$60050 to$1200

$20$30

$20$40

$100max$500

$200max$1000

50+50+

$40$60

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

California

Colorado

Connecticut

Delaware

JS4 JS5

2X1 2X2

B31 B32

SI1 SI2

LB1 LB2

LB4 LB5

LP1 LP2

LP4 LP5

KC1 KC2

591 592

594 595

621 622

624 625

CY1 CY2

CY4 CY5

G54 G55

651 652

654 655

EP4 EP5

P31 P32

P34 P35

17258 41140

15940 41769

18194 43825

18445 42566

77474 182834

71405 168807

30687 74663

27027 66198

18293 47705

35345 91275

22772 58183

14073 35293

9019 20845

22819 54699

13109 30036

12822 29119

23933 55581

9887 22345

12694 28827

64801 164359

49560 118027

61069 138677

59725 139319

62024 141416

62280 140132

122490 283205

116299 268898

74767 172871

71034 164236

62125 145373

79518 189815

66694 156061

57420 132713

36797 85048

66742 152507

53485 122549

52315 118808

67878 153407

40339 91170

51792 117616

109563 264361

94017 217102

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

California

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

Colorado

$20$35

$25$35

$20$30

$30$50

$20$30

$30$50

$25$35

$15$25

$30$40

$15$25

$30$40

$20$35

$25$40

$250day x 4

$250max4days

$200 x 3 days

$150dayx5

$150day x 4

$5$40$60

50+50+

$35$100

$5$40$70$60

$35$60

$35$65

$35$60

$35$65

$35$35

$30$30

$35$35

$30$30

$35$35

$35$60

$25$50

30to$60050 to$1200

Connecticut

$20$40

$25$40

$250x3

50+50+

$35$60

$40$80

30to$60050 to$1200

Delaware

$25$40

50+50+

30to$60050 to$1200

$20$35

$15$35

$250day x 4

20 Plan Allow

50+50+

$35$100

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Florida

877shy459shy6604

888shy789shy9065

877shy574shy3337

877shy835shy9861

877shy459shy6604

800shy882shy8633

850shy383shy3311

800shy441shy5501

888shy393shy6765

F54 F55

JN1 JN2

JN4 JN5

2G1 2G2

2G4 2G5

E31 E32

E34 E35

JP1 JP2

F54 F55

ML1 ML2

ML4 ML5

EA1 EA2

5E1 5E2

5E4 5E5

MJ4 MJ5

QP4 QP5

E21 E22

E24 E25

EE1 EE2

EE4 EE5

EX1 EX2

EX4 EX5

LL1 LL2

LL4 LL5

13058 29656

46867 105610

14021 31351

21177 48693

15284 35429

16926 42124

9646 22186

20245 50123

13058 29656

20336 56279

12604 30253

11679 30949

16664 47450

12501 30003

10247 22697

13149 29256

11834 26331

23153 51514

15825 35210

13880 30882

12491 27794

48720 108398

15825 35208

53279 120995

91271 204437

57208 127913

65067 146381

59056 132852

60731 139681

39358 90520

64116 147840

53279 120995

64209 154119

51424 123431

47650 126273

60464 145113

51005 122414

41809 92606

53648 119367

48282 107430

67082 149259

59608 132629

56629 125999

50965 113400

93161 207280

59608 132627

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

HMOPOS Nationa

30to$60050 to$1200 Yes

l Average 679 864 849 942 877 875 649

$15$30

$20$35

$25$35

Nothing$35

$150day x3

10 Plan Allow

Nothing

50+50+

$35$100

$35$65

MD IPAshyHigh

Florida

$70$70

$10$20

$20$30

$25$40

$250dayx3

$150day x 3

Nothing

$7$17 Net

$12$22Net

$35$65

$30$50$45$65

$35$55$50$70

$30$60

30to$60050 to$1200

$15$40

$25$45

Nothing$15

$15$30

$20$50

$35$55

$250dayx3

$300dayx3

Ded + $150x3

Ded + $150x5

$15 Tier 1

50+50+

$30$5030

$40$6030

$40$6020

$50$7020

$40$60

$30 Tier 2 $50 Tier 3

$35$55

$40+$60+

$40$60

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$40+$60+

$40$60

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Georgia

877shy459shy6604

888shy393shy6765

888shy865shy5813

671 479shy7982

671shy647shy3526

877shy459shy6604

800shy776shy4672

808shy432shy5955

F54 F55

2U1 2U2

AD4 AD5

LM4 LM5

CB1 CB2

CB4 CB5

DG1 DG2

DG4 DG5

DN1 DN2

DN4 DN5

F81 F82

F84 F85

B41 B42

JK1 JK2

JK4 JK5

JS4 JS5

871 872

631 632

634 635

13058 29656

44133 104232

10247 22697

15825 35210

13880 30882

15825 35210

13149 29256

15825 35210

13880 30882

15015 36863

10047 22957

11949 31399

12447 36018

10209 26960

17258 41140

11377 25325

14515 32578

7553 16846

53279 120995

88482 203031

41809 92606

59608 132629

56629 125999

59608 132629

53648 119367

59608 132629

56629 125999

58782 134315

40991 93667

48751 128109

50786 133453

41654 109996

61069 138677

46419 103326

58272 129944

30818 68731

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Georgia

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$20$35

$35$55

$250day x 4

50+50+

$35$100

$40$60

59 90 878 941 86 857 62

$35$55

$40+$60+

$40$60

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$30

$20$35

$15$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250dayx3

$10$20 Comm

$15$25 Comm

$40+$60+

$40$60

$2550 of AWP

$40$50 Comm $40$50 Comm

TakeCareshyHigh

TakeCareshyStandard

$5 at FHP$40

$25$40

$100day for 5

$150day for 5

$25$50

$40$80

30to$60050 to$1200

HMSA InshyNetwork

$15$15

50+50+

$30$65

$20$20

$30$30

$7 + 20

$45$45

$50$50

$30 + 20 $65 + 20 No

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Illinois

H44 H45

9K1 9K2

DK4 DK5

541 542

544 545

SF1 SF2

SF4 SF5

H44 H45

A21 A22

9G1 9G2

FX1 FX2

K84 K85

9F1 9F2

AB4 AB5

GB4 GB5

MW4 MW5

751 752

754 755

761 762

B91 B92

YH1 YH2

13093 29732

19819 42542

11798 25954

27070 55009

11742 26509

19210 43095

12435 27741

13093 29732

30483 71121

32158 67069

26932 67294

20323 51891

51805 115264

15825 35210

10247 22697

40638 90413

15825 35210

14109 33787

33072 74273

14091 38330

53418 121307

63682 140107

48136 105894

71078 152824

47908 108156

63060 140671

50737 113183

53418 121307

74559 169258

76267 165125

70937 165354

64196 149643

96307 214284

59608 132629

41809 92606

84917 188936

59608 132629

57566 131177

77200 172473

57491 135811

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

SelectHealthshyHigh

Illinois

$20$30

$20$40

$25$25

$25$35

$15$25

$20$30

$25$40

$100 after

$5 $25$50

50+50+

$25$50

$35$60

$40$60

$25$50$50

$25$50

30to$60050 to$1200

$20$35

$25$35

$200day x 5

$10 copay

50+50+

$40$60

$40$6025 $6025

30 after ded

$25$50

$20$35

$25$40

$35$55

30 after ded

$200day x 5

$250day x 3

$500day x 3

$35$70

$40$60

745 915 88 962 878 868 67

$35$55

$40+$60+

$40$60

$20$35

$25$40

$15$15

$25$40

$25$50

$250day x 3

$500day x 3

$40+$60+

$40$60

$35$60

$30$60

$35$50

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Indiana

JS4 JS5

FX1 FX2

K84 K85

MW4 MW5

A61 A62

A64 A65

751 752

754 755

MH1 MH2

MH4 MH5

DQ1 DQ2

H44 H45

SV1 SV2

SY4 SY5

FX1 FX2

K84 K85

V31 V32

V34 V35

AU1 AU2

AU4 AU5

YH1 YH2

17258 41140

26932 67294

20323 51891

10247 22697

13880 30882

12491 27794

40638 90413

15825 35210

13880 30882

30786 68557

13093 29732

13351 31376

9799 23027

26932 67294

20323 51891

26865 64982

8897 20464

26173 63455

23647 57594

14091 38330

61069 138677

70937 165354

64196 149643

41809 92606

56629 125999

50965 113400

84917 188936

59608 132629

56629 125999

74868 166643

53418 121307

54474 128016

39979 93951

70937 165354

64196 149643

70869 162996

36302 83494

70163 161438

67586 155460

57491 135811

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Indiana

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$25$50

$35$55

$200day x 5

50+50+

$35$70

$40$60

745 915 88 962 878 868 67

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$15

$25$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$40+$60+

$40$60

$25$50

30to$60050 to$1200

$25$50

$25$45

$0 for 3 then 20

$20$30

$200day x 5

Nothing

20 in40 out

$100day x 5

$3 $10

50+50+

$45$70$100

30$5000 Max

$35$70

$45$90

$40$70

$30$50

$25$25

$100day x 5

40+40+

$30$50

40+40+

$25$50

40+40+

$35$50

Yes 577 896 86 956 914 918 623

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Kansas

Kentucky

Louisiana

877shy459shy6604

800shy969shy3343

888shy393shy6765

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy341shy6613

888shy393shy6765

G54 G55

HY1 HY2

HA1 HA2

HA4 HA5

PH4 PH5

MS1 MS2

MS4 MS5

H44 H45

A61 A62

A64 A65

MH1 MH2

MH4 MH5

MI1 MI2

MI4 MI5

F54 F55

BJ1 BJ2

BJ4 BJ5

AE1 AE2

AE4 AE5

BC1 BC2

BC4 BC5

12822 29119

13777 50039

13519 32270

12568 29535

10247 22697

62521 139111

15825 35210

13093 29732

13880 30882

12491 27794

15825 35210

13880 30882

19459 43292

13880 30882

13058 29656

19208 48754

13035 30271

15825 35210

13149 29256

13880 30882

12491 27794

52315 118808

55396 147754

55160 129630

51276 120503

41809 92606

107238 238608

59608 132629

53418 121307

56629 125999

50965 113400

59608 132629

56629 125999

63314 140872

56629 125999

53279 120995

63058 146443

53182 123506

59608 132629

53648 119367

56629 125999

50965 113400

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Kansas

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$20$35

$30$60

$35$55

$250day x 4

$3 $12

50+50+

$35$100

$50$75

$40$60

Kentucky

$20$35

$25$40

$250day x 3

$500day x 3

$40+$60+

$40$60

30to$60050 to$1200

Louisiana

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+50+

$40$60

30to$60050 to$1200

$25$45

$30$55

$20$35

$35$40

$20$35

$35$40

Ded+$100

Ded+30

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+50+

$40$100

$40$60

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Maryland

Massachusetts

EP4 EP5

F54 F55

JN1 JN2

JN4 JN5

2G1 2G2

2G4 2G5

IG1 IG2

IG4 IG5

E31 E32

E34 E35

JP1 JP2

EP4 EP5

JG1 JG2

12694 28827

13058 29656

46867 105610

14021 31351

21177 48693

15284 35429

14998 37685

13265 30509

16926 42124

9646 22186

20245 50123

12694 28827

29337 80043

51792 117616

53279 120995

91271 204437

57208 127913

65067 146381

59056 132852

58764 135153

54121 124479

60731 139681

39358 90520

64116 147840

51792 117616

73390 178358

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

Maryland

$25$40

50+50+

30to$60050 to$1200

$15$30

$20$35

$25$35

Nothing$35

$150day x3

10 Plan Allow

Nothing

50+50+

$35$100

$35$65

MD IPAshyHigh

Massachusetts

$70$70

$20$40

$10$20

$20$30

$25$40

$200day x 3

$250dayx3

$150day x 3

Nothing

$7$17 Net

$12$22Net

$35$65

$30$60

$30$50$45$65

$35$55$50$

$30$60

30to$60050 to$1200

70 Yes

$25$35

$150to$750max

50+50+

$30$60

Yes 627 851 882 929 883 801 649

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Michigan

Minnesota

G54 G55

K51 K52

LX1 LX2

RL1 RL2

RL4 RL5

521 522

GY4 GY5

X51 X52

A51 A52

H44 H45

V31 V32

V34 V35

H44 H45

12822 29119

22055 52593

18055 50747

24184 61492

19656 50897

20111 55722

16974 48191

13915 49809

13670 50117

13093 29732

26865 64982

8897 20464

13093 29732

52315 118808

65962 150359

61882 148476

68134 159436

63515 148629

63980 153551

60780 145869

56775 147520

55776 147834

53418 121307

70869 162996

36302 83494

53418 121307

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

Michigan

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

Minnesota

$15$25

$10$10

$20$20

$10$20

$15$30

$10$20

$15$15

$25$40

Nothing

$500x3

Nothing

50+50+

$30$60

$15$15

$50$50

$40$60

$40$40

30to$60050 to$1200

$25$45

$0 for 3 then 20

$25$40

Nothing

20 in40 out

50+50+

$45$90

$40$70

30to$60050 to$1200

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Montana

Nebraska

Nevada

New Hampshire

877shy459shy6604

888shy811shy2092

800shy969shy3343

888shy393shy6765

877shy835shy9861

877shy459shy6604

877shy545shy7378

877shy459shy6604

G54 G55

HY1 HY2

9G1 9G2

HA1 HA2

HA4 HA5

PH4 PH5

MS1 MS2

MS4 MS5

B91 B92

H44 H45

G54 G55

HF1 HF2

NM1 NM2

EP4 EP5

12822 29119

13577 50039

32158 67069

13519 32270

12568 29535

10247 22697

62521 139111

15825 35210

33072 74273

13093 29732

12822 29119

11267 36491

9883 23303

12694 28827

52315 118808

55396 147754

76267 165125

55160 129630

51276 120503

41809 92606

107238 238608

59608 132629

77200 172473

53418 121307

52315 118808

45970 133935

40322 95078

51792 117616

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$20$35

$250day x 4

50+50+

$35$100 $40$60

Yes 639 862 862 94 838 901 538

30 after ded $30$60

$30$60

$35$55

30 after ded 25

NA $3 $12

$3 $12

NA $50$75

$40$60

NA Yes

Montana

$20$35

$25$40

$250day x 3

$500day x 3

$40+$60+

$40$60

$30$60

30to$60050 to$1200

Nebraska

$25$40

50+50+

30to$60050 to$1200

Nevada

$25$40

50+50+

30to$60050 to$1200

New Hampshire

$20$35

$10$25

$25$40

$250day x 4

50+50+

$35$100

$35$55$100

30to$60050 to$1200

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

New Jersey

New Mexico

EP4 EP5

JR1 JR2

JR4 JR5

P31 P32

P34 P35

801 802

804 805

G54 G55

Q11 Q12

P21 P22

12694 28827

52355 123641

34184 82457

64801 164359

49560 118027

32591 93212

14135 33572

12822 29119

13099 30785

23940 56335

51792 117616

96868 222828

78334 180821

109563 264361

94017 217102

76709 191791

57672 130958

52315 118808

53445 125603

67885 154176

Prescription Drugs

Mail lan

ll icate

r ng rmation

order discount

Overall p

satisfaction

Getting n

Getting c

quickly

doctors

commun

Custome

service

Claims

processi

New Jersey

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$20$35

$15$35

$20$35

$15$35

$20$20

$250day x 4

20 Plan Allow

$250day x 4

20 Plan Allow

$150max$450

50+50+

$35$100

$45$85

New Mexico

50 of sch

$30$30

$25$40

+50 of sch

$250day x 3

$45$85

30to$60050 to$1200

663 844 851 936 86 828 642

$25$35

$25$40

$250 after ded

$100 x 5 days

50+50+

$35$6050

$40$7550

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

New York

EP4 EP5

JC1 JC2

JC4 JC5

SG1 SG2

SG4 SG5

6V1 6V2

X41 X42

801 802

804 805

511 512

514 515

QA1 QA2

C54 C55

GA1 GA2

GA4 GA5

GV1 GV2

GV4 GV5

M91 M92

M94 M95

MF1 MF2

MF4 MF5

MX1 MX2

MX4 MX5

12694 28827

40198 109033

26007 71920

22952 71235

12294 32053

19548 60991

14167 47634

32591 93212

14135 33572

17000 63158

12206 34562

18597 58201

14454 47853

16586 53386

13377 39674

13042 35704

11193 28006

17110 54877

13779 42651

25417 75411

22349 67734

18731 58664

13657 42345

51792 117616

84468 207928

69993 170073

66877 169374

50161 129408

63405 158925

57800 145301

76709 191791

57672 130958

60806 161136

49800 131968

62435 156079

58209 145524

60384 151168

54580 137182

53210 133132

45669 114266

60918 152689

56220 140218

69392 173634

66262 165803

62572 156552

55723 139906

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

New York

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$20$35

$15$35

$20$30

$25$40

$20$20

$250day x 4

20 Plan Allow

$100 x 5

$500+10

$150max$450

50+50+

$35$100

$30$50

$45$85

50 of sch

$30$30

$20$40

$30$50

$25$25

+50 of sch

$250day x 3

$15$100Ded

$45$85

$35$75

$30$75

$35$75 $75$100Ded

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

North Carolina

North Dakota

Oklahoma

F54 F55

H44 H45

V31 V32

V34 V35

RU1 RU2

C91 C92

C94 C95

JS4 JS5

3A1 3A2

A61 A62

A64 A65

641 642

644 645

U41 U42

JS4 JS5

IM1 IM2

13058 29656

13093 29732

26865 64982

8897 20464

13803 47086

20976 51441

14143 45836

17258 41140

14204 44676

13880 30882

12491 27794

28758 69344

13114 30163

26271 60855

17258 41140

11810 28460

53279 120995

53418 121307

70869 162996

36302 83494

56317 144742

64862 149184

57705 143467

61069 138677

57953 142284

56629 125999

50965 113400

72799 167445

53504 123066

70263 158786

61069 138677

48185 116118

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

North Carolina

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

North Dakota

$25$40

50+50+

30to$60050 to$1200

$25$45

$0 for 3 then 20

$15$25

Nothing

20 in40 out

50$600ded

50+50+

$45$90

$40$70

50$600 ded

$20$30

$100day x 5

$30$50

$25$25

$100day x 5

40+40+

$30$50

40+40+

$25$40

40+40+

30to$60050 to$1200

AultCare HMOshyHigh

Oklahoma

$15$20

$20$35

$25$40

$20$20

$30$40

$10$20

$25$40

$250day x 3

$500day x 3

50+50+

$30$40$55

$40$60

$30$30

$40$40

$30$50

30to$60050 to$1200

$15$45

$250dymx1000

50+50+

$45$70

Yes 592 816 839 916 893 872 727

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Oregon

Pennsylvania

Puerto Rico

Rhode Island

South Carolina

877shy459shy6604

800shy813shy2000

877shy459shy6604

800shy447shy4000

866shy351shy5946

888shy876shy2756

800shy314shy3121

787shy774shy6060

877shy459shy6604

H44 H45

571 572

574 575

H44 H45

P31 P32

P34 P35

YE1 YE2

GG4 GG5

261 262

8W1 8W2

UW4 UW5

ZJ1 ZJ2

891 892

EP4 EP5

JS4 JS5

13093 29732

22672 52645

13617 31283

13093 29732

64801 164359

49560 118027

19203 59806

16820 41884

17814 47183

22135 54101

13345 30692

8026 18317

8829 19866

12694 28827

17258 41140

53418 121307

66592 150412

55557 127637

53418 121307

109563 264361

94017 217102

63053 157716

60623 139436

61637 144841

66044 151897

54448 125225

32748 74733

36023 81052

51792 117616

61069 138677

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Oregon

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

Pennsylvania

$20$30

$30$40

$25$40

50+50+

$40$60

30to$60050 to$1200

Puerto Rico

$20$35

$15$35

$20$35

$25$50

10 after Deduct

20 after Deduct

$250day x 4

20 Plan Allow

$250day x 4

20aftrDeduct

15 after ded

10 after deduct

20after Deduct

30 $5$15

$5 after ded

50+50+

$35$100

$35$60

$35$75

$35$75$100

$10$15

40 $40$120 50 $85$250

Rhode Island

$750$10

$25$40

$750 amp 10 +$10 amp 10 +

None 10 +

$5 or $12 NA

2025 up to$100$175max

30to$60050 to$1200

Yes No

691 874 844 963 872 75 586

South Carolina

$25$40

50+50+

30to$60050 to$1200

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

South Dakota

Tennessee

G54 G55

V31 V32

V34 V35

AU1 AU2

AU4 AU5

F54 F55

UB1 UB2

GJ1 GJ2

GJ4 GJ5

12822 29119

26865 64982

8897 20464

26173 63455

23647 57594

13058 29656

24581 76516

15825 35210

12491 27794

52315 118808

70869 162996

36302 83494

70163 161438

67586 155460

53279 120995

68539 174761

59608 132629

50965 113400

Primary

Prescription Drugs

ded ation

care Hospital Mail

Getting nee

How well

r ng rm

Level II Level III

order discount

Overall

satisfaction

Getting

quickly

doctors

commun

Custome

service

Claims

processi

Plan Info

on Costs

South Dakota

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$25$45

$0 for 3 then 20

$20$30

Nothing

20 in40 out

$100day x 5

50+50+

$45$90

$40$70

$30$50

$25$25

$100day x 5

40+40+

$30$50

Tennessee

40+40+

$25$40

40+40+

30to$60050 to$1200

$20$35

$25$40

$250day x 4

$250day x 3

$500day x 3

50+50+

$35$100

$40$60

66 875 868 959 889 914 69

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

JS4 JS5

ES1 ES2

B71 B72

CK1 CK2

CN1 CN2

CZ1 CZ2

ET1 ET2

TP4 TP5

TU4 TU5

TV4 TV5

EW1 EW2

EW4 EW5

UC1 UC2

UC4 UC5

UR1 UR2

UR4 UR5

UU1 UU2

UU4 UU5

A84 A85

GF1 GF2

17258 41140

12817 40332

11057 37880

10809 34896

13391 65886

13031 61566

12638 56836

10247 22697

13880 30882

12491 27794

17899 39821

13880 30882

55020 122416

13880 30882

26524 59015

15825 35210

14907 37260

32515 78160

61069 138677

52295 137853

45113 135352

44103 132308

54635 163918

53169 159512

51562 154687

41809 92606

56629 125999

50965 113400

61723 137332

56629 126001

99587 221579

56629 126001

70521 156910

59608 132629

58671 134720

76632 176438

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$5$25$35

50+50+

$35$60

FirstcareshyHigh

$30$55

$35$55

$250day x 5

$35$70

$40$60

$35$55

$40+$60+

$40$60

$35$55

$40+$60+

$40$60

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$45

$20$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 5

$40+$60+

$40$60

$45$100

$35$60

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Virgin Islands

G54 G55

9K1 9K2

DK4 DK5

SF1 SF2

SF4 SF5

EP4 EP5

851 852

12822 29119

19819 42542

11798 25954

19210 43095

12435 27741

12694 28827

10305 23402

52315 118808

63682 140107

48136 105894

63060 140671

50737 113183

51792 117616

42043 95481

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

SelectHealthshyHigh

$20$30

$20$40

$15$25

$20$30

$25$40

$100 after

$5$25$50

50+50+

$25$50

$35$60

$25$50$50

$25 $50$50

30to$60050 to$1200

Virgin Islands

4040 40 50+ 50+50+ No

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

None 10 +

$5 or $12 NA NA

2025 up to$100$175max

Yes No

691 874 844 963 872 75 586

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Virginia

Washington

F54 F55

JN1 JN2

JN4 JN5

D91 D92

J91 J92

2G1 2G2

2G4 2G5

A91 A92

E31 E32

E34 E35

JP1 JP2

9R1 9R2

9R4 9R5

2C1 2C2

G54 G55

C31 C32

541 542

544 545

L11 L12

VT1 VT2

571 572

574 575

13058 29656

46867 105610

14021 31351

12138 40332

11280 29365

21177 48693

15284 35429

20427 47008

16926 42124

9646 22186

20245 50123

26858 69565

11269 26665

12235 28017

12822 29119

14933 62274

27070 55009

11742 26509

12426 26823

31651 67459

22672 52645

13617 31283

53279 120995

91271 204437

57208 127913

49524 137853

46023 119808

65067 146381

59056 132852

64302 144663

60731 139681

39358 90520

64116 147840

70861 167671

45977 108794

49920 114308

52315 118808

58698 160234

71078 152824

47908 108156

50700 109437

75750 165523

66592 150412

55557 127637

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

Virginia

$25$40 4040

$15$30

$20$35

$25$35 4040

$5$25$35 4040

$25$35

Nothing$35

$150day x3

10 Plan Allow

$10 50+

Nothing

50+50+

$35$100

$35$60 4040

$35$65

30to$60050 to$1200

POS National

Yes No

Average

MD IPAshyHigh

Washington

$70$70

$10$20

$20$30

$25$40

$25$30

$35$35

$25$40 4040

$20$35

$25$25

$25$35

$154 or 2020

$30$30 $30+40+diff

$20$30

$30$40

$20$0childlt22$30

$200 x3 days

$250dayx3

$150day x 3

$150max$750

$20020

$250day x 4

Nothing Nothing

None None

Nothing

$7$17 Net

$12$22Net

$10 50+

$10 Not Covered

$5 Not Covered

$35$65

$30$50$50

$30$50$45$65

$35$55$50$70

$30$60

$40$55

50+50+

$35$100

$40$60

Not Covered

$40$60

$353050up to $3000

$355050 up to $3000

$35$50 30day$100 90day

$25$50 30day$100 90day

30to$60050 to$1200

Yes No

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

West Virginia

Wisconsin

Wyoming

F54 F55

U41 U42

JS4 JS5

F71 F72

WD1 WD2

WJ1 WJ2

V31 V32

V34 V35

EY1 EY2

LW1 LW2

H44 H45

9K1 9K2

DK4 DK5

13058 29656

26271 60855

17258 41140

10600 29208

24382 72670

15910 51534

26865 64982

8897 20464

14597 48275

16556 55954

13093 29732

19819 42542

11798 25954

53279 120995

70263 158786

61069 138677

43250 119170

68336 170838

59694 149279

70869 162996

36302 83494

58355 145955

60353 153787

53418 121307

63682 140107

48136 105894

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Claims

processing

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Plan Inform

on Costs

West Virginia

Wisconsin

Wyoming

$25$40 4040

$10$20

$25$40 4040

$25$35 4040

$25$25

$10$10

$25$45

$0 for 3 then 20

$10$10

$25$40 4040

$20$30

$20$40

Nothing

20 in40 out

Nothing

$10 Yes 50+ 50+50+ No

$15 $30$50 Yes

$10 Yes 50+ 50+50+ No

$5 $35$60 Yes 40 4040 No

$10 Yes

$5 $20$20 Yes

$12 $45$90 Yes

$9 $40$70 Yes

$10 $20$50 Yes

$10 3050 No

$10 Yes 50+ 50+50+ No

$7 $25$50 No

$7 $35$60 None

30$75max 50 wmin$50

30to$60050 to$1200

909 876 951 929 944

909 90 97 834 879

834 834 953 929 932

893 875 951 92 911

888 854 938 888 87

857 822 96 863 866

852 813 948 883 895

864 849 942 877 875

ELIGIBILITY

FUNDING

CONTRIBUTIONS

DISTRIBUTIONS

ANNUAL ROLLOVER

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

800shy718shy1299

800shy821shy6136

800shy694shy9901

888shy636shy6252

474 475

341 342

481 482

324 325

9742 21915

11021 25172

13642 30912

10454 22700

39747 89414

44967 102703

55661 126120

42653 92617

Plan Code

885 866 929 860

891 888 952 830

873 851 923 863

891 859 912 887

881 865 939 850

891 888 952 830

909 907 925 871

849 864 932 843

875 801 948 856

Getting needed care

How well doctors

Getting needed care

How well doctors

Claims processing

Plan Name

Telephone Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Premium

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Plan Name

877shy459shy6604

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

136516

151489

149613

136516

151489

149613

Self amp family

Plan Name

Benefit Type

CY Ded SelfFamily

Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Premium

Connecticut

Delaware

Florida

Georgia

Plan Name

877shy459shy6604

888shy789shy9065

877shy459shy6604

800shy441shy5501

888shy393shy6765

877shy459shy6604

888shy393shy6765

671shy647shy3526

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

145440

136516

127574

136516

141522

116366

136516

105282

110827

Self amp family

Connecticut

Delaware

Florida

Georgia

Premium

Illinois

Indiana

Kansas

Plan Name

877shy459shy6604

800shy377shy4161

877shy459shy6604

888shy393shy6765

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy257shy4692

877shy459shy6604

800shy969shy3343

888shy393shy6765

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

151489

136317

110827

110823

151489

110823

136317

149613

122219

Self amp family

Illinois

Indiana

Kansas

Premium

Kentucky

Louisiana

Maryland

Massachusetts

Michigan

Minnesota

Plan Name

877shy459shy6604

888shy393shy6765

877shy459shy6604

888shy789shy9065

800shy833shy7423

877shy459shy6604

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

136317

136516

145440

136516

127574

109488

145440

149613

136317

Self amp family

Kentucky

Louisiana

Maryland

OutshyNetWork

InshyNetwork

$3750$7500

$4167$8334

$3000$6000

$2000$4000

$6000$12000

$4000$8000

Nothing

Nothing$30$60

Massachusetts

Michigan

Minnesota

Premium

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

Plan Name

877shy459shy6604

800shy969shy3343

888shy393shy6765

877shy459shy6604

800shy501shy3439

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

149613

122219

136317

149613

145440

149613

145440

101669

Self amp family

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

Premium

North Carolina

North Dakota

Pennsylvania

Rhode Island

South Carolina

Plan Name

877shy459shy6604

330shy363shy6360

877shy459shy6604

866shy351shy5946

888shy876shy2756

877shy459shy6604

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

136516

136317

151489

136317

115650

114458

145440

151489

Self amp family

North Carolina

North Dakota

Pennsylvania

Rhode Island

South Carolina

Plan Name

CY Ded SelfFamily

Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

10After Deduct

10 after deduct

30After Deduct

30 after deduct

Premium

South Dakota

Tennessee

Vermont

Plan Name

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy377shy4161

877shy459shy6604

888shy789shy9065

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

149613

136516

151489

110827

110823

121906

149613

145440

136516

127574

Self amp family

South Dakota

Tennessee

Vermont

Premium

Wyoming

Plan Name

877shy459shy6604

800shy552shy7114

877shy459shy6604

800shy377shy4161

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

149613

136516

151489

136317

Self amp family

Wyoming

Plan Name

CY Ded SelfFamily

Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

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

______________________________________________________________________________________________________________

19122-1-14 (70-16)_20 pages

19122-15-20 (70-16)_6 pages

19122-21-86 (70-16)_0

What does TCC offer

When can I enroll

How do I enroll

Definitions

Enrollment Code

TCC 102 of your

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

MHBP shystd

MHBP shyValue Plan

NALC shyhigh

NALC Value Option

SAMBA shyhigh

SAMBA shystd

800shy222shy2798

Local phone

800shy821shy6136

800shy410shy7778

888shy636shy6252

800shy638shy6589

126114

142015

126195

145991

148291

109939

130096

168477

122733

APWU shyhigh

BCBS shystd

BCBS shybasic

GEHA shyhigh

GEHA shystd

MHBP shystd

MHBP shyvalue

NALC shyhigh

NALC shyValue

SAMBA shyhigh

SAMBA shystd

Benefit Type

Per Person

Calendar Year

Prescription Drug

Hospital Inpatient

Office Visits

Hospital Inpatient

RampB Level I

Prescription Drugs

Level II Level III

Deductible

MHBP shystd

MHBP shyValue Plan

NALC shyhigh

SAMBA shyhigh

SAMBA shystd

FFS National A

Plan Code

verage 805

Getting needed care

How well doctors

communicate

Customer service

Claims processing

Plan Name Location

Plan Code

Getting needed care

How well doctors

Claims processing

Arizona 10 11

851 747

905 898

919 884

933 923

938 914

969 928

724 680

California 10 11

809 705

915 873

897 840

954 943

881 910

937 912

677 616

768 691

935 893

930 874

951 940

882 881

898 922

657 622

Florida 10 11

864 806

942 916

922 894

952 947

934 916

954 937

733 660

Illinois 10 11

861 796

933 912

934 881

955 950

901 936

972 938

712 653

Maryland 10 11

857 770

931 897

917 898

954 940

897 921

956 967

713 666

Texas 10 11

887 825

934 898

931 883

950 955

936 910

957 967

721 617

Virginia 10 11

871 782

924 901

929 894

966 962

914 917

959 960

708 681

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Alabama

Alaska

Arizona

Arkansas

F54 F55

JS4 JS5

G54 G55

WQ1 WQ2

A71 A72

A74 A75

BF1 BF2

BF4 BF5

C71 C72

C74 C75

F54 F55

DH1 DH2

DH4 DH5

13058 29656

17258 41140

12822 29119

33482 89188

26548 80303

19509 62476

13880 30882

12491 27794

15825 35210

13149 29256

13058 29656

30353 76056

14296 38452

53279 120995

61069 138677

52315 118808

77618 187686

70545 178623

63365 160440

56629 125999

50965 113400

59608 132629

53648 119367

53279 120995

74426 174291

58048 135935

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Alabama

HMOPOS Nationa

30to$60050 to$1200 Yes

l Average 679 864 849 942 877 875 649

Alaska

$25$40

50+50+

30to$60050 to$1200

Arizona

$25$40

50+50+

30to$60050 to$1200

Arkansas

$20$35

$20$40

$25$50

$20$35

$25$40

$20$35

$25$40

$250day x 4

$250dayx5

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+50+

$35$100

$40$60

30to$60050 to$1200

$20$30

$20$40

$100max$500

$200max$1000

50+50+

$40$60

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

California

Colorado

Connecticut

Delaware

JS4 JS5

2X1 2X2

B31 B32

SI1 SI2

LB1 LB2

LB4 LB5

LP1 LP2

LP4 LP5

KC1 KC2

591 592

594 595

621 622

624 625

CY1 CY2

CY4 CY5

G54 G55

651 652

654 655

EP4 EP5

P31 P32

P34 P35

17258 41140

15940 41769

18194 43825

18445 42566

77474 182834

71405 168807

30687 74663

27027 66198

18293 47705

35345 91275

22772 58183

14073 35293

9019 20845

22819 54699

13109 30036

12822 29119

23933 55581

9887 22345

12694 28827

64801 164359

49560 118027

61069 138677

59725 139319

62024 141416

62280 140132

122490 283205

116299 268898

74767 172871

71034 164236

62125 145373

79518 189815

66694 156061

57420 132713

36797 85048

66742 152507

53485 122549

52315 118808

67878 153407

40339 91170

51792 117616

109563 264361

94017 217102

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

California

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

Colorado

$20$35

$25$35

$20$30

$30$50

$20$30

$30$50

$25$35

$15$25

$30$40

$15$25

$30$40

$20$35

$25$40

$250day x 4

$250max4days

$200 x 3 days

$150dayx5

$150day x 4

$5$40$60

50+50+

$35$100

$5$40$70$60

$35$60

$35$65

$35$60

$35$65

$35$35

$30$30

$35$35

$30$30

$35$35

$35$60

$25$50

30to$60050 to$1200

Connecticut

$20$40

$25$40

$250x3

50+50+

$35$60

$40$80

30to$60050 to$1200

Delaware

$25$40

50+50+

30to$60050 to$1200

$20$35

$15$35

$250day x 4

20 Plan Allow

50+50+

$35$100

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Florida

877shy459shy6604

888shy789shy9065

877shy574shy3337

877shy835shy9861

877shy459shy6604

800shy882shy8633

850shy383shy3311

800shy441shy5501

888shy393shy6765

F54 F55

JN1 JN2

JN4 JN5

2G1 2G2

2G4 2G5

E31 E32

E34 E35

JP1 JP2

F54 F55

ML1 ML2

ML4 ML5

EA1 EA2

5E1 5E2

5E4 5E5

MJ4 MJ5

QP4 QP5

E21 E22

E24 E25

EE1 EE2

EE4 EE5

EX1 EX2

EX4 EX5

LL1 LL2

LL4 LL5

13058 29656

46867 105610

14021 31351

21177 48693

15284 35429

16926 42124

9646 22186

20245 50123

13058 29656

20336 56279

12604 30253

11679 30949

16664 47450

12501 30003

10247 22697

13149 29256

11834 26331

23153 51514

15825 35210

13880 30882

12491 27794

48720 108398

15825 35208

53279 120995

91271 204437

57208 127913

65067 146381

59056 132852

60731 139681

39358 90520

64116 147840

53279 120995

64209 154119

51424 123431

47650 126273

60464 145113

51005 122414

41809 92606

53648 119367

48282 107430

67082 149259

59608 132629

56629 125999

50965 113400

93161 207280

59608 132627

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

HMOPOS Nationa

30to$60050 to$1200 Yes

l Average 679 864 849 942 877 875 649

$15$30

$20$35

$25$35

Nothing$35

$150day x3

10 Plan Allow

Nothing

50+50+

$35$100

$35$65

MD IPAshyHigh

Florida

$70$70

$10$20

$20$30

$25$40

$250dayx3

$150day x 3

Nothing

$7$17 Net

$12$22Net

$35$65

$30$50$45$65

$35$55$50$70

$30$60

30to$60050 to$1200

$15$40

$25$45

Nothing$15

$15$30

$20$50

$35$55

$250dayx3

$300dayx3

Ded + $150x3

Ded + $150x5

$15 Tier 1

50+50+

$30$5030

$40$6030

$40$6020

$50$7020

$40$60

$30 Tier 2 $50 Tier 3

$35$55

$40+$60+

$40$60

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$40+$60+

$40$60

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Georgia

877shy459shy6604

888shy393shy6765

888shy865shy5813

671 479shy7982

671shy647shy3526

877shy459shy6604

800shy776shy4672

808shy432shy5955

F54 F55

2U1 2U2

AD4 AD5

LM4 LM5

CB1 CB2

CB4 CB5

DG1 DG2

DG4 DG5

DN1 DN2

DN4 DN5

F81 F82

F84 F85

B41 B42

JK1 JK2

JK4 JK5

JS4 JS5

871 872

631 632

634 635

13058 29656

44133 104232

10247 22697

15825 35210

13880 30882

15825 35210

13149 29256

15825 35210

13880 30882

15015 36863

10047 22957

11949 31399

12447 36018

10209 26960

17258 41140

11377 25325

14515 32578

7553 16846

53279 120995

88482 203031

41809 92606

59608 132629

56629 125999

59608 132629

53648 119367

59608 132629

56629 125999

58782 134315

40991 93667

48751 128109

50786 133453

41654 109996

61069 138677

46419 103326

58272 129944

30818 68731

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Georgia

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$20$35

$35$55

$250day x 4

50+50+

$35$100

$40$60

59 90 878 941 86 857 62

$35$55

$40+$60+

$40$60

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$30

$20$35

$15$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250dayx3

$10$20 Comm

$15$25 Comm

$40+$60+

$40$60

$2550 of AWP

$40$50 Comm $40$50 Comm

TakeCareshyHigh

TakeCareshyStandard

$5 at FHP$40

$25$40

$100day for 5

$150day for 5

$25$50

$40$80

30to$60050 to$1200

HMSA InshyNetwork

$15$15

50+50+

$30$65

$20$20

$30$30

$7 + 20

$45$45

$50$50

$30 + 20 $65 + 20 No

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Illinois

H44 H45

9K1 9K2

DK4 DK5

541 542

544 545

SF1 SF2

SF4 SF5

H44 H45

A21 A22

9G1 9G2

FX1 FX2

K84 K85

9F1 9F2

AB4 AB5

GB4 GB5

MW4 MW5

751 752

754 755

761 762

B91 B92

YH1 YH2

13093 29732

19819 42542

11798 25954

27070 55009

11742 26509

19210 43095

12435 27741

13093 29732

30483 71121

32158 67069

26932 67294

20323 51891

51805 115264

15825 35210

10247 22697

40638 90413

15825 35210

14109 33787

33072 74273

14091 38330

53418 121307

63682 140107

48136 105894

71078 152824

47908 108156

63060 140671

50737 113183

53418 121307

74559 169258

76267 165125

70937 165354

64196 149643

96307 214284

59608 132629

41809 92606

84917 188936

59608 132629

57566 131177

77200 172473

57491 135811

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

SelectHealthshyHigh

Illinois

$20$30

$20$40

$25$25

$25$35

$15$25

$20$30

$25$40

$100 after

$5 $25$50

50+50+

$25$50

$35$60

$40$60

$25$50$50

$25$50

30to$60050 to$1200

$20$35

$25$35

$200day x 5

$10 copay

50+50+

$40$60

$40$6025 $6025

30 after ded

$25$50

$20$35

$25$40

$35$55

30 after ded

$200day x 5

$250day x 3

$500day x 3

$35$70

$40$60

745 915 88 962 878 868 67

$35$55

$40+$60+

$40$60

$20$35

$25$40

$15$15

$25$40

$25$50

$250day x 3

$500day x 3

$40+$60+

$40$60

$35$60

$30$60

$35$50

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Indiana

JS4 JS5

FX1 FX2

K84 K85

MW4 MW5

A61 A62

A64 A65

751 752

754 755

MH1 MH2

MH4 MH5

DQ1 DQ2

H44 H45

SV1 SV2

SY4 SY5

FX1 FX2

K84 K85

V31 V32

V34 V35

AU1 AU2

AU4 AU5

YH1 YH2

17258 41140

26932 67294

20323 51891

10247 22697

13880 30882

12491 27794

40638 90413

15825 35210

13880 30882

30786 68557

13093 29732

13351 31376

9799 23027

26932 67294

20323 51891

26865 64982

8897 20464

26173 63455

23647 57594

14091 38330

61069 138677

70937 165354

64196 149643

41809 92606

56629 125999

50965 113400

84917 188936

59608 132629

56629 125999

74868 166643

53418 121307

54474 128016

39979 93951

70937 165354

64196 149643

70869 162996

36302 83494

70163 161438

67586 155460

57491 135811

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Indiana

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$25$50

$35$55

$200day x 5

50+50+

$35$70

$40$60

745 915 88 962 878 868 67

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$15

$25$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$40+$60+

$40$60

$25$50

30to$60050 to$1200

$25$50

$25$45

$0 for 3 then 20

$20$30

$200day x 5

Nothing

20 in40 out

$100day x 5

$3 $10

50+50+

$45$70$100

30$5000 Max

$35$70

$45$90

$40$70

$30$50

$25$25

$100day x 5

40+40+

$30$50

40+40+

$25$50

40+40+

$35$50

Yes 577 896 86 956 914 918 623

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Kansas

Kentucky

Louisiana

877shy459shy6604

800shy969shy3343

888shy393shy6765

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy341shy6613

888shy393shy6765

G54 G55

HY1 HY2

HA1 HA2

HA4 HA5

PH4 PH5

MS1 MS2

MS4 MS5

H44 H45

A61 A62

A64 A65

MH1 MH2

MH4 MH5

MI1 MI2

MI4 MI5

F54 F55

BJ1 BJ2

BJ4 BJ5

AE1 AE2

AE4 AE5

BC1 BC2

BC4 BC5

12822 29119

13777 50039

13519 32270

12568 29535

10247 22697

62521 139111

15825 35210

13093 29732

13880 30882

12491 27794

15825 35210

13880 30882

19459 43292

13880 30882

13058 29656

19208 48754

13035 30271

15825 35210

13149 29256

13880 30882

12491 27794

52315 118808

55396 147754

55160 129630

51276 120503

41809 92606

107238 238608

59608 132629

53418 121307

56629 125999

50965 113400

59608 132629

56629 125999

63314 140872

56629 125999

53279 120995

63058 146443

53182 123506

59608 132629

53648 119367

56629 125999

50965 113400

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Kansas

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$20$35

$30$60

$35$55

$250day x 4

$3 $12

50+50+

$35$100

$50$75

$40$60

Kentucky

$20$35

$25$40

$250day x 3

$500day x 3

$40+$60+

$40$60

30to$60050 to$1200

Louisiana

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+50+

$40$60

30to$60050 to$1200

$25$45

$30$55

$20$35

$35$40

$20$35

$35$40

Ded+$100

Ded+30

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+50+

$40$100

$40$60

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Maryland

Massachusetts

EP4 EP5

F54 F55

JN1 JN2

JN4 JN5

2G1 2G2

2G4 2G5

IG1 IG2

IG4 IG5

E31 E32

E34 E35

JP1 JP2

EP4 EP5

JG1 JG2

12694 28827

13058 29656

46867 105610

14021 31351

21177 48693

15284 35429

14998 37685

13265 30509

16926 42124

9646 22186

20245 50123

12694 28827

29337 80043

51792 117616

53279 120995

91271 204437

57208 127913

65067 146381

59056 132852

58764 135153

54121 124479

60731 139681

39358 90520

64116 147840

51792 117616

73390 178358

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

Maryland

$25$40

50+50+

30to$60050 to$1200

$15$30

$20$35

$25$35

Nothing$35

$150day x3

10 Plan Allow

Nothing

50+50+

$35$100

$35$65

MD IPAshyHigh

Massachusetts

$70$70

$20$40

$10$20

$20$30

$25$40

$200day x 3

$250dayx3

$150day x 3

Nothing

$7$17 Net

$12$22Net

$35$65

$30$60

$30$50$45$65

$35$55$50$

$30$60

30to$60050 to$1200

70 Yes

$25$35

$150to$750max

50+50+

$30$60

Yes 627 851 882 929 883 801 649

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Michigan

Minnesota

G54 G55

K51 K52

LX1 LX2

RL1 RL2

RL4 RL5

521 522

GY4 GY5

X51 X52

A51 A52

H44 H45

V31 V32

V34 V35

H44 H45

12822 29119

22055 52593

18055 50747

24184 61492

19656 50897

20111 55722

16974 48191

13915 49809

13670 50117

13093 29732

26865 64982

8897 20464

13093 29732

52315 118808

65962 150359

61882 148476

68134 159436

63515 148629

63980 153551

60780 145869

56775 147520

55776 147834

53418 121307

70869 162996

36302 83494

53418 121307

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

Michigan

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

Minnesota

$15$25

$10$10

$20$20

$10$20

$15$30

$10$20

$15$15

$25$40

Nothing

$500x3

Nothing

50+50+

$30$60

$15$15

$50$50

$40$60

$40$40

30to$60050 to$1200

$25$45

$0 for 3 then 20

$25$40

Nothing

20 in40 out

50+50+

$45$90

$40$70

30to$60050 to$1200

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Montana

Nebraska

Nevada

New Hampshire

877shy459shy6604

888shy811shy2092

800shy969shy3343

888shy393shy6765

877shy835shy9861

877shy459shy6604

877shy545shy7378

877shy459shy6604

G54 G55

HY1 HY2

9G1 9G2

HA1 HA2

HA4 HA5

PH4 PH5

MS1 MS2

MS4 MS5

B91 B92

H44 H45

G54 G55

HF1 HF2

NM1 NM2

EP4 EP5

12822 29119

13577 50039

32158 67069

13519 32270

12568 29535

10247 22697

62521 139111

15825 35210

33072 74273

13093 29732

12822 29119

11267 36491

9883 23303

12694 28827

52315 118808

55396 147754

76267 165125

55160 129630

51276 120503

41809 92606

107238 238608

59608 132629

77200 172473

53418 121307

52315 118808

45970 133935

40322 95078

51792 117616

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$20$35

$250day x 4

50+50+

$35$100 $40$60

Yes 639 862 862 94 838 901 538

30 after ded $30$60

$30$60

$35$55

30 after ded 25

NA $3 $12

$3 $12

NA $50$75

$40$60

NA Yes

Montana

$20$35

$25$40

$250day x 3

$500day x 3

$40+$60+

$40$60

$30$60

30to$60050 to$1200

Nebraska

$25$40

50+50+

30to$60050 to$1200

Nevada

$25$40

50+50+

30to$60050 to$1200

New Hampshire

$20$35

$10$25

$25$40

$250day x 4

50+50+

$35$100

$35$55$100

30to$60050 to$1200

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

New Jersey

New Mexico

EP4 EP5

JR1 JR2

JR4 JR5

P31 P32

P34 P35

801 802

804 805

G54 G55

Q11 Q12

P21 P22

12694 28827

52355 123641

34184 82457

64801 164359

49560 118027

32591 93212

14135 33572

12822 29119

13099 30785

23940 56335

51792 117616

96868 222828

78334 180821

109563 264361

94017 217102

76709 191791

57672 130958

52315 118808

53445 125603

67885 154176

Prescription Drugs

Mail lan

ll icate

r ng rmation

order discount

Overall p

satisfaction

Getting n

Getting c

quickly

doctors

commun

Custome

service

Claims

processi

New Jersey

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$20$35

$15$35

$20$35

$15$35

$20$20

$250day x 4

20 Plan Allow

$250day x 4

20 Plan Allow

$150max$450

50+50+

$35$100

$45$85

New Mexico

50 of sch

$30$30

$25$40

+50 of sch

$250day x 3

$45$85

30to$60050 to$1200

663 844 851 936 86 828 642

$25$35

$25$40

$250 after ded

$100 x 5 days

50+50+

$35$6050

$40$7550

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

New York

EP4 EP5

JC1 JC2

JC4 JC5

SG1 SG2

SG4 SG5

6V1 6V2

X41 X42

801 802

804 805

511 512

514 515

QA1 QA2

C54 C55

GA1 GA2

GA4 GA5

GV1 GV2

GV4 GV5

M91 M92

M94 M95

MF1 MF2

MF4 MF5

MX1 MX2

MX4 MX5

12694 28827

40198 109033

26007 71920

22952 71235

12294 32053

19548 60991

14167 47634

32591 93212

14135 33572

17000 63158

12206 34562

18597 58201

14454 47853

16586 53386

13377 39674

13042 35704

11193 28006

17110 54877

13779 42651

25417 75411

22349 67734

18731 58664

13657 42345

51792 117616

84468 207928

69993 170073

66877 169374

50161 129408

63405 158925

57800 145301

76709 191791

57672 130958

60806 161136

49800 131968

62435 156079

58209 145524

60384 151168

54580 137182

53210 133132

45669 114266

60918 152689

56220 140218

69392 173634

66262 165803

62572 156552

55723 139906

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

New York

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$20$35

$15$35

$20$30

$25$40

$20$20

$250day x 4

20 Plan Allow

$100 x 5

$500+10

$150max$450

50+50+

$35$100

$30$50

$45$85

50 of sch

$30$30

$20$40

$30$50

$25$25

+50 of sch

$250day x 3

$15$100Ded

$45$85

$35$75

$30$75

$35$75 $75$100Ded

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

North Carolina

North Dakota

Oklahoma

F54 F55

H44 H45

V31 V32

V34 V35

RU1 RU2

C91 C92

C94 C95

JS4 JS5

3A1 3A2

A61 A62

A64 A65

641 642

644 645

U41 U42

JS4 JS5

IM1 IM2

13058 29656

13093 29732

26865 64982

8897 20464

13803 47086

20976 51441

14143 45836

17258 41140

14204 44676

13880 30882

12491 27794

28758 69344

13114 30163

26271 60855

17258 41140

11810 28460

53279 120995

53418 121307

70869 162996

36302 83494

56317 144742

64862 149184

57705 143467

61069 138677

57953 142284

56629 125999

50965 113400

72799 167445

53504 123066

70263 158786

61069 138677

48185 116118

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

North Carolina

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

North Dakota

$25$40

50+50+

30to$60050 to$1200

$25$45

$0 for 3 then 20

$15$25

Nothing

20 in40 out

50$600ded

50+50+

$45$90

$40$70

50$600 ded

$20$30

$100day x 5

$30$50

$25$25

$100day x 5

40+40+

$30$50

40+40+

$25$40

40+40+

30to$60050 to$1200

AultCare HMOshyHigh

Oklahoma

$15$20

$20$35

$25$40

$20$20

$30$40

$10$20

$25$40

$250day x 3

$500day x 3

50+50+

$30$40$55

$40$60

$30$30

$40$40

$30$50

30to$60050 to$1200

$15$45

$250dymx1000

50+50+

$45$70

Yes 592 816 839 916 893 872 727

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Oregon

Pennsylvania

Puerto Rico

Rhode Island

South Carolina

877shy459shy6604

800shy813shy2000

877shy459shy6604

800shy447shy4000

866shy351shy5946

888shy876shy2756

800shy314shy3121

787shy774shy6060

877shy459shy6604

H44 H45

571 572

574 575

H44 H45

P31 P32

P34 P35

YE1 YE2

GG4 GG5

261 262

8W1 8W2

UW4 UW5

ZJ1 ZJ2

891 892

EP4 EP5

JS4 JS5

13093 29732

22672 52645

13617 31283

13093 29732

64801 164359

49560 118027

19203 59806

16820 41884

17814 47183

22135 54101

13345 30692

8026 18317

8829 19866

12694 28827

17258 41140

53418 121307

66592 150412

55557 127637

53418 121307

109563 264361

94017 217102

63053 157716

60623 139436

61637 144841

66044 151897

54448 125225

32748 74733

36023 81052

51792 117616

61069 138677

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Oregon

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

Pennsylvania

$20$30

$30$40

$25$40

50+50+

$40$60

30to$60050 to$1200

Puerto Rico

$20$35

$15$35

$20$35

$25$50

10 after Deduct

20 after Deduct

$250day x 4

20 Plan Allow

$250day x 4

20aftrDeduct

15 after ded

10 after deduct

20after Deduct

30 $5$15

$5 after ded

50+50+

$35$100

$35$60

$35$75

$35$75$100

$10$15

40 $40$120 50 $85$250

Rhode Island

$750$10

$25$40

$750 amp 10 +$10 amp 10 +

None 10 +

$5 or $12 NA

2025 up to$100$175max

30to$60050 to$1200

Yes No

691 874 844 963 872 75 586

South Carolina

$25$40

50+50+

30to$60050 to$1200

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

South Dakota

Tennessee

G54 G55

V31 V32

V34 V35

AU1 AU2

AU4 AU5

F54 F55

UB1 UB2

GJ1 GJ2

GJ4 GJ5

12822 29119

26865 64982

8897 20464

26173 63455

23647 57594

13058 29656

24581 76516

15825 35210

12491 27794

52315 118808

70869 162996

36302 83494

70163 161438

67586 155460

53279 120995

68539 174761

59608 132629

50965 113400

Primary

Prescription Drugs

ded ation

care Hospital Mail

Getting nee

How well

r ng rm

Level II Level III

order discount

Overall

satisfaction

Getting

quickly

doctors

commun

Custome

service

Claims

processi

Plan Info

on Costs

South Dakota

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$25$45

$0 for 3 then 20

$20$30

Nothing

20 in40 out

$100day x 5

50+50+

$45$90

$40$70

$30$50

$25$25

$100day x 5

40+40+

$30$50

Tennessee

40+40+

$25$40

40+40+

30to$60050 to$1200

$20$35

$25$40

$250day x 4

$250day x 3

$500day x 3

50+50+

$35$100

$40$60

66 875 868 959 889 914 69

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

JS4 JS5

ES1 ES2

B71 B72

CK1 CK2

CN1 CN2

CZ1 CZ2

ET1 ET2

TP4 TP5

TU4 TU5

TV4 TV5

EW1 EW2

EW4 EW5

UC1 UC2

UC4 UC5

UR1 UR2

UR4 UR5

UU1 UU2

UU4 UU5

A84 A85

GF1 GF2

17258 41140

12817 40332

11057 37880

10809 34896

13391 65886

13031 61566

12638 56836

10247 22697

13880 30882

12491 27794

17899 39821

13880 30882

55020 122416

13880 30882

26524 59015

15825 35210

14907 37260

32515 78160

61069 138677

52295 137853

45113 135352

44103 132308

54635 163918

53169 159512

51562 154687

41809 92606

56629 125999

50965 113400

61723 137332

56629 126001

99587 221579

56629 126001

70521 156910

59608 132629

58671 134720

76632 176438

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$5$25$35

50+50+

$35$60

FirstcareshyHigh

$30$55

$35$55

$250day x 5

$35$70

$40$60

$35$55

$40+$60+

$40$60

$35$55

$40+$60+

$40$60

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$45

$20$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 5

$40+$60+

$40$60

$45$100

$35$60

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Virgin Islands

G54 G55

9K1 9K2

DK4 DK5

SF1 SF2

SF4 SF5

EP4 EP5

851 852

12822 29119

19819 42542

11798 25954

19210 43095

12435 27741

12694 28827

10305 23402

52315 118808

63682 140107

48136 105894

63060 140671

50737 113183

51792 117616

42043 95481

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

SelectHealthshyHigh

$20$30

$20$40

$15$25

$20$30

$25$40

$100 after

$5$25$50

50+50+

$25$50

$35$60

$25$50$50

$25 $50$50

30to$60050 to$1200

Virgin Islands

4040 40 50+ 50+50+ No

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

None 10 +

$5 or $12 NA NA

2025 up to$100$175max

Yes No

691 874 844 963 872 75 586

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Virginia

Washington

F54 F55

JN1 JN2

JN4 JN5

D91 D92

J91 J92

2G1 2G2

2G4 2G5

A91 A92

E31 E32

E34 E35

JP1 JP2

9R1 9R2

9R4 9R5

2C1 2C2

G54 G55

C31 C32

541 542

544 545

L11 L12

VT1 VT2

571 572

574 575

13058 29656

46867 105610

14021 31351

12138 40332

11280 29365

21177 48693

15284 35429

20427 47008

16926 42124

9646 22186

20245 50123

26858 69565

11269 26665

12235 28017

12822 29119

14933 62274

27070 55009

11742 26509

12426 26823

31651 67459

22672 52645

13617 31283

53279 120995

91271 204437

57208 127913

49524 137853

46023 119808

65067 146381

59056 132852

64302 144663

60731 139681

39358 90520

64116 147840

70861 167671

45977 108794

49920 114308

52315 118808

58698 160234

71078 152824

47908 108156

50700 109437

75750 165523

66592 150412

55557 127637

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

Virginia

$25$40 4040

$15$30

$20$35

$25$35 4040

$5$25$35 4040

$25$35

Nothing$35

$150day x3

10 Plan Allow

$10 50+

Nothing

50+50+

$35$100

$35$60 4040

$35$65

30to$60050 to$1200

POS National

Yes No

Average

MD IPAshyHigh

Washington

$70$70

$10$20

$20$30

$25$40

$25$30

$35$35

$25$40 4040

$20$35

$25$25

$25$35

$154 or 2020

$30$30 $30+40+diff

$20$30

$30$40

$20$0childlt22$30

$200 x3 days

$250dayx3

$150day x 3

$150max$750

$20020

$250day x 4

Nothing Nothing

None None

Nothing

$7$17 Net

$12$22Net

$10 50+

$10 Not Covered

$5 Not Covered

$35$65

$30$50$50

$30$50$45$65

$35$55$50$70

$30$60

$40$55

50+50+

$35$100

$40$60

Not Covered

$40$60

$353050up to $3000

$355050 up to $3000

$35$50 30day$100 90day

$25$50 30day$100 90day

30to$60050 to$1200

Yes No

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

West Virginia

Wisconsin

Wyoming

F54 F55

U41 U42

JS4 JS5

F71 F72

WD1 WD2

WJ1 WJ2

V31 V32

V34 V35

EY1 EY2

LW1 LW2

H44 H45

9K1 9K2

DK4 DK5

13058 29656

26271 60855

17258 41140

10600 29208

24382 72670

15910 51534

26865 64982

8897 20464

14597 48275

16556 55954

13093 29732

19819 42542

11798 25954

53279 120995

70263 158786

61069 138677

43250 119170

68336 170838

59694 149279

70869 162996

36302 83494

58355 145955

60353 153787

53418 121307

63682 140107

48136 105894

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Claims

processing

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Plan Inform

on Costs

West Virginia

Wisconsin

Wyoming

$25$40 4040

$10$20

$25$40 4040

$25$35 4040

$25$25

$10$10

$25$45

$0 for 3 then 20

$10$10

$25$40 4040

$20$30

$20$40

Nothing

20 in40 out

Nothing

$10 Yes 50+ 50+50+ No

$15 $30$50 Yes

$10 Yes 50+ 50+50+ No

$5 $35$60 Yes 40 4040 No

$10 Yes

$5 $20$20 Yes

$12 $45$90 Yes

$9 $40$70 Yes

$10 $20$50 Yes

$10 3050 No

$10 Yes 50+ 50+50+ No

$7 $25$50 No

$7 $35$60 None

30$75max 50 wmin$50

30to$60050 to$1200

909 876 951 929 944

909 90 97 834 879

834 834 953 929 932

893 875 951 92 911

888 854 938 888 87

857 822 96 863 866

852 813 948 883 895

864 849 942 877 875

ELIGIBILITY

FUNDING

CONTRIBUTIONS

DISTRIBUTIONS

ANNUAL ROLLOVER

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

800shy718shy1299

800shy821shy6136

800shy694shy9901

888shy636shy6252

474 475

341 342

481 482

324 325

9742 21915

11021 25172

13642 30912

10454 22700

39747 89414

44967 102703

55661 126120

42653 92617

Plan Code

885 866 929 860

891 888 952 830

873 851 923 863

891 859 912 887

881 865 939 850

891 888 952 830

909 907 925 871

849 864 932 843

875 801 948 856

Getting needed care

How well doctors

Getting needed care

How well doctors

Claims processing

Plan Name

Telephone Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Premium

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Plan Name

877shy459shy6604

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

136516

151489

149613

136516

151489

149613

Self amp family

Plan Name

Benefit Type

CY Ded SelfFamily

Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Premium

Connecticut

Delaware

Florida

Georgia

Plan Name

877shy459shy6604

888shy789shy9065

877shy459shy6604

800shy441shy5501

888shy393shy6765

877shy459shy6604

888shy393shy6765

671shy647shy3526

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

145440

136516

127574

136516

141522

116366

136516

105282

110827

Self amp family

Connecticut

Delaware

Florida

Georgia

Premium

Illinois

Indiana

Kansas

Plan Name

877shy459shy6604

800shy377shy4161

877shy459shy6604

888shy393shy6765

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy257shy4692

877shy459shy6604

800shy969shy3343

888shy393shy6765

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

151489

136317

110827

110823

151489

110823

136317

149613

122219

Self amp family

Illinois

Indiana

Kansas

Premium

Kentucky

Louisiana

Maryland

Massachusetts

Michigan

Minnesota

Plan Name

877shy459shy6604

888shy393shy6765

877shy459shy6604

888shy789shy9065

800shy833shy7423

877shy459shy6604

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

136317

136516

145440

136516

127574

109488

145440

149613

136317

Self amp family

Kentucky

Louisiana

Maryland

OutshyNetWork

InshyNetwork

$3750$7500

$4167$8334

$3000$6000

$2000$4000

$6000$12000

$4000$8000

Nothing

Nothing$30$60

Massachusetts

Michigan

Minnesota

Premium

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

Plan Name

877shy459shy6604

800shy969shy3343

888shy393shy6765

877shy459shy6604

800shy501shy3439

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

149613

122219

136317

149613

145440

149613

145440

101669

Self amp family

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

Premium

North Carolina

North Dakota

Pennsylvania

Rhode Island

South Carolina

Plan Name

877shy459shy6604

330shy363shy6360

877shy459shy6604

866shy351shy5946

888shy876shy2756

877shy459shy6604

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

136516

136317

151489

136317

115650

114458

145440

151489

Self amp family

North Carolina

North Dakota

Pennsylvania

Rhode Island

South Carolina

Plan Name

CY Ded SelfFamily

Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

10After Deduct

10 after deduct

30After Deduct

30 after deduct

Premium

South Dakota

Tennessee

Vermont

Plan Name

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy377shy4161

877shy459shy6604

888shy789shy9065

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

149613

136516

151489

110827

110823

121906

149613

145440

136516

127574

Self amp family

South Dakota

Tennessee

Vermont

Premium

Wyoming

Plan Name

877shy459shy6604

800shy552shy7114

877shy459shy6604

800shy377shy4161

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

149613

136516

151489

136317

Self amp family

Wyoming

Plan Name

CY Ded SelfFamily

Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

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

______________________________________________________________________________________________________________

19122-1-14 (70-16)_20 pages

19122-15-20 (70-16)_6 pages

19122-21-86 (70-16)_0

What does TCC offer

When can I enroll

How do I enroll

Definitions

Enrollment Code

TCC 102 of your

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

MHBP shystd

MHBP shyValue Plan

NALC shyhigh

NALC Value Option

SAMBA shyhigh

SAMBA shystd

800shy222shy2798

Local phone

800shy821shy6136

800shy410shy7778

888shy636shy6252

800shy638shy6589

126114

142015

126195

145991

148291

109939

130096

168477

122733

APWU shyhigh

BCBS shystd

BCBS shybasic

GEHA shyhigh

GEHA shystd

MHBP shystd

MHBP shyvalue

NALC shyhigh

NALC shyValue

SAMBA shyhigh

SAMBA shystd

Benefit Type

Per Person

Calendar Year

Prescription Drug

Hospital Inpatient

Office Visits

Hospital Inpatient

RampB Level I

Prescription Drugs

Level II Level III

Deductible

MHBP shystd

MHBP shyValue Plan

NALC shyhigh

SAMBA shyhigh

SAMBA shystd

FFS National A

Plan Code

verage 805

Getting needed care

How well doctors

communicate

Customer service

Claims processing

Plan Name Location

Plan Code

Getting needed care

How well doctors

Claims processing

Arizona 10 11

851 747

905 898

919 884

933 923

938 914

969 928

724 680

California 10 11

809 705

915 873

897 840

954 943

881 910

937 912

677 616

768 691

935 893

930 874

951 940

882 881

898 922

657 622

Florida 10 11

864 806

942 916

922 894

952 947

934 916

954 937

733 660

Illinois 10 11

861 796

933 912

934 881

955 950

901 936

972 938

712 653

Maryland 10 11

857 770

931 897

917 898

954 940

897 921

956 967

713 666

Texas 10 11

887 825

934 898

931 883

950 955

936 910

957 967

721 617

Virginia 10 11

871 782

924 901

929 894

966 962

914 917

959 960

708 681

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Alabama

Alaska

Arizona

Arkansas

F54 F55

JS4 JS5

G54 G55

WQ1 WQ2

A71 A72

A74 A75

BF1 BF2

BF4 BF5

C71 C72

C74 C75

F54 F55

DH1 DH2

DH4 DH5

13058 29656

17258 41140

12822 29119

33482 89188

26548 80303

19509 62476

13880 30882

12491 27794

15825 35210

13149 29256

13058 29656

30353 76056

14296 38452

53279 120995

61069 138677

52315 118808

77618 187686

70545 178623

63365 160440

56629 125999

50965 113400

59608 132629

53648 119367

53279 120995

74426 174291

58048 135935

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Alabama

HMOPOS Nationa

30to$60050 to$1200 Yes

l Average 679 864 849 942 877 875 649

Alaska

$25$40

50+50+

30to$60050 to$1200

Arizona

$25$40

50+50+

30to$60050 to$1200

Arkansas

$20$35

$20$40

$25$50

$20$35

$25$40

$20$35

$25$40

$250day x 4

$250dayx5

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+50+

$35$100

$40$60

30to$60050 to$1200

$20$30

$20$40

$100max$500

$200max$1000

50+50+

$40$60

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

California

Colorado

Connecticut

Delaware

JS4 JS5

2X1 2X2

B31 B32

SI1 SI2

LB1 LB2

LB4 LB5

LP1 LP2

LP4 LP5

KC1 KC2

591 592

594 595

621 622

624 625

CY1 CY2

CY4 CY5

G54 G55

651 652

654 655

EP4 EP5

P31 P32

P34 P35

17258 41140

15940 41769

18194 43825

18445 42566

77474 182834

71405 168807

30687 74663

27027 66198

18293 47705

35345 91275

22772 58183

14073 35293

9019 20845

22819 54699

13109 30036

12822 29119

23933 55581

9887 22345

12694 28827

64801 164359

49560 118027

61069 138677

59725 139319

62024 141416

62280 140132

122490 283205

116299 268898

74767 172871

71034 164236

62125 145373

79518 189815

66694 156061

57420 132713

36797 85048

66742 152507

53485 122549

52315 118808

67878 153407

40339 91170

51792 117616

109563 264361

94017 217102

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

California

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

Colorado

$20$35

$25$35

$20$30

$30$50

$20$30

$30$50

$25$35

$15$25

$30$40

$15$25

$30$40

$20$35

$25$40

$250day x 4

$250max4days

$200 x 3 days

$150dayx5

$150day x 4

$5$40$60

50+50+

$35$100

$5$40$70$60

$35$60

$35$65

$35$60

$35$65

$35$35

$30$30

$35$35

$30$30

$35$35

$35$60

$25$50

30to$60050 to$1200

Connecticut

$20$40

$25$40

$250x3

50+50+

$35$60

$40$80

30to$60050 to$1200

Delaware

$25$40

50+50+

30to$60050 to$1200

$20$35

$15$35

$250day x 4

20 Plan Allow

50+50+

$35$100

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Florida

877shy459shy6604

888shy789shy9065

877shy574shy3337

877shy835shy9861

877shy459shy6604

800shy882shy8633

850shy383shy3311

800shy441shy5501

888shy393shy6765

F54 F55

JN1 JN2

JN4 JN5

2G1 2G2

2G4 2G5

E31 E32

E34 E35

JP1 JP2

F54 F55

ML1 ML2

ML4 ML5

EA1 EA2

5E1 5E2

5E4 5E5

MJ4 MJ5

QP4 QP5

E21 E22

E24 E25

EE1 EE2

EE4 EE5

EX1 EX2

EX4 EX5

LL1 LL2

LL4 LL5

13058 29656

46867 105610

14021 31351

21177 48693

15284 35429

16926 42124

9646 22186

20245 50123

13058 29656

20336 56279

12604 30253

11679 30949

16664 47450

12501 30003

10247 22697

13149 29256

11834 26331

23153 51514

15825 35210

13880 30882

12491 27794

48720 108398

15825 35208

53279 120995

91271 204437

57208 127913

65067 146381

59056 132852

60731 139681

39358 90520

64116 147840

53279 120995

64209 154119

51424 123431

47650 126273

60464 145113

51005 122414

41809 92606

53648 119367

48282 107430

67082 149259

59608 132629

56629 125999

50965 113400

93161 207280

59608 132627

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

HMOPOS Nationa

30to$60050 to$1200 Yes

l Average 679 864 849 942 877 875 649

$15$30

$20$35

$25$35

Nothing$35

$150day x3

10 Plan Allow

Nothing

50+50+

$35$100

$35$65

MD IPAshyHigh

Florida

$70$70

$10$20

$20$30

$25$40

$250dayx3

$150day x 3

Nothing

$7$17 Net

$12$22Net

$35$65

$30$50$45$65

$35$55$50$70

$30$60

30to$60050 to$1200

$15$40

$25$45

Nothing$15

$15$30

$20$50

$35$55

$250dayx3

$300dayx3

Ded + $150x3

Ded + $150x5

$15 Tier 1

50+50+

$30$5030

$40$6030

$40$6020

$50$7020

$40$60

$30 Tier 2 $50 Tier 3

$35$55

$40+$60+

$40$60

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$40+$60+

$40$60

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Georgia

877shy459shy6604

888shy393shy6765

888shy865shy5813

671 479shy7982

671shy647shy3526

877shy459shy6604

800shy776shy4672

808shy432shy5955

F54 F55

2U1 2U2

AD4 AD5

LM4 LM5

CB1 CB2

CB4 CB5

DG1 DG2

DG4 DG5

DN1 DN2

DN4 DN5

F81 F82

F84 F85

B41 B42

JK1 JK2

JK4 JK5

JS4 JS5

871 872

631 632

634 635

13058 29656

44133 104232

10247 22697

15825 35210

13880 30882

15825 35210

13149 29256

15825 35210

13880 30882

15015 36863

10047 22957

11949 31399

12447 36018

10209 26960

17258 41140

11377 25325

14515 32578

7553 16846

53279 120995

88482 203031

41809 92606

59608 132629

56629 125999

59608 132629

53648 119367

59608 132629

56629 125999

58782 134315

40991 93667

48751 128109

50786 133453

41654 109996

61069 138677

46419 103326

58272 129944

30818 68731

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Georgia

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$20$35

$35$55

$250day x 4

50+50+

$35$100

$40$60

59 90 878 941 86 857 62

$35$55

$40+$60+

$40$60

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$30

$20$35

$15$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250dayx3

$10$20 Comm

$15$25 Comm

$40+$60+

$40$60

$2550 of AWP

$40$50 Comm $40$50 Comm

TakeCareshyHigh

TakeCareshyStandard

$5 at FHP$40

$25$40

$100day for 5

$150day for 5

$25$50

$40$80

30to$60050 to$1200

HMSA InshyNetwork

$15$15

50+50+

$30$65

$20$20

$30$30

$7 + 20

$45$45

$50$50

$30 + 20 $65 + 20 No

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Illinois

H44 H45

9K1 9K2

DK4 DK5

541 542

544 545

SF1 SF2

SF4 SF5

H44 H45

A21 A22

9G1 9G2

FX1 FX2

K84 K85

9F1 9F2

AB4 AB5

GB4 GB5

MW4 MW5

751 752

754 755

761 762

B91 B92

YH1 YH2

13093 29732

19819 42542

11798 25954

27070 55009

11742 26509

19210 43095

12435 27741

13093 29732

30483 71121

32158 67069

26932 67294

20323 51891

51805 115264

15825 35210

10247 22697

40638 90413

15825 35210

14109 33787

33072 74273

14091 38330

53418 121307

63682 140107

48136 105894

71078 152824

47908 108156

63060 140671

50737 113183

53418 121307

74559 169258

76267 165125

70937 165354

64196 149643

96307 214284

59608 132629

41809 92606

84917 188936

59608 132629

57566 131177

77200 172473

57491 135811

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

SelectHealthshyHigh

Illinois

$20$30

$20$40

$25$25

$25$35

$15$25

$20$30

$25$40

$100 after

$5 $25$50

50+50+

$25$50

$35$60

$40$60

$25$50$50

$25$50

30to$60050 to$1200

$20$35

$25$35

$200day x 5

$10 copay

50+50+

$40$60

$40$6025 $6025

30 after ded

$25$50

$20$35

$25$40

$35$55

30 after ded

$200day x 5

$250day x 3

$500day x 3

$35$70

$40$60

745 915 88 962 878 868 67

$35$55

$40+$60+

$40$60

$20$35

$25$40

$15$15

$25$40

$25$50

$250day x 3

$500day x 3

$40+$60+

$40$60

$35$60

$30$60

$35$50

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Indiana

JS4 JS5

FX1 FX2

K84 K85

MW4 MW5

A61 A62

A64 A65

751 752

754 755

MH1 MH2

MH4 MH5

DQ1 DQ2

H44 H45

SV1 SV2

SY4 SY5

FX1 FX2

K84 K85

V31 V32

V34 V35

AU1 AU2

AU4 AU5

YH1 YH2

17258 41140

26932 67294

20323 51891

10247 22697

13880 30882

12491 27794

40638 90413

15825 35210

13880 30882

30786 68557

13093 29732

13351 31376

9799 23027

26932 67294

20323 51891

26865 64982

8897 20464

26173 63455

23647 57594

14091 38330

61069 138677

70937 165354

64196 149643

41809 92606

56629 125999

50965 113400

84917 188936

59608 132629

56629 125999

74868 166643

53418 121307

54474 128016

39979 93951

70937 165354

64196 149643

70869 162996

36302 83494

70163 161438

67586 155460

57491 135811

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Indiana

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$25$50

$35$55

$200day x 5

50+50+

$35$70

$40$60

745 915 88 962 878 868 67

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$15

$25$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$40+$60+

$40$60

$25$50

30to$60050 to$1200

$25$50

$25$45

$0 for 3 then 20

$20$30

$200day x 5

Nothing

20 in40 out

$100day x 5

$3 $10

50+50+

$45$70$100

30$5000 Max

$35$70

$45$90

$40$70

$30$50

$25$25

$100day x 5

40+40+

$30$50

40+40+

$25$50

40+40+

$35$50

Yes 577 896 86 956 914 918 623

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Kansas

Kentucky

Louisiana

877shy459shy6604

800shy969shy3343

888shy393shy6765

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy341shy6613

888shy393shy6765

G54 G55

HY1 HY2

HA1 HA2

HA4 HA5

PH4 PH5

MS1 MS2

MS4 MS5

H44 H45

A61 A62

A64 A65

MH1 MH2

MH4 MH5

MI1 MI2

MI4 MI5

F54 F55

BJ1 BJ2

BJ4 BJ5

AE1 AE2

AE4 AE5

BC1 BC2

BC4 BC5

12822 29119

13777 50039

13519 32270

12568 29535

10247 22697

62521 139111

15825 35210

13093 29732

13880 30882

12491 27794

15825 35210

13880 30882

19459 43292

13880 30882

13058 29656

19208 48754

13035 30271

15825 35210

13149 29256

13880 30882

12491 27794

52315 118808

55396 147754

55160 129630

51276 120503

41809 92606

107238 238608

59608 132629

53418 121307

56629 125999

50965 113400

59608 132629

56629 125999

63314 140872

56629 125999

53279 120995

63058 146443

53182 123506

59608 132629

53648 119367

56629 125999

50965 113400

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Kansas

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$20$35

$30$60

$35$55

$250day x 4

$3 $12

50+50+

$35$100

$50$75

$40$60

Kentucky

$20$35

$25$40

$250day x 3

$500day x 3

$40+$60+

$40$60

30to$60050 to$1200

Louisiana

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+50+

$40$60

30to$60050 to$1200

$25$45

$30$55

$20$35

$35$40

$20$35

$35$40

Ded+$100

Ded+30

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+50+

$40$100

$40$60

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Maryland

Massachusetts

EP4 EP5

F54 F55

JN1 JN2

JN4 JN5

2G1 2G2

2G4 2G5

IG1 IG2

IG4 IG5

E31 E32

E34 E35

JP1 JP2

EP4 EP5

JG1 JG2

12694 28827

13058 29656

46867 105610

14021 31351

21177 48693

15284 35429

14998 37685

13265 30509

16926 42124

9646 22186

20245 50123

12694 28827

29337 80043

51792 117616

53279 120995

91271 204437

57208 127913

65067 146381

59056 132852

58764 135153

54121 124479

60731 139681

39358 90520

64116 147840

51792 117616

73390 178358

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

Maryland

$25$40

50+50+

30to$60050 to$1200

$15$30

$20$35

$25$35

Nothing$35

$150day x3

10 Plan Allow

Nothing

50+50+

$35$100

$35$65

MD IPAshyHigh

Massachusetts

$70$70

$20$40

$10$20

$20$30

$25$40

$200day x 3

$250dayx3

$150day x 3

Nothing

$7$17 Net

$12$22Net

$35$65

$30$60

$30$50$45$65

$35$55$50$

$30$60

30to$60050 to$1200

70 Yes

$25$35

$150to$750max

50+50+

$30$60

Yes 627 851 882 929 883 801 649

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Michigan

Minnesota

G54 G55

K51 K52

LX1 LX2

RL1 RL2

RL4 RL5

521 522

GY4 GY5

X51 X52

A51 A52

H44 H45

V31 V32

V34 V35

H44 H45

12822 29119

22055 52593

18055 50747

24184 61492

19656 50897

20111 55722

16974 48191

13915 49809

13670 50117

13093 29732

26865 64982

8897 20464

13093 29732

52315 118808

65962 150359

61882 148476

68134 159436

63515 148629

63980 153551

60780 145869

56775 147520

55776 147834

53418 121307

70869 162996

36302 83494

53418 121307

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

Michigan

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

Minnesota

$15$25

$10$10

$20$20

$10$20

$15$30

$10$20

$15$15

$25$40

Nothing

$500x3

Nothing

50+50+

$30$60

$15$15

$50$50

$40$60

$40$40

30to$60050 to$1200

$25$45

$0 for 3 then 20

$25$40

Nothing

20 in40 out

50+50+

$45$90

$40$70

30to$60050 to$1200

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Montana

Nebraska

Nevada

New Hampshire

877shy459shy6604

888shy811shy2092

800shy969shy3343

888shy393shy6765

877shy835shy9861

877shy459shy6604

877shy545shy7378

877shy459shy6604

G54 G55

HY1 HY2

9G1 9G2

HA1 HA2

HA4 HA5

PH4 PH5

MS1 MS2

MS4 MS5

B91 B92

H44 H45

G54 G55

HF1 HF2

NM1 NM2

EP4 EP5

12822 29119

13577 50039

32158 67069

13519 32270

12568 29535

10247 22697

62521 139111

15825 35210

33072 74273

13093 29732

12822 29119

11267 36491

9883 23303

12694 28827

52315 118808

55396 147754

76267 165125

55160 129630

51276 120503

41809 92606

107238 238608

59608 132629

77200 172473

53418 121307

52315 118808

45970 133935

40322 95078

51792 117616

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$20$35

$250day x 4

50+50+

$35$100 $40$60

Yes 639 862 862 94 838 901 538

30 after ded $30$60

$30$60

$35$55

30 after ded 25

NA $3 $12

$3 $12

NA $50$75

$40$60

NA Yes

Montana

$20$35

$25$40

$250day x 3

$500day x 3

$40+$60+

$40$60

$30$60

30to$60050 to$1200

Nebraska

$25$40

50+50+

30to$60050 to$1200

Nevada

$25$40

50+50+

30to$60050 to$1200

New Hampshire

$20$35

$10$25

$25$40

$250day x 4

50+50+

$35$100

$35$55$100

30to$60050 to$1200

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

New Jersey

New Mexico

EP4 EP5

JR1 JR2

JR4 JR5

P31 P32

P34 P35

801 802

804 805

G54 G55

Q11 Q12

P21 P22

12694 28827

52355 123641

34184 82457

64801 164359

49560 118027

32591 93212

14135 33572

12822 29119

13099 30785

23940 56335

51792 117616

96868 222828

78334 180821

109563 264361

94017 217102

76709 191791

57672 130958

52315 118808

53445 125603

67885 154176

Prescription Drugs

Mail lan

ll icate

r ng rmation

order discount

Overall p

satisfaction

Getting n

Getting c

quickly

doctors

commun

Custome

service

Claims

processi

New Jersey

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$20$35

$15$35

$20$35

$15$35

$20$20

$250day x 4

20 Plan Allow

$250day x 4

20 Plan Allow

$150max$450

50+50+

$35$100

$45$85

New Mexico

50 of sch

$30$30

$25$40

+50 of sch

$250day x 3

$45$85

30to$60050 to$1200

663 844 851 936 86 828 642

$25$35

$25$40

$250 after ded

$100 x 5 days

50+50+

$35$6050

$40$7550

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

New York

EP4 EP5

JC1 JC2

JC4 JC5

SG1 SG2

SG4 SG5

6V1 6V2

X41 X42

801 802

804 805

511 512

514 515

QA1 QA2

C54 C55

GA1 GA2

GA4 GA5

GV1 GV2

GV4 GV5

M91 M92

M94 M95

MF1 MF2

MF4 MF5

MX1 MX2

MX4 MX5

12694 28827

40198 109033

26007 71920

22952 71235

12294 32053

19548 60991

14167 47634

32591 93212

14135 33572

17000 63158

12206 34562

18597 58201

14454 47853

16586 53386

13377 39674

13042 35704

11193 28006

17110 54877

13779 42651

25417 75411

22349 67734

18731 58664

13657 42345

51792 117616

84468 207928

69993 170073

66877 169374

50161 129408

63405 158925

57800 145301

76709 191791

57672 130958

60806 161136

49800 131968

62435 156079

58209 145524

60384 151168

54580 137182

53210 133132

45669 114266

60918 152689

56220 140218

69392 173634

66262 165803

62572 156552

55723 139906

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

New York

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$20$35

$15$35

$20$30

$25$40

$20$20

$250day x 4

20 Plan Allow

$100 x 5

$500+10

$150max$450

50+50+

$35$100

$30$50

$45$85

50 of sch

$30$30

$20$40

$30$50

$25$25

+50 of sch

$250day x 3

$15$100Ded

$45$85

$35$75

$30$75

$35$75 $75$100Ded

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

North Carolina

North Dakota

Oklahoma

F54 F55

H44 H45

V31 V32

V34 V35

RU1 RU2

C91 C92

C94 C95

JS4 JS5

3A1 3A2

A61 A62

A64 A65

641 642

644 645

U41 U42

JS4 JS5

IM1 IM2

13058 29656

13093 29732

26865 64982

8897 20464

13803 47086

20976 51441

14143 45836

17258 41140

14204 44676

13880 30882

12491 27794

28758 69344

13114 30163

26271 60855

17258 41140

11810 28460

53279 120995

53418 121307

70869 162996

36302 83494

56317 144742

64862 149184

57705 143467

61069 138677

57953 142284

56629 125999

50965 113400

72799 167445

53504 123066

70263 158786

61069 138677

48185 116118

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

North Carolina

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

North Dakota

$25$40

50+50+

30to$60050 to$1200

$25$45

$0 for 3 then 20

$15$25

Nothing

20 in40 out

50$600ded

50+50+

$45$90

$40$70

50$600 ded

$20$30

$100day x 5

$30$50

$25$25

$100day x 5

40+40+

$30$50

40+40+

$25$40

40+40+

30to$60050 to$1200

AultCare HMOshyHigh

Oklahoma

$15$20

$20$35

$25$40

$20$20

$30$40

$10$20

$25$40

$250day x 3

$500day x 3

50+50+

$30$40$55

$40$60

$30$30

$40$40

$30$50

30to$60050 to$1200

$15$45

$250dymx1000

50+50+

$45$70

Yes 592 816 839 916 893 872 727

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Oregon

Pennsylvania

Puerto Rico

Rhode Island

South Carolina

877shy459shy6604

800shy813shy2000

877shy459shy6604

800shy447shy4000

866shy351shy5946

888shy876shy2756

800shy314shy3121

787shy774shy6060

877shy459shy6604

H44 H45

571 572

574 575

H44 H45

P31 P32

P34 P35

YE1 YE2

GG4 GG5

261 262

8W1 8W2

UW4 UW5

ZJ1 ZJ2

891 892

EP4 EP5

JS4 JS5

13093 29732

22672 52645

13617 31283

13093 29732

64801 164359

49560 118027

19203 59806

16820 41884

17814 47183

22135 54101

13345 30692

8026 18317

8829 19866

12694 28827

17258 41140

53418 121307

66592 150412

55557 127637

53418 121307

109563 264361

94017 217102

63053 157716

60623 139436

61637 144841

66044 151897

54448 125225

32748 74733

36023 81052

51792 117616

61069 138677

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Oregon

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

Pennsylvania

$20$30

$30$40

$25$40

50+50+

$40$60

30to$60050 to$1200

Puerto Rico

$20$35

$15$35

$20$35

$25$50

10 after Deduct

20 after Deduct

$250day x 4

20 Plan Allow

$250day x 4

20aftrDeduct

15 after ded

10 after deduct

20after Deduct

30 $5$15

$5 after ded

50+50+

$35$100

$35$60

$35$75

$35$75$100

$10$15

40 $40$120 50 $85$250

Rhode Island

$750$10

$25$40

$750 amp 10 +$10 amp 10 +

None 10 +

$5 or $12 NA

2025 up to$100$175max

30to$60050 to$1200

Yes No

691 874 844 963 872 75 586

South Carolina

$25$40

50+50+

30to$60050 to$1200

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

South Dakota

Tennessee

G54 G55

V31 V32

V34 V35

AU1 AU2

AU4 AU5

F54 F55

UB1 UB2

GJ1 GJ2

GJ4 GJ5

12822 29119

26865 64982

8897 20464

26173 63455

23647 57594

13058 29656

24581 76516

15825 35210

12491 27794

52315 118808

70869 162996

36302 83494

70163 161438

67586 155460

53279 120995

68539 174761

59608 132629

50965 113400

Primary

Prescription Drugs

ded ation

care Hospital Mail

Getting nee

How well

r ng rm

Level II Level III

order discount

Overall

satisfaction

Getting

quickly

doctors

commun

Custome

service

Claims

processi

Plan Info

on Costs

South Dakota

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$25$45

$0 for 3 then 20

$20$30

Nothing

20 in40 out

$100day x 5

50+50+

$45$90

$40$70

$30$50

$25$25

$100day x 5

40+40+

$30$50

Tennessee

40+40+

$25$40

40+40+

30to$60050 to$1200

$20$35

$25$40

$250day x 4

$250day x 3

$500day x 3

50+50+

$35$100

$40$60

66 875 868 959 889 914 69

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

JS4 JS5

ES1 ES2

B71 B72

CK1 CK2

CN1 CN2

CZ1 CZ2

ET1 ET2

TP4 TP5

TU4 TU5

TV4 TV5

EW1 EW2

EW4 EW5

UC1 UC2

UC4 UC5

UR1 UR2

UR4 UR5

UU1 UU2

UU4 UU5

A84 A85

GF1 GF2

17258 41140

12817 40332

11057 37880

10809 34896

13391 65886

13031 61566

12638 56836

10247 22697

13880 30882

12491 27794

17899 39821

13880 30882

55020 122416

13880 30882

26524 59015

15825 35210

14907 37260

32515 78160

61069 138677

52295 137853

45113 135352

44103 132308

54635 163918

53169 159512

51562 154687

41809 92606

56629 125999

50965 113400

61723 137332

56629 126001

99587 221579

56629 126001

70521 156910

59608 132629

58671 134720

76632 176438

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$5$25$35

50+50+

$35$60

FirstcareshyHigh

$30$55

$35$55

$250day x 5

$35$70

$40$60

$35$55

$40+$60+

$40$60

$35$55

$40+$60+

$40$60

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$45

$20$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 5

$40+$60+

$40$60

$45$100

$35$60

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Virgin Islands

G54 G55

9K1 9K2

DK4 DK5

SF1 SF2

SF4 SF5

EP4 EP5

851 852

12822 29119

19819 42542

11798 25954

19210 43095

12435 27741

12694 28827

10305 23402

52315 118808

63682 140107

48136 105894

63060 140671

50737 113183

51792 117616

42043 95481

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

SelectHealthshyHigh

$20$30

$20$40

$15$25

$20$30

$25$40

$100 after

$5$25$50

50+50+

$25$50

$35$60

$25$50$50

$25 $50$50

30to$60050 to$1200

Virgin Islands

4040 40 50+ 50+50+ No

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

None 10 +

$5 or $12 NA NA

2025 up to$100$175max

Yes No

691 874 844 963 872 75 586

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Virginia

Washington

F54 F55

JN1 JN2

JN4 JN5

D91 D92

J91 J92

2G1 2G2

2G4 2G5

A91 A92

E31 E32

E34 E35

JP1 JP2

9R1 9R2

9R4 9R5

2C1 2C2

G54 G55

C31 C32

541 542

544 545

L11 L12

VT1 VT2

571 572

574 575

13058 29656

46867 105610

14021 31351

12138 40332

11280 29365

21177 48693

15284 35429

20427 47008

16926 42124

9646 22186

20245 50123

26858 69565

11269 26665

12235 28017

12822 29119

14933 62274

27070 55009

11742 26509

12426 26823

31651 67459

22672 52645

13617 31283

53279 120995

91271 204437

57208 127913

49524 137853

46023 119808

65067 146381

59056 132852

64302 144663

60731 139681

39358 90520

64116 147840

70861 167671

45977 108794

49920 114308

52315 118808

58698 160234

71078 152824

47908 108156

50700 109437

75750 165523

66592 150412

55557 127637

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

Virginia

$25$40 4040

$15$30

$20$35

$25$35 4040

$5$25$35 4040

$25$35

Nothing$35

$150day x3

10 Plan Allow

$10 50+

Nothing

50+50+

$35$100

$35$60 4040

$35$65

30to$60050 to$1200

POS National

Yes No

Average

MD IPAshyHigh

Washington

$70$70

$10$20

$20$30

$25$40

$25$30

$35$35

$25$40 4040

$20$35

$25$25

$25$35

$154 or 2020

$30$30 $30+40+diff

$20$30

$30$40

$20$0childlt22$30

$200 x3 days

$250dayx3

$150day x 3

$150max$750

$20020

$250day x 4

Nothing Nothing

None None

Nothing

$7$17 Net

$12$22Net

$10 50+

$10 Not Covered

$5 Not Covered

$35$65

$30$50$50

$30$50$45$65

$35$55$50$70

$30$60

$40$55

50+50+

$35$100

$40$60

Not Covered

$40$60

$353050up to $3000

$355050 up to $3000

$35$50 30day$100 90day

$25$50 30day$100 90day

30to$60050 to$1200

Yes No

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

West Virginia

Wisconsin

Wyoming

F54 F55

U41 U42

JS4 JS5

F71 F72

WD1 WD2

WJ1 WJ2

V31 V32

V34 V35

EY1 EY2

LW1 LW2

H44 H45

9K1 9K2

DK4 DK5

13058 29656

26271 60855

17258 41140

10600 29208

24382 72670

15910 51534

26865 64982

8897 20464

14597 48275

16556 55954

13093 29732

19819 42542

11798 25954

53279 120995

70263 158786

61069 138677

43250 119170

68336 170838

59694 149279

70869 162996

36302 83494

58355 145955

60353 153787

53418 121307

63682 140107

48136 105894

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Claims

processing

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Plan Inform

on Costs

West Virginia

Wisconsin

Wyoming

$25$40 4040

$10$20

$25$40 4040

$25$35 4040

$25$25

$10$10

$25$45

$0 for 3 then 20

$10$10

$25$40 4040

$20$30

$20$40

Nothing

20 in40 out

Nothing

$10 Yes 50+ 50+50+ No

$15 $30$50 Yes

$10 Yes 50+ 50+50+ No

$5 $35$60 Yes 40 4040 No

$10 Yes

$5 $20$20 Yes

$12 $45$90 Yes

$9 $40$70 Yes

$10 $20$50 Yes

$10 3050 No

$10 Yes 50+ 50+50+ No

$7 $25$50 No

$7 $35$60 None

30$75max 50 wmin$50

30to$60050 to$1200

909 876 951 929 944

909 90 97 834 879

834 834 953 929 932

893 875 951 92 911

888 854 938 888 87

857 822 96 863 866

852 813 948 883 895

864 849 942 877 875

ELIGIBILITY

FUNDING

CONTRIBUTIONS

DISTRIBUTIONS

ANNUAL ROLLOVER

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

800shy718shy1299

800shy821shy6136

800shy694shy9901

888shy636shy6252

474 475

341 342

481 482

324 325

9742 21915

11021 25172

13642 30912

10454 22700

39747 89414

44967 102703

55661 126120

42653 92617

Plan Code

885 866 929 860

891 888 952 830

873 851 923 863

891 859 912 887

881 865 939 850

891 888 952 830

909 907 925 871

849 864 932 843

875 801 948 856

Getting needed care

How well doctors

Getting needed care

How well doctors

Claims processing

Plan Name

Telephone Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Premium

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Plan Name

877shy459shy6604

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

136516

151489

149613

136516

151489

149613

Self amp family

Plan Name

Benefit Type

CY Ded SelfFamily

Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Premium

Connecticut

Delaware

Florida

Georgia

Plan Name

877shy459shy6604

888shy789shy9065

877shy459shy6604

800shy441shy5501

888shy393shy6765

877shy459shy6604

888shy393shy6765

671shy647shy3526

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

145440

136516

127574

136516

141522

116366

136516

105282

110827

Self amp family

Connecticut

Delaware

Florida

Georgia

Premium

Illinois

Indiana

Kansas

Plan Name

877shy459shy6604

800shy377shy4161

877shy459shy6604

888shy393shy6765

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy257shy4692

877shy459shy6604

800shy969shy3343

888shy393shy6765

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

151489

136317

110827

110823

151489

110823

136317

149613

122219

Self amp family

Illinois

Indiana

Kansas

Premium

Kentucky

Louisiana

Maryland

Massachusetts

Michigan

Minnesota

Plan Name

877shy459shy6604

888shy393shy6765

877shy459shy6604

888shy789shy9065

800shy833shy7423

877shy459shy6604

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

136317

136516

145440

136516

127574

109488

145440

149613

136317

Self amp family

Kentucky

Louisiana

Maryland

OutshyNetWork

InshyNetwork

$3750$7500

$4167$8334

$3000$6000

$2000$4000

$6000$12000

$4000$8000

Nothing

Nothing$30$60

Massachusetts

Michigan

Minnesota

Premium

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

Plan Name

877shy459shy6604

800shy969shy3343

888shy393shy6765

877shy459shy6604

800shy501shy3439

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

149613

122219

136317

149613

145440

149613

145440

101669

Self amp family

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

Premium

North Carolina

North Dakota

Pennsylvania

Rhode Island

South Carolina

Plan Name

877shy459shy6604

330shy363shy6360

877shy459shy6604

866shy351shy5946

888shy876shy2756

877shy459shy6604

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

136516

136317

151489

136317

115650

114458

145440

151489

Self amp family

North Carolina

North Dakota

Pennsylvania

Rhode Island

South Carolina

Plan Name

CY Ded SelfFamily

Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

10After Deduct

10 after deduct

30After Deduct

30 after deduct

Premium

South Dakota

Tennessee

Vermont

Plan Name

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy377shy4161

877shy459shy6604

888shy789shy9065

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

149613

136516

151489

110827

110823

121906

149613

145440

136516

127574

Self amp family

South Dakota

Tennessee

Vermont

Premium

Wyoming

Plan Name

877shy459shy6604

800shy552shy7114

877shy459shy6604

800shy377shy4161

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

149613

136516

151489

136317

Self amp family

Wyoming

Plan Name

CY Ded SelfFamily

Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

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

______________________________________________________________________________________________________________

19122-1-14 (70-16)_20 pages

19122-15-20 (70-16)_6 pages

19122-21-86 (70-16)_0

What does TCC offer

When can I enroll

How do I enroll

Definitions

Enrollment Code

TCC 102 of your

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

MHBP shystd

MHBP shyValue Plan

NALC shyhigh

NALC Value Option

SAMBA shyhigh

SAMBA shystd

800shy222shy2798

Local phone

800shy821shy6136

800shy410shy7778

888shy636shy6252

800shy638shy6589

126114

142015

126195

145991

148291

109939

130096

168477

122733

APWU shyhigh

BCBS shystd

BCBS shybasic

GEHA shyhigh

GEHA shystd

MHBP shystd

MHBP shyvalue

NALC shyhigh

NALC shyValue

SAMBA shyhigh

SAMBA shystd

Benefit Type

Per Person

Calendar Year

Prescription Drug

Hospital Inpatient

Office Visits

Hospital Inpatient

RampB Level I

Prescription Drugs

Level II Level III

Deductible

MHBP shystd

MHBP shyValue Plan

NALC shyhigh

SAMBA shyhigh

SAMBA shystd

FFS National A

Plan Code

verage 805

Getting needed care

How well doctors

communicate

Customer service

Claims processing

Plan Name Location

Plan Code

Getting needed care

How well doctors

Claims processing

Arizona 10 11

851 747

905 898

919 884

933 923

938 914

969 928

724 680

California 10 11

809 705

915 873

897 840

954 943

881 910

937 912

677 616

768 691

935 893

930 874

951 940

882 881

898 922

657 622

Florida 10 11

864 806

942 916

922 894

952 947

934 916

954 937

733 660

Illinois 10 11

861 796

933 912

934 881

955 950

901 936

972 938

712 653

Maryland 10 11

857 770

931 897

917 898

954 940

897 921

956 967

713 666

Texas 10 11

887 825

934 898

931 883

950 955

936 910

957 967

721 617

Virginia 10 11

871 782

924 901

929 894

966 962

914 917

959 960

708 681

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Alabama

Alaska

Arizona

Arkansas

F54 F55

JS4 JS5

G54 G55

WQ1 WQ2

A71 A72

A74 A75

BF1 BF2

BF4 BF5

C71 C72

C74 C75

F54 F55

DH1 DH2

DH4 DH5

13058 29656

17258 41140

12822 29119

33482 89188

26548 80303

19509 62476

13880 30882

12491 27794

15825 35210

13149 29256

13058 29656

30353 76056

14296 38452

53279 120995

61069 138677

52315 118808

77618 187686

70545 178623

63365 160440

56629 125999

50965 113400

59608 132629

53648 119367

53279 120995

74426 174291

58048 135935

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Alabama

HMOPOS Nationa

30to$60050 to$1200 Yes

l Average 679 864 849 942 877 875 649

Alaska

$25$40

50+50+

30to$60050 to$1200

Arizona

$25$40

50+50+

30to$60050 to$1200

Arkansas

$20$35

$20$40

$25$50

$20$35

$25$40

$20$35

$25$40

$250day x 4

$250dayx5

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+50+

$35$100

$40$60

30to$60050 to$1200

$20$30

$20$40

$100max$500

$200max$1000

50+50+

$40$60

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

California

Colorado

Connecticut

Delaware

JS4 JS5

2X1 2X2

B31 B32

SI1 SI2

LB1 LB2

LB4 LB5

LP1 LP2

LP4 LP5

KC1 KC2

591 592

594 595

621 622

624 625

CY1 CY2

CY4 CY5

G54 G55

651 652

654 655

EP4 EP5

P31 P32

P34 P35

17258 41140

15940 41769

18194 43825

18445 42566

77474 182834

71405 168807

30687 74663

27027 66198

18293 47705

35345 91275

22772 58183

14073 35293

9019 20845

22819 54699

13109 30036

12822 29119

23933 55581

9887 22345

12694 28827

64801 164359

49560 118027

61069 138677

59725 139319

62024 141416

62280 140132

122490 283205

116299 268898

74767 172871

71034 164236

62125 145373

79518 189815

66694 156061

57420 132713

36797 85048

66742 152507

53485 122549

52315 118808

67878 153407

40339 91170

51792 117616

109563 264361

94017 217102

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

California

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

Colorado

$20$35

$25$35

$20$30

$30$50

$20$30

$30$50

$25$35

$15$25

$30$40

$15$25

$30$40

$20$35

$25$40

$250day x 4

$250max4days

$200 x 3 days

$150dayx5

$150day x 4

$5$40$60

50+50+

$35$100

$5$40$70$60

$35$60

$35$65

$35$60

$35$65

$35$35

$30$30

$35$35

$30$30

$35$35

$35$60

$25$50

30to$60050 to$1200

Connecticut

$20$40

$25$40

$250x3

50+50+

$35$60

$40$80

30to$60050 to$1200

Delaware

$25$40

50+50+

30to$60050 to$1200

$20$35

$15$35

$250day x 4

20 Plan Allow

50+50+

$35$100

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Florida

877shy459shy6604

888shy789shy9065

877shy574shy3337

877shy835shy9861

877shy459shy6604

800shy882shy8633

850shy383shy3311

800shy441shy5501

888shy393shy6765

F54 F55

JN1 JN2

JN4 JN5

2G1 2G2

2G4 2G5

E31 E32

E34 E35

JP1 JP2

F54 F55

ML1 ML2

ML4 ML5

EA1 EA2

5E1 5E2

5E4 5E5

MJ4 MJ5

QP4 QP5

E21 E22

E24 E25

EE1 EE2

EE4 EE5

EX1 EX2

EX4 EX5

LL1 LL2

LL4 LL5

13058 29656

46867 105610

14021 31351

21177 48693

15284 35429

16926 42124

9646 22186

20245 50123

13058 29656

20336 56279

12604 30253

11679 30949

16664 47450

12501 30003

10247 22697

13149 29256

11834 26331

23153 51514

15825 35210

13880 30882

12491 27794

48720 108398

15825 35208

53279 120995

91271 204437

57208 127913

65067 146381

59056 132852

60731 139681

39358 90520

64116 147840

53279 120995

64209 154119

51424 123431

47650 126273

60464 145113

51005 122414

41809 92606

53648 119367

48282 107430

67082 149259

59608 132629

56629 125999

50965 113400

93161 207280

59608 132627

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

HMOPOS Nationa

30to$60050 to$1200 Yes

l Average 679 864 849 942 877 875 649

$15$30

$20$35

$25$35

Nothing$35

$150day x3

10 Plan Allow

Nothing

50+50+

$35$100

$35$65

MD IPAshyHigh

Florida

$70$70

$10$20

$20$30

$25$40

$250dayx3

$150day x 3

Nothing

$7$17 Net

$12$22Net

$35$65

$30$50$45$65

$35$55$50$70

$30$60

30to$60050 to$1200

$15$40

$25$45

Nothing$15

$15$30

$20$50

$35$55

$250dayx3

$300dayx3

Ded + $150x3

Ded + $150x5

$15 Tier 1

50+50+

$30$5030

$40$6030

$40$6020

$50$7020

$40$60

$30 Tier 2 $50 Tier 3

$35$55

$40+$60+

$40$60

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$40+$60+

$40$60

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Georgia

877shy459shy6604

888shy393shy6765

888shy865shy5813

671 479shy7982

671shy647shy3526

877shy459shy6604

800shy776shy4672

808shy432shy5955

F54 F55

2U1 2U2

AD4 AD5

LM4 LM5

CB1 CB2

CB4 CB5

DG1 DG2

DG4 DG5

DN1 DN2

DN4 DN5

F81 F82

F84 F85

B41 B42

JK1 JK2

JK4 JK5

JS4 JS5

871 872

631 632

634 635

13058 29656

44133 104232

10247 22697

15825 35210

13880 30882

15825 35210

13149 29256

15825 35210

13880 30882

15015 36863

10047 22957

11949 31399

12447 36018

10209 26960

17258 41140

11377 25325

14515 32578

7553 16846

53279 120995

88482 203031

41809 92606

59608 132629

56629 125999

59608 132629

53648 119367

59608 132629

56629 125999

58782 134315

40991 93667

48751 128109

50786 133453

41654 109996

61069 138677

46419 103326

58272 129944

30818 68731

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Georgia

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$20$35

$35$55

$250day x 4

50+50+

$35$100

$40$60

59 90 878 941 86 857 62

$35$55

$40+$60+

$40$60

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$30

$20$35

$15$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250dayx3

$10$20 Comm

$15$25 Comm

$40+$60+

$40$60

$2550 of AWP

$40$50 Comm $40$50 Comm

TakeCareshyHigh

TakeCareshyStandard

$5 at FHP$40

$25$40

$100day for 5

$150day for 5

$25$50

$40$80

30to$60050 to$1200

HMSA InshyNetwork

$15$15

50+50+

$30$65

$20$20

$30$30

$7 + 20

$45$45

$50$50

$30 + 20 $65 + 20 No

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Illinois

H44 H45

9K1 9K2

DK4 DK5

541 542

544 545

SF1 SF2

SF4 SF5

H44 H45

A21 A22

9G1 9G2

FX1 FX2

K84 K85

9F1 9F2

AB4 AB5

GB4 GB5

MW4 MW5

751 752

754 755

761 762

B91 B92

YH1 YH2

13093 29732

19819 42542

11798 25954

27070 55009

11742 26509

19210 43095

12435 27741

13093 29732

30483 71121

32158 67069

26932 67294

20323 51891

51805 115264

15825 35210

10247 22697

40638 90413

15825 35210

14109 33787

33072 74273

14091 38330

53418 121307

63682 140107

48136 105894

71078 152824

47908 108156

63060 140671

50737 113183

53418 121307

74559 169258

76267 165125

70937 165354

64196 149643

96307 214284

59608 132629

41809 92606

84917 188936

59608 132629

57566 131177

77200 172473

57491 135811

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

SelectHealthshyHigh

Illinois

$20$30

$20$40

$25$25

$25$35

$15$25

$20$30

$25$40

$100 after

$5 $25$50

50+50+

$25$50

$35$60

$40$60

$25$50$50

$25$50

30to$60050 to$1200

$20$35

$25$35

$200day x 5

$10 copay

50+50+

$40$60

$40$6025 $6025

30 after ded

$25$50

$20$35

$25$40

$35$55

30 after ded

$200day x 5

$250day x 3

$500day x 3

$35$70

$40$60

745 915 88 962 878 868 67

$35$55

$40+$60+

$40$60

$20$35

$25$40

$15$15

$25$40

$25$50

$250day x 3

$500day x 3

$40+$60+

$40$60

$35$60

$30$60

$35$50

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Indiana

JS4 JS5

FX1 FX2

K84 K85

MW4 MW5

A61 A62

A64 A65

751 752

754 755

MH1 MH2

MH4 MH5

DQ1 DQ2

H44 H45

SV1 SV2

SY4 SY5

FX1 FX2

K84 K85

V31 V32

V34 V35

AU1 AU2

AU4 AU5

YH1 YH2

17258 41140

26932 67294

20323 51891

10247 22697

13880 30882

12491 27794

40638 90413

15825 35210

13880 30882

30786 68557

13093 29732

13351 31376

9799 23027

26932 67294

20323 51891

26865 64982

8897 20464

26173 63455

23647 57594

14091 38330

61069 138677

70937 165354

64196 149643

41809 92606

56629 125999

50965 113400

84917 188936

59608 132629

56629 125999

74868 166643

53418 121307

54474 128016

39979 93951

70937 165354

64196 149643

70869 162996

36302 83494

70163 161438

67586 155460

57491 135811

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Indiana

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$25$50

$35$55

$200day x 5

50+50+

$35$70

$40$60

745 915 88 962 878 868 67

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$15

$25$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$40+$60+

$40$60

$25$50

30to$60050 to$1200

$25$50

$25$45

$0 for 3 then 20

$20$30

$200day x 5

Nothing

20 in40 out

$100day x 5

$3 $10

50+50+

$45$70$100

30$5000 Max

$35$70

$45$90

$40$70

$30$50

$25$25

$100day x 5

40+40+

$30$50

40+40+

$25$50

40+40+

$35$50

Yes 577 896 86 956 914 918 623

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Kansas

Kentucky

Louisiana

877shy459shy6604

800shy969shy3343

888shy393shy6765

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy341shy6613

888shy393shy6765

G54 G55

HY1 HY2

HA1 HA2

HA4 HA5

PH4 PH5

MS1 MS2

MS4 MS5

H44 H45

A61 A62

A64 A65

MH1 MH2

MH4 MH5

MI1 MI2

MI4 MI5

F54 F55

BJ1 BJ2

BJ4 BJ5

AE1 AE2

AE4 AE5

BC1 BC2

BC4 BC5

12822 29119

13777 50039

13519 32270

12568 29535

10247 22697

62521 139111

15825 35210

13093 29732

13880 30882

12491 27794

15825 35210

13880 30882

19459 43292

13880 30882

13058 29656

19208 48754

13035 30271

15825 35210

13149 29256

13880 30882

12491 27794

52315 118808

55396 147754

55160 129630

51276 120503

41809 92606

107238 238608

59608 132629

53418 121307

56629 125999

50965 113400

59608 132629

56629 125999

63314 140872

56629 125999

53279 120995

63058 146443

53182 123506

59608 132629

53648 119367

56629 125999

50965 113400

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Kansas

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$20$35

$30$60

$35$55

$250day x 4

$3 $12

50+50+

$35$100

$50$75

$40$60

Kentucky

$20$35

$25$40

$250day x 3

$500day x 3

$40+$60+

$40$60

30to$60050 to$1200

Louisiana

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+50+

$40$60

30to$60050 to$1200

$25$45

$30$55

$20$35

$35$40

$20$35

$35$40

Ded+$100

Ded+30

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+50+

$40$100

$40$60

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Maryland

Massachusetts

EP4 EP5

F54 F55

JN1 JN2

JN4 JN5

2G1 2G2

2G4 2G5

IG1 IG2

IG4 IG5

E31 E32

E34 E35

JP1 JP2

EP4 EP5

JG1 JG2

12694 28827

13058 29656

46867 105610

14021 31351

21177 48693

15284 35429

14998 37685

13265 30509

16926 42124

9646 22186

20245 50123

12694 28827

29337 80043

51792 117616

53279 120995

91271 204437

57208 127913

65067 146381

59056 132852

58764 135153

54121 124479

60731 139681

39358 90520

64116 147840

51792 117616

73390 178358

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

Maryland

$25$40

50+50+

30to$60050 to$1200

$15$30

$20$35

$25$35

Nothing$35

$150day x3

10 Plan Allow

Nothing

50+50+

$35$100

$35$65

MD IPAshyHigh

Massachusetts

$70$70

$20$40

$10$20

$20$30

$25$40

$200day x 3

$250dayx3

$150day x 3

Nothing

$7$17 Net

$12$22Net

$35$65

$30$60

$30$50$45$65

$35$55$50$

$30$60

30to$60050 to$1200

70 Yes

$25$35

$150to$750max

50+50+

$30$60

Yes 627 851 882 929 883 801 649

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Michigan

Minnesota

G54 G55

K51 K52

LX1 LX2

RL1 RL2

RL4 RL5

521 522

GY4 GY5

X51 X52

A51 A52

H44 H45

V31 V32

V34 V35

H44 H45

12822 29119

22055 52593

18055 50747

24184 61492

19656 50897

20111 55722

16974 48191

13915 49809

13670 50117

13093 29732

26865 64982

8897 20464

13093 29732

52315 118808

65962 150359

61882 148476

68134 159436

63515 148629

63980 153551

60780 145869

56775 147520

55776 147834

53418 121307

70869 162996

36302 83494

53418 121307

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

Michigan

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

Minnesota

$15$25

$10$10

$20$20

$10$20

$15$30

$10$20

$15$15

$25$40

Nothing

$500x3

Nothing

50+50+

$30$60

$15$15

$50$50

$40$60

$40$40

30to$60050 to$1200

$25$45

$0 for 3 then 20

$25$40

Nothing

20 in40 out

50+50+

$45$90

$40$70

30to$60050 to$1200

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Montana

Nebraska

Nevada

New Hampshire

877shy459shy6604

888shy811shy2092

800shy969shy3343

888shy393shy6765

877shy835shy9861

877shy459shy6604

877shy545shy7378

877shy459shy6604

G54 G55

HY1 HY2

9G1 9G2

HA1 HA2

HA4 HA5

PH4 PH5

MS1 MS2

MS4 MS5

B91 B92

H44 H45

G54 G55

HF1 HF2

NM1 NM2

EP4 EP5

12822 29119

13577 50039

32158 67069

13519 32270

12568 29535

10247 22697

62521 139111

15825 35210

33072 74273

13093 29732

12822 29119

11267 36491

9883 23303

12694 28827

52315 118808

55396 147754

76267 165125

55160 129630

51276 120503

41809 92606

107238 238608

59608 132629

77200 172473

53418 121307

52315 118808

45970 133935

40322 95078

51792 117616

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$20$35

$250day x 4

50+50+

$35$100 $40$60

Yes 639 862 862 94 838 901 538

30 after ded $30$60

$30$60

$35$55

30 after ded 25

NA $3 $12

$3 $12

NA $50$75

$40$60

NA Yes

Montana

$20$35

$25$40

$250day x 3

$500day x 3

$40+$60+

$40$60

$30$60

30to$60050 to$1200

Nebraska

$25$40

50+50+

30to$60050 to$1200

Nevada

$25$40

50+50+

30to$60050 to$1200

New Hampshire

$20$35

$10$25

$25$40

$250day x 4

50+50+

$35$100

$35$55$100

30to$60050 to$1200

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

New Jersey

New Mexico

EP4 EP5

JR1 JR2

JR4 JR5

P31 P32

P34 P35

801 802

804 805

G54 G55

Q11 Q12

P21 P22

12694 28827

52355 123641

34184 82457

64801 164359

49560 118027

32591 93212

14135 33572

12822 29119

13099 30785

23940 56335

51792 117616

96868 222828

78334 180821

109563 264361

94017 217102

76709 191791

57672 130958

52315 118808

53445 125603

67885 154176

Prescription Drugs

Mail lan

ll icate

r ng rmation

order discount

Overall p

satisfaction

Getting n

Getting c

quickly

doctors

commun

Custome

service

Claims

processi

New Jersey

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$20$35

$15$35

$20$35

$15$35

$20$20

$250day x 4

20 Plan Allow

$250day x 4

20 Plan Allow

$150max$450

50+50+

$35$100

$45$85

New Mexico

50 of sch

$30$30

$25$40

+50 of sch

$250day x 3

$45$85

30to$60050 to$1200

663 844 851 936 86 828 642

$25$35

$25$40

$250 after ded

$100 x 5 days

50+50+

$35$6050

$40$7550

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

New York

EP4 EP5

JC1 JC2

JC4 JC5

SG1 SG2

SG4 SG5

6V1 6V2

X41 X42

801 802

804 805

511 512

514 515

QA1 QA2

C54 C55

GA1 GA2

GA4 GA5

GV1 GV2

GV4 GV5

M91 M92

M94 M95

MF1 MF2

MF4 MF5

MX1 MX2

MX4 MX5

12694 28827

40198 109033

26007 71920

22952 71235

12294 32053

19548 60991

14167 47634

32591 93212

14135 33572

17000 63158

12206 34562

18597 58201

14454 47853

16586 53386

13377 39674

13042 35704

11193 28006

17110 54877

13779 42651

25417 75411

22349 67734

18731 58664

13657 42345

51792 117616

84468 207928

69993 170073

66877 169374

50161 129408

63405 158925

57800 145301

76709 191791

57672 130958

60806 161136

49800 131968

62435 156079

58209 145524

60384 151168

54580 137182

53210 133132

45669 114266

60918 152689

56220 140218

69392 173634

66262 165803

62572 156552

55723 139906

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

New York

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$20$35

$15$35

$20$30

$25$40

$20$20

$250day x 4

20 Plan Allow

$100 x 5

$500+10

$150max$450

50+50+

$35$100

$30$50

$45$85

50 of sch

$30$30

$20$40

$30$50

$25$25

+50 of sch

$250day x 3

$15$100Ded

$45$85

$35$75

$30$75

$35$75 $75$100Ded

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

North Carolina

North Dakota

Oklahoma

F54 F55

H44 H45

V31 V32

V34 V35

RU1 RU2

C91 C92

C94 C95

JS4 JS5

3A1 3A2

A61 A62

A64 A65

641 642

644 645

U41 U42

JS4 JS5

IM1 IM2

13058 29656

13093 29732

26865 64982

8897 20464

13803 47086

20976 51441

14143 45836

17258 41140

14204 44676

13880 30882

12491 27794

28758 69344

13114 30163

26271 60855

17258 41140

11810 28460

53279 120995

53418 121307

70869 162996

36302 83494

56317 144742

64862 149184

57705 143467

61069 138677

57953 142284

56629 125999

50965 113400

72799 167445

53504 123066

70263 158786

61069 138677

48185 116118

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

North Carolina

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

North Dakota

$25$40

50+50+

30to$60050 to$1200

$25$45

$0 for 3 then 20

$15$25

Nothing

20 in40 out

50$600ded

50+50+

$45$90

$40$70

50$600 ded

$20$30

$100day x 5

$30$50

$25$25

$100day x 5

40+40+

$30$50

40+40+

$25$40

40+40+

30to$60050 to$1200

AultCare HMOshyHigh

Oklahoma

$15$20

$20$35

$25$40

$20$20

$30$40

$10$20

$25$40

$250day x 3

$500day x 3

50+50+

$30$40$55

$40$60

$30$30

$40$40

$30$50

30to$60050 to$1200

$15$45

$250dymx1000

50+50+

$45$70

Yes 592 816 839 916 893 872 727

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Oregon

Pennsylvania

Puerto Rico

Rhode Island

South Carolina

877shy459shy6604

800shy813shy2000

877shy459shy6604

800shy447shy4000

866shy351shy5946

888shy876shy2756

800shy314shy3121

787shy774shy6060

877shy459shy6604

H44 H45

571 572

574 575

H44 H45

P31 P32

P34 P35

YE1 YE2

GG4 GG5

261 262

8W1 8W2

UW4 UW5

ZJ1 ZJ2

891 892

EP4 EP5

JS4 JS5

13093 29732

22672 52645

13617 31283

13093 29732

64801 164359

49560 118027

19203 59806

16820 41884

17814 47183

22135 54101

13345 30692

8026 18317

8829 19866

12694 28827

17258 41140

53418 121307

66592 150412

55557 127637

53418 121307

109563 264361

94017 217102

63053 157716

60623 139436

61637 144841

66044 151897

54448 125225

32748 74733

36023 81052

51792 117616

61069 138677

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Oregon

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

Pennsylvania

$20$30

$30$40

$25$40

50+50+

$40$60

30to$60050 to$1200

Puerto Rico

$20$35

$15$35

$20$35

$25$50

10 after Deduct

20 after Deduct

$250day x 4

20 Plan Allow

$250day x 4

20aftrDeduct

15 after ded

10 after deduct

20after Deduct

30 $5$15

$5 after ded

50+50+

$35$100

$35$60

$35$75

$35$75$100

$10$15

40 $40$120 50 $85$250

Rhode Island

$750$10

$25$40

$750 amp 10 +$10 amp 10 +

None 10 +

$5 or $12 NA

2025 up to$100$175max

30to$60050 to$1200

Yes No

691 874 844 963 872 75 586

South Carolina

$25$40

50+50+

30to$60050 to$1200

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

South Dakota

Tennessee

G54 G55

V31 V32

V34 V35

AU1 AU2

AU4 AU5

F54 F55

UB1 UB2

GJ1 GJ2

GJ4 GJ5

12822 29119

26865 64982

8897 20464

26173 63455

23647 57594

13058 29656

24581 76516

15825 35210

12491 27794

52315 118808

70869 162996

36302 83494

70163 161438

67586 155460

53279 120995

68539 174761

59608 132629

50965 113400

Primary

Prescription Drugs

ded ation

care Hospital Mail

Getting nee

How well

r ng rm

Level II Level III

order discount

Overall

satisfaction

Getting

quickly

doctors

commun

Custome

service

Claims

processi

Plan Info

on Costs

South Dakota

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$25$45

$0 for 3 then 20

$20$30

Nothing

20 in40 out

$100day x 5

50+50+

$45$90

$40$70

$30$50

$25$25

$100day x 5

40+40+

$30$50

Tennessee

40+40+

$25$40

40+40+

30to$60050 to$1200

$20$35

$25$40

$250day x 4

$250day x 3

$500day x 3

50+50+

$35$100

$40$60

66 875 868 959 889 914 69

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

JS4 JS5

ES1 ES2

B71 B72

CK1 CK2

CN1 CN2

CZ1 CZ2

ET1 ET2

TP4 TP5

TU4 TU5

TV4 TV5

EW1 EW2

EW4 EW5

UC1 UC2

UC4 UC5

UR1 UR2

UR4 UR5

UU1 UU2

UU4 UU5

A84 A85

GF1 GF2

17258 41140

12817 40332

11057 37880

10809 34896

13391 65886

13031 61566

12638 56836

10247 22697

13880 30882

12491 27794

17899 39821

13880 30882

55020 122416

13880 30882

26524 59015

15825 35210

14907 37260

32515 78160

61069 138677

52295 137853

45113 135352

44103 132308

54635 163918

53169 159512

51562 154687

41809 92606

56629 125999

50965 113400

61723 137332

56629 126001

99587 221579

56629 126001

70521 156910

59608 132629

58671 134720

76632 176438

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$5$25$35

50+50+

$35$60

FirstcareshyHigh

$30$55

$35$55

$250day x 5

$35$70

$40$60

$35$55

$40+$60+

$40$60

$35$55

$40+$60+

$40$60

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$45

$20$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 5

$40+$60+

$40$60

$45$100

$35$60

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Virgin Islands

G54 G55

9K1 9K2

DK4 DK5

SF1 SF2

SF4 SF5

EP4 EP5

851 852

12822 29119

19819 42542

11798 25954

19210 43095

12435 27741

12694 28827

10305 23402

52315 118808

63682 140107

48136 105894

63060 140671

50737 113183

51792 117616

42043 95481

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

SelectHealthshyHigh

$20$30

$20$40

$15$25

$20$30

$25$40

$100 after

$5$25$50

50+50+

$25$50

$35$60

$25$50$50

$25 $50$50

30to$60050 to$1200

Virgin Islands

4040 40 50+ 50+50+ No

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

None 10 +

$5 or $12 NA NA

2025 up to$100$175max

Yes No

691 874 844 963 872 75 586

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Virginia

Washington

F54 F55

JN1 JN2

JN4 JN5

D91 D92

J91 J92

2G1 2G2

2G4 2G5

A91 A92

E31 E32

E34 E35

JP1 JP2

9R1 9R2

9R4 9R5

2C1 2C2

G54 G55

C31 C32

541 542

544 545

L11 L12

VT1 VT2

571 572

574 575

13058 29656

46867 105610

14021 31351

12138 40332

11280 29365

21177 48693

15284 35429

20427 47008

16926 42124

9646 22186

20245 50123

26858 69565

11269 26665

12235 28017

12822 29119

14933 62274

27070 55009

11742 26509

12426 26823

31651 67459

22672 52645

13617 31283

53279 120995

91271 204437

57208 127913

49524 137853

46023 119808

65067 146381

59056 132852

64302 144663

60731 139681

39358 90520

64116 147840

70861 167671

45977 108794

49920 114308

52315 118808

58698 160234

71078 152824

47908 108156

50700 109437

75750 165523

66592 150412

55557 127637

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

Virginia

$25$40 4040

$15$30

$20$35

$25$35 4040

$5$25$35 4040

$25$35

Nothing$35

$150day x3

10 Plan Allow

$10 50+

Nothing

50+50+

$35$100

$35$60 4040

$35$65

30to$60050 to$1200

POS National

Yes No

Average

MD IPAshyHigh

Washington

$70$70

$10$20

$20$30

$25$40

$25$30

$35$35

$25$40 4040

$20$35

$25$25

$25$35

$154 or 2020

$30$30 $30+40+diff

$20$30

$30$40

$20$0childlt22$30

$200 x3 days

$250dayx3

$150day x 3

$150max$750

$20020

$250day x 4

Nothing Nothing

None None

Nothing

$7$17 Net

$12$22Net

$10 50+

$10 Not Covered

$5 Not Covered

$35$65

$30$50$50

$30$50$45$65

$35$55$50$70

$30$60

$40$55

50+50+

$35$100

$40$60

Not Covered

$40$60

$353050up to $3000

$355050 up to $3000

$35$50 30day$100 90day

$25$50 30day$100 90day

30to$60050 to$1200

Yes No

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

West Virginia

Wisconsin

Wyoming

F54 F55

U41 U42

JS4 JS5

F71 F72

WD1 WD2

WJ1 WJ2

V31 V32

V34 V35

EY1 EY2

LW1 LW2

H44 H45

9K1 9K2

DK4 DK5

13058 29656

26271 60855

17258 41140

10600 29208

24382 72670

15910 51534

26865 64982

8897 20464

14597 48275

16556 55954

13093 29732

19819 42542

11798 25954

53279 120995

70263 158786

61069 138677

43250 119170

68336 170838

59694 149279

70869 162996

36302 83494

58355 145955

60353 153787

53418 121307

63682 140107

48136 105894

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Claims

processing

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Plan Inform

on Costs

West Virginia

Wisconsin

Wyoming

$25$40 4040

$10$20

$25$40 4040

$25$35 4040

$25$25

$10$10

$25$45

$0 for 3 then 20

$10$10

$25$40 4040

$20$30

$20$40

Nothing

20 in40 out

Nothing

$10 Yes 50+ 50+50+ No

$15 $30$50 Yes

$10 Yes 50+ 50+50+ No

$5 $35$60 Yes 40 4040 No

$10 Yes

$5 $20$20 Yes

$12 $45$90 Yes

$9 $40$70 Yes

$10 $20$50 Yes

$10 3050 No

$10 Yes 50+ 50+50+ No

$7 $25$50 No

$7 $35$60 None

30$75max 50 wmin$50

30to$60050 to$1200

909 876 951 929 944

909 90 97 834 879

834 834 953 929 932

893 875 951 92 911

888 854 938 888 87

857 822 96 863 866

852 813 948 883 895

864 849 942 877 875

ELIGIBILITY

FUNDING

CONTRIBUTIONS

DISTRIBUTIONS

ANNUAL ROLLOVER

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

800shy718shy1299

800shy821shy6136

800shy694shy9901

888shy636shy6252

474 475

341 342

481 482

324 325

9742 21915

11021 25172

13642 30912

10454 22700

39747 89414

44967 102703

55661 126120

42653 92617

Plan Code

885 866 929 860

891 888 952 830

873 851 923 863

891 859 912 887

881 865 939 850

891 888 952 830

909 907 925 871

849 864 932 843

875 801 948 856

Getting needed care

How well doctors

Getting needed care

How well doctors

Claims processing

Plan Name

Telephone Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Premium

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Plan Name

877shy459shy6604

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

136516

151489

149613

136516

151489

149613

Self amp family

Plan Name

Benefit Type

CY Ded SelfFamily

Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Premium

Connecticut

Delaware

Florida

Georgia

Plan Name

877shy459shy6604

888shy789shy9065

877shy459shy6604

800shy441shy5501

888shy393shy6765

877shy459shy6604

888shy393shy6765

671shy647shy3526

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

145440

136516

127574

136516

141522

116366

136516

105282

110827

Self amp family

Connecticut

Delaware

Florida

Georgia

Premium

Illinois

Indiana

Kansas

Plan Name

877shy459shy6604

800shy377shy4161

877shy459shy6604

888shy393shy6765

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy257shy4692

877shy459shy6604

800shy969shy3343

888shy393shy6765

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

151489

136317

110827

110823

151489

110823

136317

149613

122219

Self amp family

Illinois

Indiana

Kansas

Premium

Kentucky

Louisiana

Maryland

Massachusetts

Michigan

Minnesota

Plan Name

877shy459shy6604

888shy393shy6765

877shy459shy6604

888shy789shy9065

800shy833shy7423

877shy459shy6604

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

136317

136516

145440

136516

127574

109488

145440

149613

136317

Self amp family

Kentucky

Louisiana

Maryland

OutshyNetWork

InshyNetwork

$3750$7500

$4167$8334

$3000$6000

$2000$4000

$6000$12000

$4000$8000

Nothing

Nothing$30$60

Massachusetts

Michigan

Minnesota

Premium

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

Plan Name

877shy459shy6604

800shy969shy3343

888shy393shy6765

877shy459shy6604

800shy501shy3439

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

149613

122219

136317

149613

145440

149613

145440

101669

Self amp family

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

Premium

North Carolina

North Dakota

Pennsylvania

Rhode Island

South Carolina

Plan Name

877shy459shy6604

330shy363shy6360

877shy459shy6604

866shy351shy5946

888shy876shy2756

877shy459shy6604

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

136516

136317

151489

136317

115650

114458

145440

151489

Self amp family

North Carolina

North Dakota

Pennsylvania

Rhode Island

South Carolina

Plan Name

CY Ded SelfFamily

Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

10After Deduct

10 after deduct

30After Deduct

30 after deduct

Premium

South Dakota

Tennessee

Vermont

Plan Name

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy377shy4161

877shy459shy6604

888shy789shy9065

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

149613

136516

151489

110827

110823

121906

149613

145440

136516

127574

Self amp family

South Dakota

Tennessee

Vermont

Premium

Wyoming

Plan Name

877shy459shy6604

800shy552shy7114

877shy459shy6604

800shy377shy4161

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

149613

136516

151489

136317

Self amp family

Wyoming

Plan Name

CY Ded SelfFamily

Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

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

______________________________________________________________________________________________________________

19122-1-14 (70-16)_20 pages

19122-15-20 (70-16)_6 pages

19122-21-86 (70-16)_0

When can I enroll

How do I enroll

Definitions

Enrollment Code

TCC 102 of your

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

MHBP shystd

MHBP shyValue Plan

NALC shyhigh

NALC Value Option

SAMBA shyhigh

SAMBA shystd

800shy222shy2798

Local phone

800shy821shy6136

800shy410shy7778

888shy636shy6252

800shy638shy6589

126114

142015

126195

145991

148291

109939

130096

168477

122733

APWU shyhigh

BCBS shystd

BCBS shybasic

GEHA shyhigh

GEHA shystd

MHBP shystd

MHBP shyvalue

NALC shyhigh

NALC shyValue

SAMBA shyhigh

SAMBA shystd

Benefit Type

Per Person

Calendar Year

Prescription Drug

Hospital Inpatient

Office Visits

Hospital Inpatient

RampB Level I

Prescription Drugs

Level II Level III

Deductible

MHBP shystd

MHBP shyValue Plan

NALC shyhigh

SAMBA shyhigh

SAMBA shystd

FFS National A

Plan Code

verage 805

Getting needed care

How well doctors

communicate

Customer service

Claims processing

Plan Name Location

Plan Code

Getting needed care

How well doctors

Claims processing

Arizona 10 11

851 747

905 898

919 884

933 923

938 914

969 928

724 680

California 10 11

809 705

915 873

897 840

954 943

881 910

937 912

677 616

768 691

935 893

930 874

951 940

882 881

898 922

657 622

Florida 10 11

864 806

942 916

922 894

952 947

934 916

954 937

733 660

Illinois 10 11

861 796

933 912

934 881

955 950

901 936

972 938

712 653

Maryland 10 11

857 770

931 897

917 898

954 940

897 921

956 967

713 666

Texas 10 11

887 825

934 898

931 883

950 955

936 910

957 967

721 617

Virginia 10 11

871 782

924 901

929 894

966 962

914 917

959 960

708 681

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Alabama

Alaska

Arizona

Arkansas

F54 F55

JS4 JS5

G54 G55

WQ1 WQ2

A71 A72

A74 A75

BF1 BF2

BF4 BF5

C71 C72

C74 C75

F54 F55

DH1 DH2

DH4 DH5

13058 29656

17258 41140

12822 29119

33482 89188

26548 80303

19509 62476

13880 30882

12491 27794

15825 35210

13149 29256

13058 29656

30353 76056

14296 38452

53279 120995

61069 138677

52315 118808

77618 187686

70545 178623

63365 160440

56629 125999

50965 113400

59608 132629

53648 119367

53279 120995

74426 174291

58048 135935

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Alabama

HMOPOS Nationa

30to$60050 to$1200 Yes

l Average 679 864 849 942 877 875 649

Alaska

$25$40

50+50+

30to$60050 to$1200

Arizona

$25$40

50+50+

30to$60050 to$1200

Arkansas

$20$35

$20$40

$25$50

$20$35

$25$40

$20$35

$25$40

$250day x 4

$250dayx5

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+50+

$35$100

$40$60

30to$60050 to$1200

$20$30

$20$40

$100max$500

$200max$1000

50+50+

$40$60

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

California

Colorado

Connecticut

Delaware

JS4 JS5

2X1 2X2

B31 B32

SI1 SI2

LB1 LB2

LB4 LB5

LP1 LP2

LP4 LP5

KC1 KC2

591 592

594 595

621 622

624 625

CY1 CY2

CY4 CY5

G54 G55

651 652

654 655

EP4 EP5

P31 P32

P34 P35

17258 41140

15940 41769

18194 43825

18445 42566

77474 182834

71405 168807

30687 74663

27027 66198

18293 47705

35345 91275

22772 58183

14073 35293

9019 20845

22819 54699

13109 30036

12822 29119

23933 55581

9887 22345

12694 28827

64801 164359

49560 118027

61069 138677

59725 139319

62024 141416

62280 140132

122490 283205

116299 268898

74767 172871

71034 164236

62125 145373

79518 189815

66694 156061

57420 132713

36797 85048

66742 152507

53485 122549

52315 118808

67878 153407

40339 91170

51792 117616

109563 264361

94017 217102

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

California

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

Colorado

$20$35

$25$35

$20$30

$30$50

$20$30

$30$50

$25$35

$15$25

$30$40

$15$25

$30$40

$20$35

$25$40

$250day x 4

$250max4days

$200 x 3 days

$150dayx5

$150day x 4

$5$40$60

50+50+

$35$100

$5$40$70$60

$35$60

$35$65

$35$60

$35$65

$35$35

$30$30

$35$35

$30$30

$35$35

$35$60

$25$50

30to$60050 to$1200

Connecticut

$20$40

$25$40

$250x3

50+50+

$35$60

$40$80

30to$60050 to$1200

Delaware

$25$40

50+50+

30to$60050 to$1200

$20$35

$15$35

$250day x 4

20 Plan Allow

50+50+

$35$100

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Florida

877shy459shy6604

888shy789shy9065

877shy574shy3337

877shy835shy9861

877shy459shy6604

800shy882shy8633

850shy383shy3311

800shy441shy5501

888shy393shy6765

F54 F55

JN1 JN2

JN4 JN5

2G1 2G2

2G4 2G5

E31 E32

E34 E35

JP1 JP2

F54 F55

ML1 ML2

ML4 ML5

EA1 EA2

5E1 5E2

5E4 5E5

MJ4 MJ5

QP4 QP5

E21 E22

E24 E25

EE1 EE2

EE4 EE5

EX1 EX2

EX4 EX5

LL1 LL2

LL4 LL5

13058 29656

46867 105610

14021 31351

21177 48693

15284 35429

16926 42124

9646 22186

20245 50123

13058 29656

20336 56279

12604 30253

11679 30949

16664 47450

12501 30003

10247 22697

13149 29256

11834 26331

23153 51514

15825 35210

13880 30882

12491 27794

48720 108398

15825 35208

53279 120995

91271 204437

57208 127913

65067 146381

59056 132852

60731 139681

39358 90520

64116 147840

53279 120995

64209 154119

51424 123431

47650 126273

60464 145113

51005 122414

41809 92606

53648 119367

48282 107430

67082 149259

59608 132629

56629 125999

50965 113400

93161 207280

59608 132627

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

HMOPOS Nationa

30to$60050 to$1200 Yes

l Average 679 864 849 942 877 875 649

$15$30

$20$35

$25$35

Nothing$35

$150day x3

10 Plan Allow

Nothing

50+50+

$35$100

$35$65

MD IPAshyHigh

Florida

$70$70

$10$20

$20$30

$25$40

$250dayx3

$150day x 3

Nothing

$7$17 Net

$12$22Net

$35$65

$30$50$45$65

$35$55$50$70

$30$60

30to$60050 to$1200

$15$40

$25$45

Nothing$15

$15$30

$20$50

$35$55

$250dayx3

$300dayx3

Ded + $150x3

Ded + $150x5

$15 Tier 1

50+50+

$30$5030

$40$6030

$40$6020

$50$7020

$40$60

$30 Tier 2 $50 Tier 3

$35$55

$40+$60+

$40$60

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$40+$60+

$40$60

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Georgia

877shy459shy6604

888shy393shy6765

888shy865shy5813

671 479shy7982

671shy647shy3526

877shy459shy6604

800shy776shy4672

808shy432shy5955

F54 F55

2U1 2U2

AD4 AD5

LM4 LM5

CB1 CB2

CB4 CB5

DG1 DG2

DG4 DG5

DN1 DN2

DN4 DN5

F81 F82

F84 F85

B41 B42

JK1 JK2

JK4 JK5

JS4 JS5

871 872

631 632

634 635

13058 29656

44133 104232

10247 22697

15825 35210

13880 30882

15825 35210

13149 29256

15825 35210

13880 30882

15015 36863

10047 22957

11949 31399

12447 36018

10209 26960

17258 41140

11377 25325

14515 32578

7553 16846

53279 120995

88482 203031

41809 92606

59608 132629

56629 125999

59608 132629

53648 119367

59608 132629

56629 125999

58782 134315

40991 93667

48751 128109

50786 133453

41654 109996

61069 138677

46419 103326

58272 129944

30818 68731

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Georgia

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$20$35

$35$55

$250day x 4

50+50+

$35$100

$40$60

59 90 878 941 86 857 62

$35$55

$40+$60+

$40$60

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$30

$20$35

$15$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250dayx3

$10$20 Comm

$15$25 Comm

$40+$60+

$40$60

$2550 of AWP

$40$50 Comm $40$50 Comm

TakeCareshyHigh

TakeCareshyStandard

$5 at FHP$40

$25$40

$100day for 5

$150day for 5

$25$50

$40$80

30to$60050 to$1200

HMSA InshyNetwork

$15$15

50+50+

$30$65

$20$20

$30$30

$7 + 20

$45$45

$50$50

$30 + 20 $65 + 20 No

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Illinois

H44 H45

9K1 9K2

DK4 DK5

541 542

544 545

SF1 SF2

SF4 SF5

H44 H45

A21 A22

9G1 9G2

FX1 FX2

K84 K85

9F1 9F2

AB4 AB5

GB4 GB5

MW4 MW5

751 752

754 755

761 762

B91 B92

YH1 YH2

13093 29732

19819 42542

11798 25954

27070 55009

11742 26509

19210 43095

12435 27741

13093 29732

30483 71121

32158 67069

26932 67294

20323 51891

51805 115264

15825 35210

10247 22697

40638 90413

15825 35210

14109 33787

33072 74273

14091 38330

53418 121307

63682 140107

48136 105894

71078 152824

47908 108156

63060 140671

50737 113183

53418 121307

74559 169258

76267 165125

70937 165354

64196 149643

96307 214284

59608 132629

41809 92606

84917 188936

59608 132629

57566 131177

77200 172473

57491 135811

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

SelectHealthshyHigh

Illinois

$20$30

$20$40

$25$25

$25$35

$15$25

$20$30

$25$40

$100 after

$5 $25$50

50+50+

$25$50

$35$60

$40$60

$25$50$50

$25$50

30to$60050 to$1200

$20$35

$25$35

$200day x 5

$10 copay

50+50+

$40$60

$40$6025 $6025

30 after ded

$25$50

$20$35

$25$40

$35$55

30 after ded

$200day x 5

$250day x 3

$500day x 3

$35$70

$40$60

745 915 88 962 878 868 67

$35$55

$40+$60+

$40$60

$20$35

$25$40

$15$15

$25$40

$25$50

$250day x 3

$500day x 3

$40+$60+

$40$60

$35$60

$30$60

$35$50

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Indiana

JS4 JS5

FX1 FX2

K84 K85

MW4 MW5

A61 A62

A64 A65

751 752

754 755

MH1 MH2

MH4 MH5

DQ1 DQ2

H44 H45

SV1 SV2

SY4 SY5

FX1 FX2

K84 K85

V31 V32

V34 V35

AU1 AU2

AU4 AU5

YH1 YH2

17258 41140

26932 67294

20323 51891

10247 22697

13880 30882

12491 27794

40638 90413

15825 35210

13880 30882

30786 68557

13093 29732

13351 31376

9799 23027

26932 67294

20323 51891

26865 64982

8897 20464

26173 63455

23647 57594

14091 38330

61069 138677

70937 165354

64196 149643

41809 92606

56629 125999

50965 113400

84917 188936

59608 132629

56629 125999

74868 166643

53418 121307

54474 128016

39979 93951

70937 165354

64196 149643

70869 162996

36302 83494

70163 161438

67586 155460

57491 135811

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Indiana

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$25$50

$35$55

$200day x 5

50+50+

$35$70

$40$60

745 915 88 962 878 868 67

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$15

$25$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$40+$60+

$40$60

$25$50

30to$60050 to$1200

$25$50

$25$45

$0 for 3 then 20

$20$30

$200day x 5

Nothing

20 in40 out

$100day x 5

$3 $10

50+50+

$45$70$100

30$5000 Max

$35$70

$45$90

$40$70

$30$50

$25$25

$100day x 5

40+40+

$30$50

40+40+

$25$50

40+40+

$35$50

Yes 577 896 86 956 914 918 623

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Kansas

Kentucky

Louisiana

877shy459shy6604

800shy969shy3343

888shy393shy6765

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy341shy6613

888shy393shy6765

G54 G55

HY1 HY2

HA1 HA2

HA4 HA5

PH4 PH5

MS1 MS2

MS4 MS5

H44 H45

A61 A62

A64 A65

MH1 MH2

MH4 MH5

MI1 MI2

MI4 MI5

F54 F55

BJ1 BJ2

BJ4 BJ5

AE1 AE2

AE4 AE5

BC1 BC2

BC4 BC5

12822 29119

13777 50039

13519 32270

12568 29535

10247 22697

62521 139111

15825 35210

13093 29732

13880 30882

12491 27794

15825 35210

13880 30882

19459 43292

13880 30882

13058 29656

19208 48754

13035 30271

15825 35210

13149 29256

13880 30882

12491 27794

52315 118808

55396 147754

55160 129630

51276 120503

41809 92606

107238 238608

59608 132629

53418 121307

56629 125999

50965 113400

59608 132629

56629 125999

63314 140872

56629 125999

53279 120995

63058 146443

53182 123506

59608 132629

53648 119367

56629 125999

50965 113400

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Kansas

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$20$35

$30$60

$35$55

$250day x 4

$3 $12

50+50+

$35$100

$50$75

$40$60

Kentucky

$20$35

$25$40

$250day x 3

$500day x 3

$40+$60+

$40$60

30to$60050 to$1200

Louisiana

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+50+

$40$60

30to$60050 to$1200

$25$45

$30$55

$20$35

$35$40

$20$35

$35$40

Ded+$100

Ded+30

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+50+

$40$100

$40$60

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Maryland

Massachusetts

EP4 EP5

F54 F55

JN1 JN2

JN4 JN5

2G1 2G2

2G4 2G5

IG1 IG2

IG4 IG5

E31 E32

E34 E35

JP1 JP2

EP4 EP5

JG1 JG2

12694 28827

13058 29656

46867 105610

14021 31351

21177 48693

15284 35429

14998 37685

13265 30509

16926 42124

9646 22186

20245 50123

12694 28827

29337 80043

51792 117616

53279 120995

91271 204437

57208 127913

65067 146381

59056 132852

58764 135153

54121 124479

60731 139681

39358 90520

64116 147840

51792 117616

73390 178358

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

Maryland

$25$40

50+50+

30to$60050 to$1200

$15$30

$20$35

$25$35

Nothing$35

$150day x3

10 Plan Allow

Nothing

50+50+

$35$100

$35$65

MD IPAshyHigh

Massachusetts

$70$70

$20$40

$10$20

$20$30

$25$40

$200day x 3

$250dayx3

$150day x 3

Nothing

$7$17 Net

$12$22Net

$35$65

$30$60

$30$50$45$65

$35$55$50$

$30$60

30to$60050 to$1200

70 Yes

$25$35

$150to$750max

50+50+

$30$60

Yes 627 851 882 929 883 801 649

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Michigan

Minnesota

G54 G55

K51 K52

LX1 LX2

RL1 RL2

RL4 RL5

521 522

GY4 GY5

X51 X52

A51 A52

H44 H45

V31 V32

V34 V35

H44 H45

12822 29119

22055 52593

18055 50747

24184 61492

19656 50897

20111 55722

16974 48191

13915 49809

13670 50117

13093 29732

26865 64982

8897 20464

13093 29732

52315 118808

65962 150359

61882 148476

68134 159436

63515 148629

63980 153551

60780 145869

56775 147520

55776 147834

53418 121307

70869 162996

36302 83494

53418 121307

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

Michigan

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

Minnesota

$15$25

$10$10

$20$20

$10$20

$15$30

$10$20

$15$15

$25$40

Nothing

$500x3

Nothing

50+50+

$30$60

$15$15

$50$50

$40$60

$40$40

30to$60050 to$1200

$25$45

$0 for 3 then 20

$25$40

Nothing

20 in40 out

50+50+

$45$90

$40$70

30to$60050 to$1200

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Montana

Nebraska

Nevada

New Hampshire

877shy459shy6604

888shy811shy2092

800shy969shy3343

888shy393shy6765

877shy835shy9861

877shy459shy6604

877shy545shy7378

877shy459shy6604

G54 G55

HY1 HY2

9G1 9G2

HA1 HA2

HA4 HA5

PH4 PH5

MS1 MS2

MS4 MS5

B91 B92

H44 H45

G54 G55

HF1 HF2

NM1 NM2

EP4 EP5

12822 29119

13577 50039

32158 67069

13519 32270

12568 29535

10247 22697

62521 139111

15825 35210

33072 74273

13093 29732

12822 29119

11267 36491

9883 23303

12694 28827

52315 118808

55396 147754

76267 165125

55160 129630

51276 120503

41809 92606

107238 238608

59608 132629

77200 172473

53418 121307

52315 118808

45970 133935

40322 95078

51792 117616

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$20$35

$250day x 4

50+50+

$35$100 $40$60

Yes 639 862 862 94 838 901 538

30 after ded $30$60

$30$60

$35$55

30 after ded 25

NA $3 $12

$3 $12

NA $50$75

$40$60

NA Yes

Montana

$20$35

$25$40

$250day x 3

$500day x 3

$40+$60+

$40$60

$30$60

30to$60050 to$1200

Nebraska

$25$40

50+50+

30to$60050 to$1200

Nevada

$25$40

50+50+

30to$60050 to$1200

New Hampshire

$20$35

$10$25

$25$40

$250day x 4

50+50+

$35$100

$35$55$100

30to$60050 to$1200

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

New Jersey

New Mexico

EP4 EP5

JR1 JR2

JR4 JR5

P31 P32

P34 P35

801 802

804 805

G54 G55

Q11 Q12

P21 P22

12694 28827

52355 123641

34184 82457

64801 164359

49560 118027

32591 93212

14135 33572

12822 29119

13099 30785

23940 56335

51792 117616

96868 222828

78334 180821

109563 264361

94017 217102

76709 191791

57672 130958

52315 118808

53445 125603

67885 154176

Prescription Drugs

Mail lan

ll icate

r ng rmation

order discount

Overall p

satisfaction

Getting n

Getting c

quickly

doctors

commun

Custome

service

Claims

processi

New Jersey

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$20$35

$15$35

$20$35

$15$35

$20$20

$250day x 4

20 Plan Allow

$250day x 4

20 Plan Allow

$150max$450

50+50+

$35$100

$45$85

New Mexico

50 of sch

$30$30

$25$40

+50 of sch

$250day x 3

$45$85

30to$60050 to$1200

663 844 851 936 86 828 642

$25$35

$25$40

$250 after ded

$100 x 5 days

50+50+

$35$6050

$40$7550

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

New York

EP4 EP5

JC1 JC2

JC4 JC5

SG1 SG2

SG4 SG5

6V1 6V2

X41 X42

801 802

804 805

511 512

514 515

QA1 QA2

C54 C55

GA1 GA2

GA4 GA5

GV1 GV2

GV4 GV5

M91 M92

M94 M95

MF1 MF2

MF4 MF5

MX1 MX2

MX4 MX5

12694 28827

40198 109033

26007 71920

22952 71235

12294 32053

19548 60991

14167 47634

32591 93212

14135 33572

17000 63158

12206 34562

18597 58201

14454 47853

16586 53386

13377 39674

13042 35704

11193 28006

17110 54877

13779 42651

25417 75411

22349 67734

18731 58664

13657 42345

51792 117616

84468 207928

69993 170073

66877 169374

50161 129408

63405 158925

57800 145301

76709 191791

57672 130958

60806 161136

49800 131968

62435 156079

58209 145524

60384 151168

54580 137182

53210 133132

45669 114266

60918 152689

56220 140218

69392 173634

66262 165803

62572 156552

55723 139906

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

New York

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$20$35

$15$35

$20$30

$25$40

$20$20

$250day x 4

20 Plan Allow

$100 x 5

$500+10

$150max$450

50+50+

$35$100

$30$50

$45$85

50 of sch

$30$30

$20$40

$30$50

$25$25

+50 of sch

$250day x 3

$15$100Ded

$45$85

$35$75

$30$75

$35$75 $75$100Ded

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

North Carolina

North Dakota

Oklahoma

F54 F55

H44 H45

V31 V32

V34 V35

RU1 RU2

C91 C92

C94 C95

JS4 JS5

3A1 3A2

A61 A62

A64 A65

641 642

644 645

U41 U42

JS4 JS5

IM1 IM2

13058 29656

13093 29732

26865 64982

8897 20464

13803 47086

20976 51441

14143 45836

17258 41140

14204 44676

13880 30882

12491 27794

28758 69344

13114 30163

26271 60855

17258 41140

11810 28460

53279 120995

53418 121307

70869 162996

36302 83494

56317 144742

64862 149184

57705 143467

61069 138677

57953 142284

56629 125999

50965 113400

72799 167445

53504 123066

70263 158786

61069 138677

48185 116118

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

North Carolina

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

North Dakota

$25$40

50+50+

30to$60050 to$1200

$25$45

$0 for 3 then 20

$15$25

Nothing

20 in40 out

50$600ded

50+50+

$45$90

$40$70

50$600 ded

$20$30

$100day x 5

$30$50

$25$25

$100day x 5

40+40+

$30$50

40+40+

$25$40

40+40+

30to$60050 to$1200

AultCare HMOshyHigh

Oklahoma

$15$20

$20$35

$25$40

$20$20

$30$40

$10$20

$25$40

$250day x 3

$500day x 3

50+50+

$30$40$55

$40$60

$30$30

$40$40

$30$50

30to$60050 to$1200

$15$45

$250dymx1000

50+50+

$45$70

Yes 592 816 839 916 893 872 727

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Oregon

Pennsylvania

Puerto Rico

Rhode Island

South Carolina

877shy459shy6604

800shy813shy2000

877shy459shy6604

800shy447shy4000

866shy351shy5946

888shy876shy2756

800shy314shy3121

787shy774shy6060

877shy459shy6604

H44 H45

571 572

574 575

H44 H45

P31 P32

P34 P35

YE1 YE2

GG4 GG5

261 262

8W1 8W2

UW4 UW5

ZJ1 ZJ2

891 892

EP4 EP5

JS4 JS5

13093 29732

22672 52645

13617 31283

13093 29732

64801 164359

49560 118027

19203 59806

16820 41884

17814 47183

22135 54101

13345 30692

8026 18317

8829 19866

12694 28827

17258 41140

53418 121307

66592 150412

55557 127637

53418 121307

109563 264361

94017 217102

63053 157716

60623 139436

61637 144841

66044 151897

54448 125225

32748 74733

36023 81052

51792 117616

61069 138677

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Oregon

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

Pennsylvania

$20$30

$30$40

$25$40

50+50+

$40$60

30to$60050 to$1200

Puerto Rico

$20$35

$15$35

$20$35

$25$50

10 after Deduct

20 after Deduct

$250day x 4

20 Plan Allow

$250day x 4

20aftrDeduct

15 after ded

10 after deduct

20after Deduct

30 $5$15

$5 after ded

50+50+

$35$100

$35$60

$35$75

$35$75$100

$10$15

40 $40$120 50 $85$250

Rhode Island

$750$10

$25$40

$750 amp 10 +$10 amp 10 +

None 10 +

$5 or $12 NA

2025 up to$100$175max

30to$60050 to$1200

Yes No

691 874 844 963 872 75 586

South Carolina

$25$40

50+50+

30to$60050 to$1200

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

South Dakota

Tennessee

G54 G55

V31 V32

V34 V35

AU1 AU2

AU4 AU5

F54 F55

UB1 UB2

GJ1 GJ2

GJ4 GJ5

12822 29119

26865 64982

8897 20464

26173 63455

23647 57594

13058 29656

24581 76516

15825 35210

12491 27794

52315 118808

70869 162996

36302 83494

70163 161438

67586 155460

53279 120995

68539 174761

59608 132629

50965 113400

Primary

Prescription Drugs

ded ation

care Hospital Mail

Getting nee

How well

r ng rm

Level II Level III

order discount

Overall

satisfaction

Getting

quickly

doctors

commun

Custome

service

Claims

processi

Plan Info

on Costs

South Dakota

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$25$45

$0 for 3 then 20

$20$30

Nothing

20 in40 out

$100day x 5

50+50+

$45$90

$40$70

$30$50

$25$25

$100day x 5

40+40+

$30$50

Tennessee

40+40+

$25$40

40+40+

30to$60050 to$1200

$20$35

$25$40

$250day x 4

$250day x 3

$500day x 3

50+50+

$35$100

$40$60

66 875 868 959 889 914 69

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

JS4 JS5

ES1 ES2

B71 B72

CK1 CK2

CN1 CN2

CZ1 CZ2

ET1 ET2

TP4 TP5

TU4 TU5

TV4 TV5

EW1 EW2

EW4 EW5

UC1 UC2

UC4 UC5

UR1 UR2

UR4 UR5

UU1 UU2

UU4 UU5

A84 A85

GF1 GF2

17258 41140

12817 40332

11057 37880

10809 34896

13391 65886

13031 61566

12638 56836

10247 22697

13880 30882

12491 27794

17899 39821

13880 30882

55020 122416

13880 30882

26524 59015

15825 35210

14907 37260

32515 78160

61069 138677

52295 137853

45113 135352

44103 132308

54635 163918

53169 159512

51562 154687

41809 92606

56629 125999

50965 113400

61723 137332

56629 126001

99587 221579

56629 126001

70521 156910

59608 132629

58671 134720

76632 176438

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$5$25$35

50+50+

$35$60

FirstcareshyHigh

$30$55

$35$55

$250day x 5

$35$70

$40$60

$35$55

$40+$60+

$40$60

$35$55

$40+$60+

$40$60

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$45

$20$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 5

$40+$60+

$40$60

$45$100

$35$60

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Virgin Islands

G54 G55

9K1 9K2

DK4 DK5

SF1 SF2

SF4 SF5

EP4 EP5

851 852

12822 29119

19819 42542

11798 25954

19210 43095

12435 27741

12694 28827

10305 23402

52315 118808

63682 140107

48136 105894

63060 140671

50737 113183

51792 117616

42043 95481

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

SelectHealthshyHigh

$20$30

$20$40

$15$25

$20$30

$25$40

$100 after

$5$25$50

50+50+

$25$50

$35$60

$25$50$50

$25 $50$50

30to$60050 to$1200

Virgin Islands

4040 40 50+ 50+50+ No

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

None 10 +

$5 or $12 NA NA

2025 up to$100$175max

Yes No

691 874 844 963 872 75 586

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Virginia

Washington

F54 F55

JN1 JN2

JN4 JN5

D91 D92

J91 J92

2G1 2G2

2G4 2G5

A91 A92

E31 E32

E34 E35

JP1 JP2

9R1 9R2

9R4 9R5

2C1 2C2

G54 G55

C31 C32

541 542

544 545

L11 L12

VT1 VT2

571 572

574 575

13058 29656

46867 105610

14021 31351

12138 40332

11280 29365

21177 48693

15284 35429

20427 47008

16926 42124

9646 22186

20245 50123

26858 69565

11269 26665

12235 28017

12822 29119

14933 62274

27070 55009

11742 26509

12426 26823

31651 67459

22672 52645

13617 31283

53279 120995

91271 204437

57208 127913

49524 137853

46023 119808

65067 146381

59056 132852

64302 144663

60731 139681

39358 90520

64116 147840

70861 167671

45977 108794

49920 114308

52315 118808

58698 160234

71078 152824

47908 108156

50700 109437

75750 165523

66592 150412

55557 127637

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

Virginia

$25$40 4040

$15$30

$20$35

$25$35 4040

$5$25$35 4040

$25$35

Nothing$35

$150day x3

10 Plan Allow

$10 50+

Nothing

50+50+

$35$100

$35$60 4040

$35$65

30to$60050 to$1200

POS National

Yes No

Average

MD IPAshyHigh

Washington

$70$70

$10$20

$20$30

$25$40

$25$30

$35$35

$25$40 4040

$20$35

$25$25

$25$35

$154 or 2020

$30$30 $30+40+diff

$20$30

$30$40

$20$0childlt22$30

$200 x3 days

$250dayx3

$150day x 3

$150max$750

$20020

$250day x 4

Nothing Nothing

None None

Nothing

$7$17 Net

$12$22Net

$10 50+

$10 Not Covered

$5 Not Covered

$35$65

$30$50$50

$30$50$45$65

$35$55$50$70

$30$60

$40$55

50+50+

$35$100

$40$60

Not Covered

$40$60

$353050up to $3000

$355050 up to $3000

$35$50 30day$100 90day

$25$50 30day$100 90day

30to$60050 to$1200

Yes No

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

West Virginia

Wisconsin

Wyoming

F54 F55

U41 U42

JS4 JS5

F71 F72

WD1 WD2

WJ1 WJ2

V31 V32

V34 V35

EY1 EY2

LW1 LW2

H44 H45

9K1 9K2

DK4 DK5

13058 29656

26271 60855

17258 41140

10600 29208

24382 72670

15910 51534

26865 64982

8897 20464

14597 48275

16556 55954

13093 29732

19819 42542

11798 25954

53279 120995

70263 158786

61069 138677

43250 119170

68336 170838

59694 149279

70869 162996

36302 83494

58355 145955

60353 153787

53418 121307

63682 140107

48136 105894

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Claims

processing

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Plan Inform

on Costs

West Virginia

Wisconsin

Wyoming

$25$40 4040

$10$20

$25$40 4040

$25$35 4040

$25$25

$10$10

$25$45

$0 for 3 then 20

$10$10

$25$40 4040

$20$30

$20$40

Nothing

20 in40 out

Nothing

$10 Yes 50+ 50+50+ No

$15 $30$50 Yes

$10 Yes 50+ 50+50+ No

$5 $35$60 Yes 40 4040 No

$10 Yes

$5 $20$20 Yes

$12 $45$90 Yes

$9 $40$70 Yes

$10 $20$50 Yes

$10 3050 No

$10 Yes 50+ 50+50+ No

$7 $25$50 No

$7 $35$60 None

30$75max 50 wmin$50

30to$60050 to$1200

909 876 951 929 944

909 90 97 834 879

834 834 953 929 932

893 875 951 92 911

888 854 938 888 87

857 822 96 863 866

852 813 948 883 895

864 849 942 877 875

ELIGIBILITY

FUNDING

CONTRIBUTIONS

DISTRIBUTIONS

ANNUAL ROLLOVER

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

800shy718shy1299

800shy821shy6136

800shy694shy9901

888shy636shy6252

474 475

341 342

481 482

324 325

9742 21915

11021 25172

13642 30912

10454 22700

39747 89414

44967 102703

55661 126120

42653 92617

Plan Code

885 866 929 860

891 888 952 830

873 851 923 863

891 859 912 887

881 865 939 850

891 888 952 830

909 907 925 871

849 864 932 843

875 801 948 856

Getting needed care

How well doctors

Getting needed care

How well doctors

Claims processing

Plan Name

Telephone Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Premium

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Plan Name

877shy459shy6604

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

136516

151489

149613

136516

151489

149613

Self amp family

Plan Name

Benefit Type

CY Ded SelfFamily

Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Premium

Connecticut

Delaware

Florida

Georgia

Plan Name

877shy459shy6604

888shy789shy9065

877shy459shy6604

800shy441shy5501

888shy393shy6765

877shy459shy6604

888shy393shy6765

671shy647shy3526

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

145440

136516

127574

136516

141522

116366

136516

105282

110827

Self amp family

Connecticut

Delaware

Florida

Georgia

Premium

Illinois

Indiana

Kansas

Plan Name

877shy459shy6604

800shy377shy4161

877shy459shy6604

888shy393shy6765

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy257shy4692

877shy459shy6604

800shy969shy3343

888shy393shy6765

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

151489

136317

110827

110823

151489

110823

136317

149613

122219

Self amp family

Illinois

Indiana

Kansas

Premium

Kentucky

Louisiana

Maryland

Massachusetts

Michigan

Minnesota

Plan Name

877shy459shy6604

888shy393shy6765

877shy459shy6604

888shy789shy9065

800shy833shy7423

877shy459shy6604

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

136317

136516

145440

136516

127574

109488

145440

149613

136317

Self amp family

Kentucky

Louisiana

Maryland

OutshyNetWork

InshyNetwork

$3750$7500

$4167$8334

$3000$6000

$2000$4000

$6000$12000

$4000$8000

Nothing

Nothing$30$60

Massachusetts

Michigan

Minnesota

Premium

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

Plan Name

877shy459shy6604

800shy969shy3343

888shy393shy6765

877shy459shy6604

800shy501shy3439

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

149613

122219

136317

149613

145440

149613

145440

101669

Self amp family

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

Premium

North Carolina

North Dakota

Pennsylvania

Rhode Island

South Carolina

Plan Name

877shy459shy6604

330shy363shy6360

877shy459shy6604

866shy351shy5946

888shy876shy2756

877shy459shy6604

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

136516

136317

151489

136317

115650

114458

145440

151489

Self amp family

North Carolina

North Dakota

Pennsylvania

Rhode Island

South Carolina

Plan Name

CY Ded SelfFamily

Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

10After Deduct

10 after deduct

30After Deduct

30 after deduct

Premium

South Dakota

Tennessee

Vermont

Plan Name

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy377shy4161

877shy459shy6604

888shy789shy9065

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

149613

136516

151489

110827

110823

121906

149613

145440

136516

127574

Self amp family

South Dakota

Tennessee

Vermont

Premium

Wyoming

Plan Name

877shy459shy6604

800shy552shy7114

877shy459shy6604

800shy377shy4161

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

149613

136516

151489

136317

Self amp family

Wyoming

Plan Name

CY Ded SelfFamily

Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

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

______________________________________________________________________________________________________________

19122-1-14 (70-16)_20 pages

19122-15-20 (70-16)_6 pages

19122-21-86 (70-16)_0

Definitions

Enrollment Code

TCC 102 of your

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

MHBP shystd

MHBP shyValue Plan

NALC shyhigh

NALC Value Option

SAMBA shyhigh

SAMBA shystd

800shy222shy2798

Local phone

800shy821shy6136

800shy410shy7778

888shy636shy6252

800shy638shy6589

126114

142015

126195

145991

148291

109939

130096

168477

122733

APWU shyhigh

BCBS shystd

BCBS shybasic

GEHA shyhigh

GEHA shystd

MHBP shystd

MHBP shyvalue

NALC shyhigh

NALC shyValue

SAMBA shyhigh

SAMBA shystd

Benefit Type

Per Person

Calendar Year

Prescription Drug

Hospital Inpatient

Office Visits

Hospital Inpatient

RampB Level I

Prescription Drugs

Level II Level III

Deductible

MHBP shystd

MHBP shyValue Plan

NALC shyhigh

SAMBA shyhigh

SAMBA shystd

FFS National A

Plan Code

verage 805

Getting needed care

How well doctors

communicate

Customer service

Claims processing

Plan Name Location

Plan Code

Getting needed care

How well doctors

Claims processing

Arizona 10 11

851 747

905 898

919 884

933 923

938 914

969 928

724 680

California 10 11

809 705

915 873

897 840

954 943

881 910

937 912

677 616

768 691

935 893

930 874

951 940

882 881

898 922

657 622

Florida 10 11

864 806

942 916

922 894

952 947

934 916

954 937

733 660

Illinois 10 11

861 796

933 912

934 881

955 950

901 936

972 938

712 653

Maryland 10 11

857 770

931 897

917 898

954 940

897 921

956 967

713 666

Texas 10 11

887 825

934 898

931 883

950 955

936 910

957 967

721 617

Virginia 10 11

871 782

924 901

929 894

966 962

914 917

959 960

708 681

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Alabama

Alaska

Arizona

Arkansas

F54 F55

JS4 JS5

G54 G55

WQ1 WQ2

A71 A72

A74 A75

BF1 BF2

BF4 BF5

C71 C72

C74 C75

F54 F55

DH1 DH2

DH4 DH5

13058 29656

17258 41140

12822 29119

33482 89188

26548 80303

19509 62476

13880 30882

12491 27794

15825 35210

13149 29256

13058 29656

30353 76056

14296 38452

53279 120995

61069 138677

52315 118808

77618 187686

70545 178623

63365 160440

56629 125999

50965 113400

59608 132629

53648 119367

53279 120995

74426 174291

58048 135935

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Alabama

HMOPOS Nationa

30to$60050 to$1200 Yes

l Average 679 864 849 942 877 875 649

Alaska

$25$40

50+50+

30to$60050 to$1200

Arizona

$25$40

50+50+

30to$60050 to$1200

Arkansas

$20$35

$20$40

$25$50

$20$35

$25$40

$20$35

$25$40

$250day x 4

$250dayx5

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+50+

$35$100

$40$60

30to$60050 to$1200

$20$30

$20$40

$100max$500

$200max$1000

50+50+

$40$60

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

California

Colorado

Connecticut

Delaware

JS4 JS5

2X1 2X2

B31 B32

SI1 SI2

LB1 LB2

LB4 LB5

LP1 LP2

LP4 LP5

KC1 KC2

591 592

594 595

621 622

624 625

CY1 CY2

CY4 CY5

G54 G55

651 652

654 655

EP4 EP5

P31 P32

P34 P35

17258 41140

15940 41769

18194 43825

18445 42566

77474 182834

71405 168807

30687 74663

27027 66198

18293 47705

35345 91275

22772 58183

14073 35293

9019 20845

22819 54699

13109 30036

12822 29119

23933 55581

9887 22345

12694 28827

64801 164359

49560 118027

61069 138677

59725 139319

62024 141416

62280 140132

122490 283205

116299 268898

74767 172871

71034 164236

62125 145373

79518 189815

66694 156061

57420 132713

36797 85048

66742 152507

53485 122549

52315 118808

67878 153407

40339 91170

51792 117616

109563 264361

94017 217102

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

California

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

Colorado

$20$35

$25$35

$20$30

$30$50

$20$30

$30$50

$25$35

$15$25

$30$40

$15$25

$30$40

$20$35

$25$40

$250day x 4

$250max4days

$200 x 3 days

$150dayx5

$150day x 4

$5$40$60

50+50+

$35$100

$5$40$70$60

$35$60

$35$65

$35$60

$35$65

$35$35

$30$30

$35$35

$30$30

$35$35

$35$60

$25$50

30to$60050 to$1200

Connecticut

$20$40

$25$40

$250x3

50+50+

$35$60

$40$80

30to$60050 to$1200

Delaware

$25$40

50+50+

30to$60050 to$1200

$20$35

$15$35

$250day x 4

20 Plan Allow

50+50+

$35$100

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Florida

877shy459shy6604

888shy789shy9065

877shy574shy3337

877shy835shy9861

877shy459shy6604

800shy882shy8633

850shy383shy3311

800shy441shy5501

888shy393shy6765

F54 F55

JN1 JN2

JN4 JN5

2G1 2G2

2G4 2G5

E31 E32

E34 E35

JP1 JP2

F54 F55

ML1 ML2

ML4 ML5

EA1 EA2

5E1 5E2

5E4 5E5

MJ4 MJ5

QP4 QP5

E21 E22

E24 E25

EE1 EE2

EE4 EE5

EX1 EX2

EX4 EX5

LL1 LL2

LL4 LL5

13058 29656

46867 105610

14021 31351

21177 48693

15284 35429

16926 42124

9646 22186

20245 50123

13058 29656

20336 56279

12604 30253

11679 30949

16664 47450

12501 30003

10247 22697

13149 29256

11834 26331

23153 51514

15825 35210

13880 30882

12491 27794

48720 108398

15825 35208

53279 120995

91271 204437

57208 127913

65067 146381

59056 132852

60731 139681

39358 90520

64116 147840

53279 120995

64209 154119

51424 123431

47650 126273

60464 145113

51005 122414

41809 92606

53648 119367

48282 107430

67082 149259

59608 132629

56629 125999

50965 113400

93161 207280

59608 132627

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

HMOPOS Nationa

30to$60050 to$1200 Yes

l Average 679 864 849 942 877 875 649

$15$30

$20$35

$25$35

Nothing$35

$150day x3

10 Plan Allow

Nothing

50+50+

$35$100

$35$65

MD IPAshyHigh

Florida

$70$70

$10$20

$20$30

$25$40

$250dayx3

$150day x 3

Nothing

$7$17 Net

$12$22Net

$35$65

$30$50$45$65

$35$55$50$70

$30$60

30to$60050 to$1200

$15$40

$25$45

Nothing$15

$15$30

$20$50

$35$55

$250dayx3

$300dayx3

Ded + $150x3

Ded + $150x5

$15 Tier 1

50+50+

$30$5030

$40$6030

$40$6020

$50$7020

$40$60

$30 Tier 2 $50 Tier 3

$35$55

$40+$60+

$40$60

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$40+$60+

$40$60

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Georgia

877shy459shy6604

888shy393shy6765

888shy865shy5813

671 479shy7982

671shy647shy3526

877shy459shy6604

800shy776shy4672

808shy432shy5955

F54 F55

2U1 2U2

AD4 AD5

LM4 LM5

CB1 CB2

CB4 CB5

DG1 DG2

DG4 DG5

DN1 DN2

DN4 DN5

F81 F82

F84 F85

B41 B42

JK1 JK2

JK4 JK5

JS4 JS5

871 872

631 632

634 635

13058 29656

44133 104232

10247 22697

15825 35210

13880 30882

15825 35210

13149 29256

15825 35210

13880 30882

15015 36863

10047 22957

11949 31399

12447 36018

10209 26960

17258 41140

11377 25325

14515 32578

7553 16846

53279 120995

88482 203031

41809 92606

59608 132629

56629 125999

59608 132629

53648 119367

59608 132629

56629 125999

58782 134315

40991 93667

48751 128109

50786 133453

41654 109996

61069 138677

46419 103326

58272 129944

30818 68731

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Georgia

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$20$35

$35$55

$250day x 4

50+50+

$35$100

$40$60

59 90 878 941 86 857 62

$35$55

$40+$60+

$40$60

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$30

$20$35

$15$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250dayx3

$10$20 Comm

$15$25 Comm

$40+$60+

$40$60

$2550 of AWP

$40$50 Comm $40$50 Comm

TakeCareshyHigh

TakeCareshyStandard

$5 at FHP$40

$25$40

$100day for 5

$150day for 5

$25$50

$40$80

30to$60050 to$1200

HMSA InshyNetwork

$15$15

50+50+

$30$65

$20$20

$30$30

$7 + 20

$45$45

$50$50

$30 + 20 $65 + 20 No

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Illinois

H44 H45

9K1 9K2

DK4 DK5

541 542

544 545

SF1 SF2

SF4 SF5

H44 H45

A21 A22

9G1 9G2

FX1 FX2

K84 K85

9F1 9F2

AB4 AB5

GB4 GB5

MW4 MW5

751 752

754 755

761 762

B91 B92

YH1 YH2

13093 29732

19819 42542

11798 25954

27070 55009

11742 26509

19210 43095

12435 27741

13093 29732

30483 71121

32158 67069

26932 67294

20323 51891

51805 115264

15825 35210

10247 22697

40638 90413

15825 35210

14109 33787

33072 74273

14091 38330

53418 121307

63682 140107

48136 105894

71078 152824

47908 108156

63060 140671

50737 113183

53418 121307

74559 169258

76267 165125

70937 165354

64196 149643

96307 214284

59608 132629

41809 92606

84917 188936

59608 132629

57566 131177

77200 172473

57491 135811

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

SelectHealthshyHigh

Illinois

$20$30

$20$40

$25$25

$25$35

$15$25

$20$30

$25$40

$100 after

$5 $25$50

50+50+

$25$50

$35$60

$40$60

$25$50$50

$25$50

30to$60050 to$1200

$20$35

$25$35

$200day x 5

$10 copay

50+50+

$40$60

$40$6025 $6025

30 after ded

$25$50

$20$35

$25$40

$35$55

30 after ded

$200day x 5

$250day x 3

$500day x 3

$35$70

$40$60

745 915 88 962 878 868 67

$35$55

$40+$60+

$40$60

$20$35

$25$40

$15$15

$25$40

$25$50

$250day x 3

$500day x 3

$40+$60+

$40$60

$35$60

$30$60

$35$50

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Indiana

JS4 JS5

FX1 FX2

K84 K85

MW4 MW5

A61 A62

A64 A65

751 752

754 755

MH1 MH2

MH4 MH5

DQ1 DQ2

H44 H45

SV1 SV2

SY4 SY5

FX1 FX2

K84 K85

V31 V32

V34 V35

AU1 AU2

AU4 AU5

YH1 YH2

17258 41140

26932 67294

20323 51891

10247 22697

13880 30882

12491 27794

40638 90413

15825 35210

13880 30882

30786 68557

13093 29732

13351 31376

9799 23027

26932 67294

20323 51891

26865 64982

8897 20464

26173 63455

23647 57594

14091 38330

61069 138677

70937 165354

64196 149643

41809 92606

56629 125999

50965 113400

84917 188936

59608 132629

56629 125999

74868 166643

53418 121307

54474 128016

39979 93951

70937 165354

64196 149643

70869 162996

36302 83494

70163 161438

67586 155460

57491 135811

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Indiana

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$25$50

$35$55

$200day x 5

50+50+

$35$70

$40$60

745 915 88 962 878 868 67

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$15$15

$25$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$40+$60+

$40$60

$25$50

30to$60050 to$1200

$25$50

$25$45

$0 for 3 then 20

$20$30

$200day x 5

Nothing

20 in40 out

$100day x 5

$3 $10

50+50+

$45$70$100

30$5000 Max

$35$70

$45$90

$40$70

$30$50

$25$25

$100day x 5

40+40+

$30$50

40+40+

$25$50

40+40+

$35$50

Yes 577 896 86 956 914 918 623

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Kansas

Kentucky

Louisiana

877shy459shy6604

800shy969shy3343

888shy393shy6765

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy341shy6613

888shy393shy6765

G54 G55

HY1 HY2

HA1 HA2

HA4 HA5

PH4 PH5

MS1 MS2

MS4 MS5

H44 H45

A61 A62

A64 A65

MH1 MH2

MH4 MH5

MI1 MI2

MI4 MI5

F54 F55

BJ1 BJ2

BJ4 BJ5

AE1 AE2

AE4 AE5

BC1 BC2

BC4 BC5

12822 29119

13777 50039

13519 32270

12568 29535

10247 22697

62521 139111

15825 35210

13093 29732

13880 30882

12491 27794

15825 35210

13880 30882

19459 43292

13880 30882

13058 29656

19208 48754

13035 30271

15825 35210

13149 29256

13880 30882

12491 27794

52315 118808

55396 147754

55160 129630

51276 120503

41809 92606

107238 238608

59608 132629

53418 121307

56629 125999

50965 113400

59608 132629

56629 125999

63314 140872

56629 125999

53279 120995

63058 146443

53182 123506

59608 132629

53648 119367

56629 125999

50965 113400

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Kansas

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$20$35

$30$60

$35$55

$250day x 4

$3 $12

50+50+

$35$100

$50$75

$40$60

Kentucky

$20$35

$25$40

$250day x 3

$500day x 3

$40+$60+

$40$60

30to$60050 to$1200

Louisiana

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+50+

$40$60

30to$60050 to$1200

$25$45

$30$55

$20$35

$35$40

$20$35

$35$40

Ded+$100

Ded+30

$250day x 3

$500day x 3

$250day x 3

$500day x 3

50+50+

$40$100

$40$60

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Maryland

Massachusetts

EP4 EP5

F54 F55

JN1 JN2

JN4 JN5

2G1 2G2

2G4 2G5

IG1 IG2

IG4 IG5

E31 E32

E34 E35

JP1 JP2

EP4 EP5

JG1 JG2

12694 28827

13058 29656

46867 105610

14021 31351

21177 48693

15284 35429

14998 37685

13265 30509

16926 42124

9646 22186

20245 50123

12694 28827

29337 80043

51792 117616

53279 120995

91271 204437

57208 127913

65067 146381

59056 132852

58764 135153

54121 124479

60731 139681

39358 90520

64116 147840

51792 117616

73390 178358

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

Maryland

$25$40

50+50+

30to$60050 to$1200

$15$30

$20$35

$25$35

Nothing$35

$150day x3

10 Plan Allow

Nothing

50+50+

$35$100

$35$65

MD IPAshyHigh

Massachusetts

$70$70

$20$40

$10$20

$20$30

$25$40

$200day x 3

$250dayx3

$150day x 3

Nothing

$7$17 Net

$12$22Net

$35$65

$30$60

$30$50$45$65

$35$55$50$

$30$60

30to$60050 to$1200

70 Yes

$25$35

$150to$750max

50+50+

$30$60

Yes 627 851 882 929 883 801 649

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Michigan

Minnesota

G54 G55

K51 K52

LX1 LX2

RL1 RL2

RL4 RL5

521 522

GY4 GY5

X51 X52

A51 A52

H44 H45

V31 V32

V34 V35

H44 H45

12822 29119

22055 52593

18055 50747

24184 61492

19656 50897

20111 55722

16974 48191

13915 49809

13670 50117

13093 29732

26865 64982

8897 20464

13093 29732

52315 118808

65962 150359

61882 148476

68134 159436

63515 148629

63980 153551

60780 145869

56775 147520

55776 147834

53418 121307

70869 162996

36302 83494

53418 121307

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

Michigan

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

Minnesota

$15$25

$10$10

$20$20

$10$20

$15$30

$10$20

$15$15

$25$40

Nothing

$500x3

Nothing

50+50+

$30$60

$15$15

$50$50

$40$60

$40$40

30to$60050 to$1200

$25$45

$0 for 3 then 20

$25$40

Nothing

20 in40 out

50+50+

$45$90

$40$70

30to$60050 to$1200

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Montana

Nebraska

Nevada

New Hampshire

877shy459shy6604

888shy811shy2092

800shy969shy3343

888shy393shy6765

877shy835shy9861

877shy459shy6604

877shy545shy7378

877shy459shy6604

G54 G55

HY1 HY2

9G1 9G2

HA1 HA2

HA4 HA5

PH4 PH5

MS1 MS2

MS4 MS5

B91 B92

H44 H45

G54 G55

HF1 HF2

NM1 NM2

EP4 EP5

12822 29119

13577 50039

32158 67069

13519 32270

12568 29535

10247 22697

62521 139111

15825 35210

33072 74273

13093 29732

12822 29119

11267 36491

9883 23303

12694 28827

52315 118808

55396 147754

76267 165125

55160 129630

51276 120503

41809 92606

107238 238608

59608 132629

77200 172473

53418 121307

52315 118808

45970 133935

40322 95078

51792 117616

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$20$35

$250day x 4

50+50+

$35$100 $40$60

Yes 639 862 862 94 838 901 538

30 after ded $30$60

$30$60

$35$55

30 after ded 25

NA $3 $12

$3 $12

NA $50$75

$40$60

NA Yes

Montana

$20$35

$25$40

$250day x 3

$500day x 3

$40+$60+

$40$60

$30$60

30to$60050 to$1200

Nebraska

$25$40

50+50+

30to$60050 to$1200

Nevada

$25$40

50+50+

30to$60050 to$1200

New Hampshire

$20$35

$10$25

$25$40

$250day x 4

50+50+

$35$100

$35$55$100

30to$60050 to$1200

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

New Jersey

New Mexico

EP4 EP5

JR1 JR2

JR4 JR5

P31 P32

P34 P35

801 802

804 805

G54 G55

Q11 Q12

P21 P22

12694 28827

52355 123641

34184 82457

64801 164359

49560 118027

32591 93212

14135 33572

12822 29119

13099 30785

23940 56335

51792 117616

96868 222828

78334 180821

109563 264361

94017 217102

76709 191791

57672 130958

52315 118808

53445 125603

67885 154176

Prescription Drugs

Mail lan

ll icate

r ng rmation

order discount

Overall p

satisfaction

Getting n

Getting c

quickly

doctors

commun

Custome

service

Claims

processi

New Jersey

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$20$35

$15$35

$20$35

$15$35

$20$20

$250day x 4

20 Plan Allow

$250day x 4

20 Plan Allow

$150max$450

50+50+

$35$100

$45$85

New Mexico

50 of sch

$30$30

$25$40

+50 of sch

$250day x 3

$45$85

30to$60050 to$1200

663 844 851 936 86 828 642

$25$35

$25$40

$250 after ded

$100 x 5 days

50+50+

$35$6050

$40$7550

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

New York

EP4 EP5

JC1 JC2

JC4 JC5

SG1 SG2

SG4 SG5

6V1 6V2

X41 X42

801 802

804 805

511 512

514 515

QA1 QA2

C54 C55

GA1 GA2

GA4 GA5

GV1 GV2

GV4 GV5

M91 M92

M94 M95

MF1 MF2

MF4 MF5

MX1 MX2

MX4 MX5

12694 28827

40198 109033

26007 71920

22952 71235

12294 32053

19548 60991

14167 47634

32591 93212

14135 33572

17000 63158

12206 34562

18597 58201

14454 47853

16586 53386

13377 39674

13042 35704

11193 28006

17110 54877

13779 42651

25417 75411

22349 67734

18731 58664

13657 42345

51792 117616

84468 207928

69993 170073

66877 169374

50161 129408

63405 158925

57800 145301

76709 191791

57672 130958

60806 161136

49800 131968

62435 156079

58209 145524

60384 151168

54580 137182

53210 133132

45669 114266

60918 152689

56220 140218

69392 173634

66262 165803

62572 156552

55723 139906

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

New York

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$20$35

$15$35

$20$30

$25$40

$20$20

$250day x 4

20 Plan Allow

$100 x 5

$500+10

$150max$450

50+50+

$35$100

$30$50

$45$85

50 of sch

$30$30

$20$40

$30$50

$25$25

+50 of sch

$250day x 3

$15$100Ded

$45$85

$35$75

$30$75

$35$75 $75$100Ded

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$25$25

$30$50

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

$35$70

$45$90

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

North Carolina

North Dakota

Oklahoma

F54 F55

H44 H45

V31 V32

V34 V35

RU1 RU2

C91 C92

C94 C95

JS4 JS5

3A1 3A2

A61 A62

A64 A65

641 642

644 645

U41 U42

JS4 JS5

IM1 IM2

13058 29656

13093 29732

26865 64982

8897 20464

13803 47086

20976 51441

14143 45836

17258 41140

14204 44676

13880 30882

12491 27794

28758 69344

13114 30163

26271 60855

17258 41140

11810 28460

53279 120995

53418 121307

70869 162996

36302 83494

56317 144742

64862 149184

57705 143467

61069 138677

57953 142284

56629 125999

50965 113400

72799 167445

53504 123066

70263 158786

61069 138677

48185 116118

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

North Carolina

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

North Dakota

$25$40

50+50+

30to$60050 to$1200

$25$45

$0 for 3 then 20

$15$25

Nothing

20 in40 out

50$600ded

50+50+

$45$90

$40$70

50$600 ded

$20$30

$100day x 5

$30$50

$25$25

$100day x 5

40+40+

$30$50

40+40+

$25$40

40+40+

30to$60050 to$1200

AultCare HMOshyHigh

Oklahoma

$15$20

$20$35

$25$40

$20$20

$30$40

$10$20

$25$40

$250day x 3

$500day x 3

50+50+

$30$40$55

$40$60

$30$30

$40$40

$30$50

30to$60050 to$1200

$15$45

$250dymx1000

50+50+

$45$70

Yes 592 816 839 916 893 872 727

Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Oregon

Pennsylvania

Puerto Rico

Rhode Island

South Carolina

877shy459shy6604

800shy813shy2000

877shy459shy6604

800shy447shy4000

866shy351shy5946

888shy876shy2756

800shy314shy3121

787shy774shy6060

877shy459shy6604

H44 H45

571 572

574 575

H44 H45

P31 P32

P34 P35

YE1 YE2

GG4 GG5

261 262

8W1 8W2

UW4 UW5

ZJ1 ZJ2

891 892

EP4 EP5

JS4 JS5

13093 29732

22672 52645

13617 31283

13093 29732

64801 164359

49560 118027

19203 59806

16820 41884

17814 47183

22135 54101

13345 30692

8026 18317

8829 19866

12694 28827

17258 41140

53418 121307

66592 150412

55557 127637

53418 121307

109563 264361

94017 217102

63053 157716

60623 139436

61637 144841

66044 151897

54448 125225

32748 74733

36023 81052

51792 117616

61069 138677

Primary care

Hospital per stay

deductible

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

doctors

communicate

Customer

service

Claims

processing

Information

Oregon

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

Pennsylvania

$20$30

$30$40

$25$40

50+50+

$40$60

30to$60050 to$1200

Puerto Rico

$20$35

$15$35

$20$35

$25$50

10 after Deduct

20 after Deduct

$250day x 4

20 Plan Allow

$250day x 4

20aftrDeduct

15 after ded

10 after deduct

20after Deduct

30 $5$15

$5 after ded

50+50+

$35$100

$35$60

$35$75

$35$75$100

$10$15

40 $40$120 50 $85$250

Rhode Island

$750$10

$25$40

$750 amp 10 +$10 amp 10 +

None 10 +

$5 or $12 NA

2025 up to$100$175max

30to$60050 to$1200

Yes No

691 874 844 963 872 75 586

South Carolina

$25$40

50+50+

30to$60050 to$1200

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

South Dakota

Tennessee

G54 G55

V31 V32

V34 V35

AU1 AU2

AU4 AU5

F54 F55

UB1 UB2

GJ1 GJ2

GJ4 GJ5

12822 29119

26865 64982

8897 20464

26173 63455

23647 57594

13058 29656

24581 76516

15825 35210

12491 27794

52315 118808

70869 162996

36302 83494

70163 161438

67586 155460

53279 120995

68539 174761

59608 132629

50965 113400

Primary

Prescription Drugs

ded ation

care Hospital Mail

Getting nee

How well

r ng rm

Level II Level III

order discount

Overall

satisfaction

Getting

quickly

doctors

commun

Custome

service

Claims

processi

Plan Info

on Costs

South Dakota

30to$60050 to$1200

OS National

Average 679 864 849 942 877 875 649

$25$45

$0 for 3 then 20

$20$30

Nothing

20 in40 out

$100day x 5

50+50+

$45$90

$40$70

$30$50

$25$25

$100day x 5

40+40+

$30$50

Tennessee

40+40+

$25$40

40+40+

30to$60050 to$1200

$20$35

$25$40

$250day x 4

$250day x 3

$500day x 3

50+50+

$35$100

$40$60

66 875 868 959 889 914 69

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

JS4 JS5

ES1 ES2

B71 B72

CK1 CK2

CN1 CN2

CZ1 CZ2

ET1 ET2

TP4 TP5

TU4 TU5

TV4 TV5

EW1 EW2

EW4 EW5

UC1 UC2

UC4 UC5

UR1 UR2

UR4 UR5

UU1 UU2

UU4 UU5

A84 A85

GF1 GF2

17258 41140

12817 40332

11057 37880

10809 34896

13391 65886

13031 61566

12638 56836

10247 22697

13880 30882

12491 27794

17899 39821

13880 30882

55020 122416

13880 30882

26524 59015

15825 35210

14907 37260

32515 78160

61069 138677

52295 137853

45113 135352

44103 132308

54635 163918

53169 159512

51562 154687

41809 92606

56629 125999

50965 113400

61723 137332

56629 126001

99587 221579

56629 126001

70521 156910

59608 132629

58671 134720

76632 176438

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

$5$25$35

50+50+

$35$60

FirstcareshyHigh

$30$55

$35$55

$250day x 5

$35$70

$40$60

$35$55

$40+$60+

$40$60

$35$55

$40+$60+

$40$60

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$35

$25$40

$20$45

$20$40

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 3

$500day x 3

$250day x 5

$40+$60+

$40$60

$45$100

$35$60

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Virgin Islands

G54 G55

9K1 9K2

DK4 DK5

SF1 SF2

SF4 SF5

EP4 EP5

851 852

12822 29119

19819 42542

11798 25954

19210 43095

12435 27741

12694 28827

10305 23402

52315 118808

63682 140107

48136 105894

63060 140671

50737 113183

51792 117616

42043 95481

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

30to$60050 to$1200

POS National

Average 679 864 849 942 877 875 649

SelectHealthshyHigh

$20$30

$20$40

$15$25

$20$30

$25$40

$100 after

$5$25$50

50+50+

$25$50

$35$60

$25$50$50

$25 $50$50

30to$60050 to$1200

Virgin Islands

4040 40 50+ 50+50+ No

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

None 10 +

$5 or $12 NA NA

2025 up to$100$175max

Yes No

691 874 844 963 872 75 586

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Virginia

Washington

F54 F55

JN1 JN2

JN4 JN5

D91 D92

J91 J92

2G1 2G2

2G4 2G5

A91 A92

E31 E32

E34 E35

JP1 JP2

9R1 9R2

9R4 9R5

2C1 2C2

G54 G55

C31 C32

541 542

544 545

L11 L12

VT1 VT2

571 572

574 575

13058 29656

46867 105610

14021 31351

12138 40332

11280 29365

21177 48693

15284 35429

20427 47008

16926 42124

9646 22186

20245 50123

26858 69565

11269 26665

12235 28017

12822 29119

14933 62274

27070 55009

11742 26509

12426 26823

31651 67459

22672 52645

13617 31283

53279 120995

91271 204437

57208 127913

49524 137853

46023 119808

65067 146381

59056 132852

64302 144663

60731 139681

39358 90520

64116 147840

70861 167671

45977 108794

49920 114308

52315 118808

58698 160234

71078 152824

47908 108156

50700 109437

75750 165523

66592 150412

55557 127637

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Claims

processing

Plan Inform

on Costs

Virginia

$25$40 4040

$15$30

$20$35

$25$35 4040

$5$25$35 4040

$25$35

Nothing$35

$150day x3

10 Plan Allow

$10 50+

Nothing

50+50+

$35$100

$35$60 4040

$35$65

30to$60050 to$1200

POS National

Yes No

Average

MD IPAshyHigh

Washington

$70$70

$10$20

$20$30

$25$40

$25$30

$35$35

$25$40 4040

$20$35

$25$25

$25$35

$154 or 2020

$30$30 $30+40+diff

$20$30

$30$40

$20$0childlt22$30

$200 x3 days

$250dayx3

$150day x 3

$150max$750

$20020

$250day x 4

Nothing Nothing

None None

Nothing

$7$17 Net

$12$22Net

$10 50+

$10 Not Covered

$5 Not Covered

$35$65

$30$50$50

$30$50$45$65

$35$55$50$70

$30$60

$40$55

50+50+

$35$100

$40$60

Not Covered

$40$60

$353050up to $3000

$355050 up to $3000

$35$50 30day$100 90day

$25$50 30day$100 90day

30to$60050 to$1200

Yes No

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

West Virginia

Wisconsin

Wyoming

F54 F55

U41 U42

JS4 JS5

F71 F72

WD1 WD2

WJ1 WJ2

V31 V32

V34 V35

EY1 EY2

LW1 LW2

H44 H45

9K1 9K2

DK4 DK5

13058 29656

26271 60855

17258 41140

10600 29208

24382 72670

15910 51534

26865 64982

8897 20464

14597 48275

16556 55954

13093 29732

19819 42542

11798 25954

53279 120995

70263 158786

61069 138677

43250 119170

68336 170838

59694 149279

70869 162996

36302 83494

58355 145955

60353 153787

53418 121307

63682 140107

48136 105894

Primary care

Prescription Drugs

Mail order

discount

Overall plan

satisfaction

Claims

processing

Getting needed

Getting care

quickly

How well

doctors

communicate

Customer

service

Plan Inform

on Costs

West Virginia

Wisconsin

Wyoming

$25$40 4040

$10$20

$25$40 4040

$25$35 4040

$25$25

$10$10

$25$45

$0 for 3 then 20

$10$10

$25$40 4040

$20$30

$20$40

Nothing

20 in40 out

Nothing

$10 Yes 50+ 50+50+ No

$15 $30$50 Yes

$10 Yes 50+ 50+50+ No

$5 $35$60 Yes 40 4040 No

$10 Yes

$5 $20$20 Yes

$12 $45$90 Yes

$9 $40$70 Yes

$10 $20$50 Yes

$10 3050 No

$10 Yes 50+ 50+50+ No

$7 $25$50 No

$7 $35$60 None

30$75max 50 wmin$50

30to$60050 to$1200

909 876 951 929 944

909 90 97 834 879

834 834 953 929 932

893 875 951 92 911

888 854 938 888 87

857 822 96 863 866

852 813 948 883 895

864 849 942 877 875

ELIGIBILITY

FUNDING

CONTRIBUTIONS

DISTRIBUTIONS

ANNUAL ROLLOVER

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

800shy718shy1299

800shy821shy6136

800shy694shy9901

888shy636shy6252

474 475

341 342

481 482

324 325

9742 21915

11021 25172

13642 30912

10454 22700

39747 89414

44967 102703

55661 126120

42653 92617

Plan Code

885 866 929 860

891 888 952 830

873 851 923 863

891 859 912 887

881 865 939 850

891 888 952 830

909 907 925 871

849 864 932 843

875 801 948 856

Getting needed care

How well doctors

Getting needed care

How well doctors

Claims processing

Plan Name

Telephone Number

Enrollment Code

Premium

Self only

Self amp family

Self only

Self amp family

Self only

Self amp family

Premium

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Plan Name

877shy459shy6604

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

136516

151489

149613

136516

151489

149613

Self amp family

Plan Name

Benefit Type

CY Ded SelfFamily

Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Premium

Connecticut

Delaware

Florida

Georgia

Plan Name

877shy459shy6604

888shy789shy9065

877shy459shy6604

800shy441shy5501

888shy393shy6765

877shy459shy6604

888shy393shy6765

671shy647shy3526

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

145440

136516

127574

136516

141522

116366

136516

105282

110827

Self amp family

Connecticut

Delaware

Florida

Georgia

Premium

Illinois

Indiana

Kansas

Plan Name

877shy459shy6604

800shy377shy4161

877shy459shy6604

888shy393shy6765

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy257shy4692

877shy459shy6604

800shy969shy3343

888shy393shy6765

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

151489

136317

110827

110823

151489

110823

136317

149613

122219

Self amp family

Illinois

Indiana

Kansas

Premium

Kentucky

Louisiana

Maryland

Massachusetts

Michigan

Minnesota

Plan Name

877shy459shy6604

888shy393shy6765

877shy459shy6604

888shy789shy9065

800shy833shy7423

877shy459shy6604

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

136317

136516

145440

136516

127574

109488

145440

149613

136317

Self amp family

Kentucky

Louisiana

Maryland

OutshyNetWork

InshyNetwork

$3750$7500

$4167$8334

$3000$6000

$2000$4000

$6000$12000

$4000$8000

Nothing

Nothing$30$60

Massachusetts

Michigan

Minnesota

Premium

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

Plan Name

877shy459shy6604

800shy969shy3343

888shy393shy6765

877shy459shy6604

800shy501shy3439

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

149613

122219

136317

149613

145440

149613

145440

101669

Self amp family

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

Premium

North Carolina

North Dakota

Pennsylvania

Rhode Island

South Carolina

Plan Name

877shy459shy6604

330shy363shy6360

877shy459shy6604

866shy351shy5946

888shy876shy2756

877shy459shy6604

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

136516

136317

151489

136317

115650

114458

145440

151489

Self amp family

North Carolina

North Dakota

Pennsylvania

Rhode Island

South Carolina

Plan Name

CY Ded SelfFamily

Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

10After Deduct

10 after deduct

30After Deduct

30 after deduct

Premium

South Dakota

Tennessee

Vermont

Plan Name

877shy459shy6604

888shy393shy6765

877shy459shy6604

800shy377shy4161

877shy459shy6604

888shy789shy9065

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

149613

136516

151489

110827

110823

121906

149613

145440

136516

127574

Self amp family

South Dakota

Tennessee

Vermont

Premium

Wyoming

Plan Name

877shy459shy6604

800shy552shy7114

877shy459shy6604

800shy377shy4161

Telephone Number

Enrollment Code

Self only

Self amp family

Self only

Self amp family

Self only

149613

136516

151489

136317

Self amp family

Wyoming

Plan Name

CY Ded SelfFamily

Office Visit

Inpatient Hospital

Outpatient Surgery

Preventive Services

Prescription Drugs

Levels I II III

Benefit Type

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

______________________________________________________________________________________________________________

19122-1-14 (70-16)_20 pages

19122-15-20 (70-16)_6 pages

19122-21-86 (70-16)_0

Documents

FEHB Guide - OPM.gov