Pages 1--68 from Aetna U.S. Healthcare 2001

RI 73-052
Aetna U. S. Healthcare (r) 2001 http:// www. aetnaushc. com/ feds.
A Health Maintenance Organization
Enrollment in this Plan is limited; see page 8 for requirements.

Serving: Southwestern, Central and Northeastern Pennsylvania
Enrollment code:
KL1 High Option Self Only
KL2 High Option Self and Family

KL4 Standard Option Self Only
KL5 Standard Option Self and Family

Serving: Southeastern Pennsylvania and Delaware
Enrollment code:
SU1 High Option Self Only
SU2 High Option Self and Family

SU4 Standard Option Self Only
SU5 Standard Option Self and Family

Serving: New Jersey
Enrollment code:
P31 High Option Self Only
P32 High Option Self and Family

P34 Standard Option Self Only
P35 Standard Option Self and Family

Serving: All of Washington, DC, North and Central Maryland and Northern Virginia
Enrollment code:
JN1 High Option Self Only
JN2 High Option Self and Family

JN4 Standard Option Self Only
JN5 Standard Option Self and Family

Serving: All of Central, Richmond and Tri-Cities Virginia
Enrollment code:
XE1 High Option Self Only
XE2 High Option Self and Family

XE4 Standard Option Self Only XE5 Standard Option Self and Family

Special Notice
This brochure includes benefits for
Prudential HealthCare members
transferred to Aetna U. S. Healthcare

For changes
in benefits
see page 10. 1
1 Page 2 3

2001 Aetna U. S. Healthcare HMO 2 Table of Contents
Table of Contents
Introduction ........................................................................................................................................................................... 4
Plain Language ...................................................................................................................................................................... 4
Section 1. Facts about this HMO plan.................................................................................................................................. 5
How we pay providers........................................................................................................................................ 5
Patients' Bill of Rights ....................................................................................................................................... 6
Service Area........................................................................................................................................................ 8
Section 2. How we change for 2001................................................................................................................................... 10
Program-wide changes ..................................................................................................................................... 10
Changes to this Plan ......................................................................................................................................... 10
Section 3. How you get care ............................................................................................................................................... 12
Identification cards ........................................................................................................................................... 12
Where you get covered care............................................................................................................................. 12
Plan providers ............................................................................................................................................ 12
Plan facilities.............................................................................................................................................. 12
What you must do to get covered care............................................................................................................. 12

Primary care ............................................................................................................................................... 12
Specialty care ............................................................................................................................................. 12
Hospital care .............................................................................................................................................. 13
Circumstances beyond our control .................................................................................................................. 14
Services requiring our prior approval .............................................................................................................. 14
Section 4. Your costs for covered services......................................................................................................................... 15
Copayments................................................................................................................................................ 15
Deductible .................................................................................................................................................. 15
Coinsurance................................................................................................................................................ 15
Your out-of-pocket maximum ......................................................................................................................... 15
Section 5. Benefits............................................................................................................................................................... 16
Overview........................................................................................................................................................... 16
(a) Medical services and supplies provided by physicians and
other health care professionals.............................................................................................................. 17

(b) Surgical and anesthesia services provided by physicians and
other health care professionals.............................................................................................................. 25

(c) Services provided by a hospital or other facility, and ambulance services......................................... 28
(d) Emergency services/ accidents .............................................................................................................. 31
(e) Mental health and substance abuse benefits......................................................................................... 34
(f) Prescription drug benefits ..................................................................................................................... 36 2
2 Page 3 4

2001 Aetna U. S. Healthcare HMO 3 Table of Contents
(g) Special features...................................................................................................................................... 39
(h) Dental benefits....................................................................................................................................... 40
(i) Non-FEHB benefits available to Plan members .................................................................................. 44
Section 6. General exclusions things we don't cover ................................................................................................... 45
Section 7. Filing a claim for covered services ................................................................................................................... 46
Section 8. The disputed claims process.............................................................................................................................. 47
Section 9. Coordinating benefits with other coverage ....................................................................................................... 49
When you have
Other health coverage .............................................................................................................................. 49
Original Medicare .................................................................................................................................... 49
Medicare managed care plan ................................................................................................................... 51
TRICARE/ Workers' Compensation/ Medicaid ............................................................................................... 51
Other Government agencies............................................................................................................................. 52
When others are responsible for injuries ......................................................................................................... 52
Section 10. Definitions of terms we use in this brochure .................................................................................................. 54
Section 11. FEHB facts....................................................................................................................................................... 57
Coverage information....................................................................................................................................... 57
No pre-existing condition limitation ....................................................................................................... 57
Where you get information about enrolling in the FEHB Program....................................................... 57
Types of coverage available for you and your family ............................................................................ 57
When benefits and premiums start .......................................................................................................... 58
Your medical and claims records are confidential ................................................................................. 58
When you retire........................................................................................................................................ 58
When you lose benefits .................................................................................................................................... 58

When FEHB coverage ends..................................................................................................................... 58
Spouse equity coverage ........................................................................................................................... 58
Temporary Continuation of Coverage (TCC)......................................................................................... 58
Enrolling in TCC...................................................................................................................................... 58
Converting to individual coverage .......................................................................................................... 59
Getting a Certificate of Group Health Plan Coverage............................................................................ 59
Inspector General Advisory ............................................................................................................................. 59
Department of Defense/ FEHB Demonstration Project...................................................................................................... 61
Index .................................................................................................................................................................................... 63
Summary of benefits ........................................................................................................................................................... 65
Rates..................................................................................................................................................................................... 67 3
3 Page 4 5
2001 Aetna U. S. Healthcare HMO 4 Introduction/ Plain Language
Introduction
Aetna U. S. Healthcare, Inc.
1425 Union Meeting Road
P. O. Box 1126, Mail Stop U32A
Blue Bell, PA 19422

This brochure describes the benefits you can receive from Aetna U. S. Healthcare under our contract (CS 1766) with the
Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. This brochure is
the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and
exclusions of this brochure.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled for Self
and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits
that were available before January 1, 2001, unless these benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2001, and are
summarized on page 10. Rates are shown at the end of this brochure.

Plain language
The President and Vice President are making the Government's communication more responsive, accessible, and
understandable to the public by requiring agencies to use plain language. In response, a team of health plan
representatives and OPM staff worked cooperatively to make this brochure clearer. Except for necessary technical
terms, we use common words. "You" means the enrollee or family member; "we" means Aetna U. S. Healthcare.

The plain language team reorganized the brochure and the way we describe our benefits. When you compare this Plan
with other FEHB plans, you will find that the brochures have the same format and similar information to make
comparisons easier.

If you have comments or suggestions about how to improve this brochure, let us know. Visit OPM's "Rate Us"
feedback area at www. opm. gov/ insure or e-mail us at fehbwebcomments@ opm. gov or write to OPM at Insurance
Planning and Evaluation Division, P. O. Box 436, Washington, DC 20044-0436. 4
4 Page 5 6
2001 Aetna U. S. Healthcare HMO 5 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other
providers that contract with us. These Plan providers coordinate your health care services.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in
addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing
any course of treatment.

When you receive services from participating providers, you will not have to submit claim forms or pay bills. You only
pay the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services
from non-Plan providers, you may have to submit claim forms.

You should join an HMO because you prefer the plan's benefits, not because a particular provider is available.
You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract with us.

How we pay providers Provider Compensation We contract with individual physicians, medical groups, and hospitals
to provide the benefits in this brochure. These Plan providers accept a
negotiated payment from us, and you will only be responsible for your
copayments or coinsurance.

This is a direct contract prepayment Plan, which means that participating
providers are neither agents nor employees of the Plan. Rather, they are
independent doctors and providers who practice in their own offices or
facilities. The Plan arranges with licensed providers and hospitals to
provide medical services for both the prevention of disease and the
treatment of illness and injury for benefits covered under the Plan.

Plan providers in our network have agreed to be compensated in various
ways. Many participating primary care physicians (PCPs) are paid by
capitation. Under capitation, a physician receives payment for a patient
whether the physician sees the patient that month or not.

Specialists, hospitals, primary care physicians and other providers
in the Aetna U. S. Healthcare network may also be paid in the
following ways:

Per individual service (fee-for-service at contracted rates),
Per hospital day (per diem contracted rates),
Under other capitation methods (a certain amount per member, per month), and

By Integrated Delivery Systems (" IDS"), Independent Practice Associations (" IPAs"), Physician Medical Groups (" PMGs"), Physician
Hospital Organizations (" PHOs"), behavioral health organizations
and similar provider organizations or groups that are paid by Aetna
U. S. Healthcare; the organization or group pays the physician or facility
directly. In such arrangements, that group or organization has a
financial incentive to control the costs of providing care.

You are encouraged to ask your physicians and other providers how they are compensated for their services,
including whether their specific arrangements include any financial incentives to control costs. 5
5 Page 6 7
2001 Aetna U. S. Healthcare HMO 6 Section 1
Patients' Bill of Rights OPM requires that all FEHB Plans comply with the Patients' Bill of Rights, which allows you to get information about
your health plan, its networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific
types of information that we must make available to you. Some of the required information is listed below.

Medical Necessity
Covered services include most types of treatment by PCPs, specialists and hospitals. However, the health plan also
excludes or limits coverage for some services, including but not limited to cosmetic surgery and experimental
procedures. In addition, in order to be covered, all services, including the location (type of facility), duration and costs
of services, must be medically necessary as defined in this Plan and as determined by us. (See definition on page 55).

Direct Access Ob/ Gyn Program
This program allows female members to visit any participating gynecologist for a routine well-woman exam, including
a Pap smear (if appropriate) and an unlimited number of visits for gynecologic problems and follow-up care as
described in your benefits plan. Gynecologists may also refer a woman directly for covered gynecologic services
without the patient's having to go back to her participating primary care physician. If your Ob/ Gyn is part of an
Independent Practice Association (IPA), a Physician Medical Group (PMG) or a similar organization, covered care must
be coordinated through the IPA, the PMG or the similar organization.

Mental Health/ Substance Abuse
In most areas, certain behavioral health care services (e. g., treatment or care for mental disease or illness, alcohol abuse
and/ or substance abuse) are managed by an independently contracted organization. This organization makes initial
coverage determinations and coordinates referrals; any behavioral health care referrals will generally be made to
providers affiliated with the organization, unless your needs for covered services extend beyond the capability of the
affiliated providers. You can receive information regarding the appropriate way to access the behavioral health care
services that are covered under your specific plan by calling Member Services at 1-800-537-9384. As with other
coverage determinations, you may appeal behavioral health care coverage decisions in accordance with the provisions
of your Plan.

Ongoing Reviews
We conduct ongoing reviews of those services and supplies which are recommended or provided by health
professionals to determine whether such services and supplies are covered benefits under this Plan. If we determine that
the recommended services and supplies are not covered benefits, you will be notified. If you wish to appeal such
determination, you may then contact us to seek a review of the determination.

Authorization
Certain services and supplies under this Plan may require authorization by us to determine if they are covered benefits
under this Plan.

Patient Management
We have developed a patient management program to assist in determining what health care services are covered under
the health plan and the extent of such coverage. The program assists members in receiving the appropriate health care
and maximizing coverage for those health care services.

Only medical directors make decisions denying coverage for services for reasons of medical necessity. Coverage denial
letters delineate any unmet criteria, standards and guidelines, and inform the provider and member of the appeal
process.

Our patient management staff uses national guidelines and resources to guide the precertification, concurrent review and
retrospective review processes. Using the information obtained from providers, patient management staff utilize
Milliman & Robertson Health Care Management Guidelines when conducting concurrent review. If there is no
applicable Milliman & Robertson Guideline, patient management staff utilizes InterQual ISD criteria. When applicable,
Medicare National Coverage Decisions are followed for Medicare Managed Care members. To the extent certain patient
management functions are delegated to integrated delivery systems, independent practice associations or other provider
groups (" Delegates"), such Delegates utilize criteria that they deem appropriate. 6
6 Page 7 8
2001 Aetna U. S. Healthcare HMO 7 Section 1
Precertification Certain health care services, such as hospitalization or outpatient surgery, require precertification by us to ensure coverage for those services. When
a member is to obtain services requiring precertification through a Plan
provider, this provider should precertify those services prior to treatment.

Concurrent Review The concurrent review process assesses the necessity for continued stay, level of care, and quality of care for members receiving inpatient services.

All inpatient services extending beyond the initial certification period will
require Concurrent Review.

Discharge Planning Discharge planning may be initiated at any stage of the patient management process and begins immediately upon identification of post-discharge

needs during precertification or concurrent review. The
discharge plan may include initiation of a variety of services/ benefits to be
utilized by the member upon discharge from an inpatient stay.

Retrospective Record Review The purpose of retrospective review is to retrospectively analyze potential quality and utilization issues, initiate appropriate follow-up action based on

quality or utilization issues, and review all appeals of inpatient concurrent
review decisions for coverage and payment of health care services. Our
effort to manage the services provided to members includes the
retrospective review of claims submitted for payment, and of medical
records submitted for potential quality and utilization concerns.

Member Services
Representatives from Member Services are trained to answer your questions and to assist you in using the Aetna U. S.
Healthcare plan properly and efficiently. After you receive your ID card, you can call the Member Services toll-free
number on the card when you need to:

Ask questions about benefits and coverage.
Notify us of changes in your name, address or telephone number.
Change your primary care physician or office.
Obtain information about how to file a grievance.
Confidentiality
We protect the privacy of confidential Plan member medical information. We contractually require that participating
providers keep member information confidential in accordance with applicable laws. Furthermore, you have the right to
access your medical records from participating providers, at any time. Aetna U. S. Healthcare (including its affiliates and
authorized agents, collectively "Aetna U. S. Healthcare") and participating providers require access to member medical
information for a number of important and appropriate purposes, including claims payment, fraud prevention,
coordination of care, data collection, performance measurement, fulfilling state and federal requirements, quality
management, utilization review, research and accreditation activities, preventive health, early detection and disease
management programs. Accordingly, for these purposes, members authorize the sharing of member medical information
about themselves and their dependents between Aetna U. S. Healthcare and Plan providers and health delivery systems.

If you want more information about us, call 1-800-537-9384, or write to 1425 Union Meeting Road, P. O. Box 1126,
Mail Stop U32A, Blue Bell, PA 19422. You may also contact us by fax at 215-775-6550 or visit our website at
www. aetnaushc. com/ feds. 7
7 Page 8 9
2001 Aetna U. S. Healthcare HMO 8 Section 1
Service Area What is this Plan's service
area?
To enroll with us, you must live or work in our service area. This is where our
providers practice. Our service area is:

Pennsylvania

4/ 00
This service has Commendable
accreditation from the NCQA.
See the FEHB Guide for more
information on NCQA.

Serving: Southwestern, Central and Northeastern Pennsylvania
Enrollment Code:
KL1 High Option Self Only
KL2 High Option Self and Family

KL4 Standard Option Self Only
KL5 Standard Option Self and Family

Adams, Allegheny, Armstrong, Beaver, Blair, Bradford, Butler, Cambria, Carbon,
Clarion, Clinton, Columbia, Cumberland, Dauphin, Erie, Fayette, Franklin, Fulton,
Greene, Jefferson, Lawrence, Lackawanna, Lancaster, Lebanon, Luzerne,
Lycoming, Mercer, Monroe, Northumberland, Perry, Pike, Schuylkill, Snyder,
Somerset, Sullivan, Susquehanna, Washington, Wayne, Westmoreland, Wyoming
and York counties

12/ 99
This service has Excellent
accreditation from the NCQA.
See the FEHB Guide for more
information on NCQA.

Serving: Southeastern Pennsylvania
Enrollment Code:
SU1 High Option Self Only
SU2 High Option Self and Family

SU4 Standard Option Self Only
SU5 Standard Option Self and Family

Berks, Bucks, Chester, Delaware, Lehigh, Montgomery, and Northampton
counties and Philadelphia

Delaware

5/ 98
This service has Excellent
accreditation from the NCQA.
See the FEHB Guide for more
information on NCQA.

Serving: All of Delaware
Enrollment Code:
SU1 High Option Self Only
SU2 High Option Self and Family

SU4 Standard Option Self Only
SU5 Standard Option Self and Family

The State of Delaware

New Jersey

5/ 98
This service has Commendable
accreditation from the NCQA.
See the FEHB Guide for more
information on NCQA.

Serving: All of New Jersey
Enrollment Code:
P31 High Option Self Only
P32 High Option Self and Family

P34 Standard Option Self Only
P35 Standard Option Self and Family

The State of New Jersey 8
8 Page 9 10
2001 Aetna U. S. Healthcare HMO 9 Section 1
Maryland/ DC/
Northern Virginia

3/ 99
This service has Commendable
accreditation from the NCQA.
See the FEHB Guide for more
information on NCQA.

Serving: All of Washington, DC, North and Central Maryland and Northern
Virginia

Enrollment Code:
JN1 High Option Self Only
JN2 High Option Self and Family

JN4 Standard Option Self Only
JN5 Standard Option Self and Family

All of Washington, DC; the Maryland counties of Anne Arundel, Baltimore,
Baltimore City, Calvert, Carroll, Cecil, Charles, Frederick, Harford, Howard, Kent,
Montgomery, Prince George's, Queen Anne's, St. Mary's, Talbot, Washington,
Wicomico and Worcester; The Virginia counties of Arlington, Caroline, Fairfax,
Fauquier, King George, Loudon, Louisa, Prince William, Spotsylvania, Stafford
and Westmoreland; plus the cities of Alexandria, Fairfax, Falls Church,
Fredericksburg, Manassas and Manassas Park.

Central, Richmond and
Tri-Cities Virginia
Serving: Central, Richmond and Tri-Cities Virginia

Enrollment Code:
XE1 High Option Self Only
XE2 High Option Self and Family

XE4 Standard Option Self Only
XE5 Standard Option Self and Family

The Virginia Counties of: Charles, Chesterfield, Colonial Heights, Dinwiddie,
Goochland, Hanover, Henrico, Hopewell, King William, New Kent, Nottaway,
Petersburg, Powhattan, Richmond. 9
9 Page 10 11
2001 Aetna U. S. Healthcare HMO 10 Section 2
Section 2. How we change for 2001
Program-wide changes The plain language team reorganized the brochure and the way we describe our benefits. We hope this will make it

easier for you to compare plans.
This year, the Federal Employees Health Benefits Program is implementing network mental health and substance
abuse parity. This means that your coverage for mental health, substance abuse, medical, surgical, and hospital
services from providers in our plan network will be the same with regard to deductibles, coinsurance, copays, and day
and visit limitations when you follow a treatment plan that we approve. Previously, higher cost sharing and shorter
day limitations were placed on mental health and substance abuse services than we did on services to treat physical
illness, injury, or disease.

Many healthcare organizations have turned their attention this past year to improving healthcare quality and patient
safety. OPM asked all FEHB plans to join them in this effort. You can find specific information on our patient safety
activities by calling Customer Service at 1-800-537-9384, or checking our website at www. aetnaushc. com/ feds. You
can find out more about patient safety on the OPM website, www. opm. gov/ insure. To improve your healthcare, take
these five steps:

Speak up if you have questions or concerns.
Keep a list of all the medicines you take.
Make sure you get the results of any test or procedure.
Talk with your doctor and health care team about your options if you need hospital care.
Make sure you understand what will happen if you need surgery.

We clarified the language to show that anyone who needs a mastectomy may choose to have the procedure performed
on an inpatient basis and remain in the hospital up to 48 hours after the procedure. Previously, the language
referenced only women.

Changes to this Plan If your are enrolled in Prudential Healthcare HMO Mid-Atlantic enrollment Code JB in Maryland, Northern Virginia,
and Washington, DC your enrollment will automatically be transferred into Aetna U. S. Healthcare enrollment Code
JN, High Option. However, you may change to a Standard Option enrollment during Open Season. Please review this
brochure for your benefits.

If your are enrolled in Prudential Healthcare HMO New Jersey enrollment Code 8P in New Jersey, your enrollment
will automatically be transferred into Aetna U. S. Healthcare enrollment Code P3, High Option. However, you may
change to a Standard Option enrollment during Open Season. Please review this brochure for your benefits.

If your are enrolled in Prudential Healthcare HMO Philadelphia enrollment Code VV in Pennsylvania, your
enrollment will automatically be transferred into Aetna U. S. Healthcare enrollment Code SU, High Option. However,
you may change to a Standard Option enrollment during Open Season. Please review this brochure for your benefits.

If your are enrolled in Aetna U. S. Healthcare enrollment Code NK in Delaware, your enrollment will automatically be
transferred into Aetna U. S. Healthcare enrollment Code SU, High Option. However, you may change to a Standard
Option enrollment during Open Season. Please review this brochure for your benefits.

If your are enrolled in Aetna U. S. Healthcare enrollment Code Z1 in Virginia, your enrollment will automatically be
transferred into Aetna U. S. Healthcare enrollment Code XE, High Option. However, you may change to a Standard
Option enrollment during Open Season. Please review this brochure for your benefits.

The Plan expanded its Virginia service area and added a new enrollment code, Code XE. The following counties have
been added: Charles, Chesterfield, Colonial Heights, Dinwiddie, Hanover, Henrico, Hopewell, King William, New
Kent, Nottaway, Petersburg, Powhattan, and Richmond.

The Plan expanded its service area for Code SU to add the State of Delaware (formerly Code NK).
The copay for specialist office under High Option has increased from $10 to $15 per visit. See Sections 5A-5F. 10
10 Page 11 12
2001 Aetna U. S. Healthcare HMO 11 Section 2
The copay for specialist office visit under Standard Option has increased from $15 to $20 per visit. See Sections
5A-5F.

The copay for at home specialist visit under Standard Option has increased from $20 to $25 per visit. See Section 5A.
The Standard Option per admission copay to treat mental health and substance abuse increased from nothing to $240
to equal the copay for medical and surgical hospital admissions under Standard Option. See page 34.

Prophylaxis (cleaning of teeth) changed from once every 6 months to cover 2 treatments per year. See page 40.
Benefits for dental diagnostic and preventive services changed. See page 40.
For certain age groups, women may now access additional routine mammograms. See page 18.
Pennsylvania, Code KL. Your share of the Standard Option non-postal premium will increase by 4.1% for Self Only
and increase by 3.8% for Self and Family. Your share of the High Option non-postal premium will increase by 0.7%
for Self Only and decrease by 8.3% for Self and Family.

Pennsylvania, Code SU. Your share of the Standard Option non-postal premium will increase by 9.1% for Self Only
and increase by 4.2% for Self and Family. Your share of the High Option non-postal premium will decrease by 1.9%
for Self Only and decrease by 0.5% for Self and Family.

New Jersey, Code P3. Your share of the Standard Option non-postal premium will increase by 34.2% for Self Only
and increase by 32.3% for Self and Family. Your share of the High Option non-postal premium will decrease by
13.9% for Self Only and decrease by 3% for Self and Family.

Delaware, Code SU. Your share of the Standard Option non-postal premium will increase by 9.1% for Self Only and
increase by 4.2% for Self and Family. Your share of the High Option non-postal premium will decrease by 1.9% for
Self Only and increase by 0.5% for Self and Family.

Maryland, Washington DC and Northern Virginia, Code JN. Your share of the Standard Option non-postal premium
will increase by 11.4% for Self Only and increase by 11.1% for Self and Family. Your share of the High Option non-postal
premium will decrease by 2.8% for Self Only and decrease by 11.5% for Self and Family. 11
11 Page 12 13
2001 Aetna U. S. Healthcare HMO 12 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you

receive services from a Plan provider, or fill a prescription at a Plan
pharmacy. Until you receive your ID card, use your copy of the Health
Benefits Election Form, SF-2809, your health benefits enrollment
confirmation (for annuitants), or your Employee Express confirmation
letter.

If you do not receive your ID card within 30 days after the effective date of
your enrollment, or if you need replacement cards, call us at 1-800-537-9384.

Where you get covered care You get covered care from "Plan providers" and "Plan facilities." You will only pay copayments or coinsurance, and you will not have to file claims.
Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our
members. We credential Plan providers according to national standards.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website at www. aetnaushc. com/ feds.

Plan facilities Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these

facilities in the provider directory, which we update periodically. The list is
also on our website at www. aetnaushc. com/ feds.

What you must do
to get covered care It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since

your primary care physician provides or arranges for most of your health
care. You must select a Plan provider who is located in your service area as
defined by your enrollment code.

Primary care Your primary care physician can be a general practitioner, family practitioner, internist or pediatrician. Your primary care physician will

provide or coordinate most of your health care, or give you a referral to see
a specialist.

If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us or visit our website. We will change your
primary care physician to a newly-selected primary care physician.

Specialty care Your primary care physician will refer you to a specialist for needed care. However, you may see any Plan gynecologist for a routine well-woman

exam, including a pap smear (if appropriate) and an unlimited number of
visits for gynecological problems and follow-up care as described in your
benefit plan without a referral. You may also see a Plan mental health
provider, Plan vision specialist or a Plan dentist without a referral. 12
12 Page 13 14
2001 Aetna U. S. Healthcare HMO 13 Section 3
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop

a treatment plan that allows you to see your specialist for a certain
number of visits without additional referrals. Your primary care
physician will use our criteria when creating your treatment plan (the
physician may have to get an authorization or approval beforehand).

If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what

treatment you need. If he or she decides to refer you to a specialist, ask
if you can see your current specialist. If your current specialist does not
participate with us, you must receive treatment from a specialist who
does. Generally, we will not pay for you to see a specialist who does
not participate with our Plan.

If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another

specialist. You may receive services from your current specialist until
we can make arrangements for you to see someone else.

If you have a chronic or disabling condition and lose access to your specialist because we:

terminate our contract with your specialist for other than cause; or drop out of the Federal Employees Health Benefits (FEHB) Program
and you enroll in another FEHB Plan; or
reduce our service area and you enroll in another FEHB Plan,

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

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

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise covered care. This includes admission

to a skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our
customer service department immediately at 1-800-537-9384. If you are
new to the FEHB Program, we will arrange for you to receive care.

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

You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the hospital benefit of the hospitalized
person. 13
13 Page 14 15
2001 Aetna U. S. Healthcare HMO 14 Section 3
Circumstances beyond
our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In

that case, we will make all reasonable efforts to provide you with the
necessary care.

Services requiring our
prior approval Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain approval from

us. Before giving approval, we consider if the service is covered, medically
necessary, and follows generally accepted medical practice.

We call this review and approval process precertification. Your Plan
physician must obtain approval for certain services such as hospitalization
or outpatient surgery and the following services:

For artificial insemination you must contact the Infertility Case Manager at 1-800-575-5999;
For surgical treatment of morbid obesity;
For ambulance transportation service;
For covered transplant surgery from the Plan's medical director;
When full-time skilled nursing care is necessary in an extended care facility;

You must obtain precertification from your primary care doctor and Aetna U. S. Healthcare for covered follow-up care with a
nonparticipating provider;
You must contact Customer Service at 1-800-537-9384 for information on precertification before you have mental health and substance abuse

services; and
For certain drugs before they can be prescribed. 14
14 Page 15 16
2001 Aetna U. S. Healthcare HMO 15 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider when you receive services.

Example: Under the High Option, when you see your primary care
physician you pay a copayment of $10 per office visit or $15 per office
visit when you see a Plan specialist. Under the Standard Option, you pay
$15 for a primary care physician office visit, $20 per office visit for a Plan
specialist and a $50 copay per outpatient surgical visit. When you go in the
hospital, you pay a $240 copay per admission under the Standard Option,
you pay nothing under the High Option.

Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.

Example: In our Plan, you pay 50% of charges for drugs to treat sexual
dysfunction.

Your out-of-pocket maximum After your copayments and coinsurance total $1,500 per person or $3,000 per family enrollment in any calendar year, you do not have to pay any
more for covered services. However, copayments and coinsurance for the
following services do not count toward your out-of-pocket maximum, and
you must continue to pay copayments and coinsurance for these services:

Prescription drugs
Dental services
Be sure to keep accurate records of your copayments and coinsurance since
you are responsible for informing us when you reach the maximum. 15
15 Page 16 17
2001 Aetna U. S. Healthcare HMO 16 Section 5
Section 5. Benefits OVERVIEW
(See page 10 for how our benefits changed this year and page 65 for a benefits summary.) NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at

the beginning of each subsection. Also, read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. For more information about our benefits, contact us at 1-800-537-9384 or at our website at
www. aetnaushc. com/ feds.

(a) Medical services and supplies provided by physicians and other health care professionals.................................... 17
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests

Preventive care, adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Rehabilitative therapies

Hearing services (testing, treatment, and supplies)
Vision services (testing, treatment, and supplies)
Foot care Orthopedic and prosthetic devices
Durable medical equipment (DME) Home health services
Alternative treatments Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals ................................ 25
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants

Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services ............................................................... 28
Inpatient hospital Outpatient hospital or ambulatory

surgical center
Extended care benefits/ skilled nursing care facility benefits
Hospice care Ambulance

(d) Emergency services/ accidents..................................................................................................................................... 31
Medical emergency Ambulance

(e) Mental health and substance abuse benefits ............................................................................................................... 34
(f) Prescription drug benefits............................................................................................................................................ 36
(g) Special features ............................................................................................................................................................ 39
Services for deaf and hearing-impaired ............................................................................................................... 39

Reciprocity ............................................................................................................................................................ 39
High-risk pregnancies ........................................................................................................................................... 39
Centers for excellence for transplants/ surgery etc............................................................................................... 39
(h) Dental benefits ............................................................................................................................................................. 40
(i) Non-FEHB benefits available to Plan members......................................................................................................... 44
Summary of benefits ........................................................................................................................................................... 65 16
16 Page 17 18
2001 Aetna U. S. Healthcare HMO 17 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and
exclusions in this brochure and are payable only when we determine they are
medically necessary.

Plan physicians must provide or arrange your covered care.
Be sure to read Section 4, Your costs for covered services for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other coverage, including with Medicare.

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Benefit Description You pay
Diagnostic and treatment services Standard Option High Option
Professional services of physicians
In physician's office
Office medical consultations
Second surgical opinion
Initial examination of a newborn child covered under a family enrollment

$15 per primary
care physician
visit
$20 per specialist
visit

$10 per primary
care physician
visit
$15 per specialist
visit

Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing facility

$15 per PCP visit
$20 per specialist
visit

$10 per PCP visit
$15 per specialist
visit

At home $20 per PCP visit
$25 per specialist
visit

$15 per PCP visit
$20 per specialist
visit

At home visits by nurses and health aides Nothing Nothing
Lab, X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing if you
receive these
services during
your office visit;
otherwise, $15
per PCP visit
$20 per specialist
visit

Nothing if you
receive these
services during
your office visit;
otherwise, $10
per PCP visit
$15 per specialist
visit 17
17 Page 18 19
2001 Aetna U. S. Healthcare HMO 18 Section 5( a)
Preventive care, adult You Pay Standard Option You Pay High Option
Routine screenings, such as:
Blood lead level One annually
Total Blood Cholesterol once every three years, ages 19 through 64

Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening every five years starting at age 50

$15 per PCP visit
$20 per specialist
visit

$10 per PCP visit
$15 per specialist
visit

Prostate Specific Antigen (PSA test) one annually for men
age 40 and older
$15 per PCP visit
$20 per specialist
visit

$10 per PCP visit
$15 per specialist
visit

Routine pap test
NOTE: Nothing for the pap test if performed on the same
day as the office visit.

$15 per PCP visit
$20 per specialist
visit

$10 per PCP visit
$15 per specialist
visit

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

From age 35 through 39, one during this five year period
From age 40 through 64, one every calendar year
At age 65 and older, one every two consecutive calendar years

$15 per PCP visit
$20 per specialist
visit

$10 per PCP visit
$15 per specialist
visit

Routine immunizations and boosters Nothing if provided during
the office visit.
Nothing if
provided during
the office visit.

Not covered:
Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or

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

All charges All charges 18
18 Page 19 20
2001 Aetna U. S. Healthcare HMO 19 Section 5( a)
Preventive care, children You Pay Standard Option You Pay High Option
Childhood immunizations recommended by the American Academy of Pediatrics Nothing if provided during
the office visit.
Nothing if
provided during
the office visit.

Examinations, such as:
Eye exams through age 17 to determine the need for vision correction.

Ear exams through age 17 to determine the need for hearing correction
Examinations done on the day of immunizations (through age 22)
Well-child visits for routine examinations, immunizations and care (through age 22)

$15 per PCP visit
$20 per specialist
visit

$10 per PCP visit
$15 per specialist
visit

Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care

NOTE: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see below for other circumstances, such as extended stays for

you or your baby.
You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery.

We will cover an extended inpatient stay if your
Physician determines it is medically necessary.

We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We

will cover other care of an infant who requires non-routine
treatment only if we cover the infant under a Self
and Family enrollment.

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

(Section 5c) and Surgery benefits (Section 5b).

$15 for the first
PCP office visit
only or $20 for
the first specialist
visit only

$10 for the first
PCP office visit
only or $15 for
the first specialist
visit only

Not covered: Routine sonograms to determine fetal age, size
or sex
All charges All charges 19
19 Page 20 21
2001 Aetna U. S. Healthcare HMO 20 Section 5( a)
Family planning You Pay Standard Option You Pay High Option
Voluntary sterilization
Surgically implanted contraceptives
Injectable contraceptive drugs
Intrauterine devices (IUDs)

$20 per specialist
visit
$15 per specialist
visit

Not covered: reversal of voluntary surgical sterilization,
genetic counseling,
All charges All charges

Infertility services
Diagnosis and treatment of infertility, such as:
Artificial insemination:
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
NOTE: Coverage is for 6 cycles. Artificial insemination must
be authorized. You must contact the Infertility Case Manager
at 1-800-575-5999. You must use our select network of Plan
infertility providers.

Fertility drugs
NOTE: We cover oral fertility drugs under the prescription
drug benefit. Injectable fertility drugs are not covered.

$20 per specialist
visit
$15 per specialist
visit

Not covered:
Reversal of voluntary, surgically-induced sterility.

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

Infertility treatment when the FSH level is greater than 19 mIU/ ml.
The purchase, freezing and storage of donor sperm and donor embryos.
Assisted reproductive technology (ART) procedures not shown, such as in vitro fertilization and embryo transfer
including, but not limited to, GIFT and ZIFT.

All charges All charges

Allergy care
Testing and treatment
Allergy injection
$15 per PCP visit
$20 per specialist
visit

$10 per PCP visit
$15 per specialist
visit

Allergy serum Nothing Nothing 20
20 Page 21 22
2001 Aetna U. S. Healthcare HMO 21 Section 5( a)
Treatment therapies You Pay Standard Option You Pay High Option
Chemotherapy and radiation therapy
NOTE: High dose chemotherapy in association with
autologous bone marrow transplants are limited to those
transplants listed under Organ/ Tissue Transplants on page 27.

Respiratory and inhalation therapy
Dialysis Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy

Growth hormone therapy (GHT)

$20 per specialist
visit
$15 per specialist
visit

Rehabilitative therapies
Physical therapy, occupational therapy, speech therapy and
pulmonary therapy

Two consecutive months per condition, beginning with the first day of treatment for each of the following:

Qualified physical therapies
Speech therapies
Occupational therapy
Pulmonary rehabilitation

NOTE: We only cover speech therapy for certain speech
impairments of organic origin. Occupational therapy is
limited to services that assist the member to achieve and
maintain self-care and improved functioning in other
activities of daily living.

Inpatient rehabilitation is covered under
Hospital/ Extended Care Benefits.

Cardiac rehabilitation following angioplasty, cardiovascular surgery, congestive heart failure or a

myocardial infarction is provided for up to 3 visits a week
for a total of 18 visits.

Physical therapy to treat temporomandibular joint (TMJ) dysfunction syndrome

$20 per specialist
visit
$15 per specialist
visit

Not covered:
Long-term rehabilitative therapy
All charges All charges 21
21 Page 22 23
2001 Aetna U. S. Healthcare HMO 22 Section 5( a)
Hearing services (testing, treatment, and supplies) You Pay Standard Option You Pay High Option
Hearing testing for children through age 17 (see Preventive care, children) $15 per PCP visit $20 per specialist
visit
$10 per PCP visit
$15 per specialist
visit

Not covered:
All other hearing testing
Hearing aids, testing and examinations for them

All charges All charges

Vision services (testing, treatment, and supplies)
Treatment of eye diseases and injury
Routine eye refraction based on the following schedule:
If member wears eyeglasses or contact lenses:
Age 1 through 18 once every 12-month period
Age 19 and over once every 24-month period
If member does not wear eyeglasses or contact lenses:
To age 45 once every 36-month period

Age 45 and over once every 24-month period refractions

$20 per specialist
visit
$15 per specialist
visit

Corrective eyeglasses and frames or contact lenses (hard or soft) All charges over $100 in a
24-month period
All charges
over $100 in a
24-month period

Not covered:
Fitting of contact lenses
Eye exercises
Radial keratotomy and other refractive surgery

All charges All charges

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

See orthopedic and prosthetic devices for information on
podiatric shoe inserts.

$15 per PCP visit
$20 per specialist
visit

$10 per PCP visit
$15 per specialist
visit

Not covered:
Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of

conditions of the foot, except as stated above
Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of

the foot (unless the treatment is by open cutting surgery)
Foot orthotics

All charges All charges 22
22 Page 23 24
2001 Aetna U. S. Healthcare HMO 23 Section 5( a)
Orthopedic and prosthetic devices You Pay Standard Option You Pay High Option
External prosthetic devices which replace all or part of an internal or external body organ or an external part.
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy,
orthopedic devices such as braces and prosthetic devices
such as artificial limbs.

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, defibrillators, surgically

implanted breast implants following mastectomy, and
lenses following cataract removal.

NOTE: Coverage includes repair and replacement when due to
growth or normal wear and tear.

See 5( b) for coverage of the surgery to insert the device.

Nothing Nothing

Durable medical equipment (DME)
Rental or purchase, including replacement, repair and
adjustment, of durable medical equipment prescribed by your
Plan Physician, such as hospital beds and wheelchairs.
Coverage is determined in accordance with Medicare
guidelines

Nothing Nothing

Home health services
Home health care ordered by a Plan Physician and provided by nurses and home health aides. Your Plan
Physician will periodically review the program for
continuing appropriateness and need.

Services include oxygen therapy, intravenous therapy and medications.

Nothing Nothing

Not covered:
Homemaker services, respite care, services that may be provided in a less costly setting such as a skilled nursing

facility

All charges All charges

Alternative treatments
Chiropractic services up to 20 visits per calendar year $15 per PCP visit
$20 per specialist
visit

$10 per PCP visit
$15 per specialist
visit

Not covered: Any services not listed above All charges All charges 23
23 Page 24 25
2001 Aetna U. S. Healthcare HMO 24 Section 5( a)
Educational classes and programs You Pay Standard Option You Pay High Option
Our L'il Appleseed (r) Program provides risk screening and
assistance for all pregnant members. We also offer special
benefits, such as educational literature about pregnancy and
childbirth, $40 reimbursement for attending prenatal classes,
nurse visits, and discounts on baby products.

Also see the Non-FEHB page for our Member Health
Education, Informed Health Line and Intelihealth.

Nothing Nothing 24
24 Page 25 26
2001 Aetna U. S. Healthcare HMO 25 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
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T

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are

medically necessary.
Plan physicians must provide or arrange covered care.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about

coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section (c) for changes

associated with the facility (i. e. hospital, surgical center, etc.)
Y O U MU ST G ET P RECERTI F I CA TI O N FO R S U RG I CA L P RO CED U RES .

I M
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Benefit Description You pay
Surgical procedures Standard Option High Option
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedure
Biopsy procedure
Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery)

Surgical treatment of morbid obesity a condition in which an individual weighs 100 pounds or 100% over his or her
normal weight according to current underwriting standards;
eligible members must be age 18 or over. This procedure
must be approved in advance by HMO.

Insertion of internal prosthetic devices. See 5( a) Orthopedic braces and prosthetic devices for device

coverage information.
Voluntary sterilization
Norplant (a surgically implanted contraceptive) and intrauterine devices (IUDs) NOTE: Devices are covered

under 5( a).
Treatment of burns

$20 per specialist
visit
$15 per specialist
visit

Not covered:
Reversal of voluntary surgically-induced sterilization
Surgery primarily for cosmetic purposes
Refractive eye surgery, such as radial keratotomy
Blood and blood derivatives, except blood derived clotting factors, and the storage of the patient's own blood for

later administration

All charges All charges 25
25 Page 26 27
2001 Aetna U. S. Healthcare HMO 26 Section 5( b)
Reconstructive surgery You Pay Standard Option You Pay High Option
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the member's appearance and

the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or
norm. Examples of congenital anomalies are: protruding
ear deformities; cleft lip; cleft palate; birth marks; webbed
fingers; and webbed toes.

All stages of breast reconstruction surgery following a mastectomy, such as:

surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas;
breast prostheses and surgical bras and replacements (see Prosthetic devices)
NOTE: If you need a mastectomy, you may choose to have
the procedure performed on an inpatient basis and remain in
the hospital up to 48 hours after the procedure.

$20 per specialist
visit
$15 per specialist
visit

Not covered:
Cosmetic surgery any surgical procedure (or any portion of a procedure) performed primarily to improve

physical appearance through change in bodily form,
except repair of accidental injury

Surgeries related to sex transformation

All charges All charges

Oral and maxillofacial surgery
Oral surgical procedures, such as:
Treatment of fractures of the jaws or facial bones;
Surgical correction of congenital defects, such as cleft lip and cleft palate;

Removal of stones from salivary ducts;
Exclusion of leukoplakia or malignancies;
Removal of bony impacted wisdom teeth;
Excision of tumors and cysts
Other surgical procedures that do not involve the teeth or their supporting structures.

$20 per specialist
visit
$15 per specialist
visit

Not covered:
Dental implants
Dental care involved with the treatment of temporomandibular joint dysfunction

All charges All charges 26
26 Page 27 28
2001 Aetna U. S. Healthcare HMO 27 Section 5( b)
Organ/ tissue transplants You Pay Standard Option You Pay High Option
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Liver
Lung: Single Double
Pancreas
Skin
Tissue
Allogeneic donor bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions:

acute lymphocytic or non-lymphocytic leukemia; advanced
Hodgkin's lymphoma; advanced non-Hodgkin's lymphoma;
advanced neuroblastoma; breast cancer; multiple myeloma;
epithelial ovarian cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ cell tumors

National Transplant Program (NTP) Transplants which are non-experimental or non-investigational are a covered

benefit. Covered transplants must be ordered by your Primary
Care Physician and specialist physician and approved by our
medical director in advance of the surgery. The transplant
must be performed at hospitals specifically approved and
designated by us to perform these procedures. A transplant
is non-experimental and non-investigational when we have
deter-mined, in our sole discretion, that the medical
community has generally accepted the procedure as
appropriate treatment for your specific condition. Coverage
for a transplant where you are the recipient includes coverage
for the medical and surgical expenses of a live donor to the
extent these services are not covered by another plan or
program.

NOTE: We cover related medical and hospital expenses of
the donor when we cover the recipient.

$20 per specialist
office visit and
nothing for the
surgery

$15 per specialist
office visit and
nothing for the
surgery

Not covered:
Transplants not listed as covered
All charges All charges

Anesthesia
Professional services provided in
Hospital (inpatient)
Nothing Nothing

Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office

$20 per specialist
visit
$15 per specialist
visit 27
27 Page 28 29
2001 Aetna U. S. Healthcare HMO 28 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
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Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine

they are medically necessary.
Plan physicians must provide or arrange your covered care and you must be hospitalized in a Plan facility.

Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by the facility (i. e., hospital or surgical center) or ambulance service for your surgery or

covered care. Any costs associated with the professional charge (i. e.,
physicians, etc.) are covered in Section 5( a) or (b).

YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS

I M
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Benefit Description You pay
Inpatient hospital Standard Option High Option
Room and board, such as
Ward, semiprivate, or intensive care accommodations;
General nursing care; and
Meals and special diets.

NOTE: If you want a private room when it is not medically
necessary, you pay the additional charge above the
semiprivate room rate.

$240 per
admission
Nothing

Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
The withdrawal, processing and storage of the patient's own blood for later administration, and the administration

of this blood to the patient
Serum, clotting factors and immunoglobulins
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Take-home items
Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

Nothing Nothing

Inpatient hospital Continued on the next page 28
28 Page 29 30
2001 Aetna U. S. Healthcare HMO 29 Section 5( c)
Inpatient hospital (Continued) You Pay Standard Option You Pay High Option
Not covered:
Custodial care, rest cures, domiciliary or convalescent cares
Personal comfort items, such as telephone and, television

All charges All charges

Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services

Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service

NOTE: We cover hospital services and supplies related to
dental procedures when necessitated by a non-dental physical
impairment. We do not cover the dental procedures.

$50 outpatient
surgery copay
Nothing

Not covered: Blood and blood derivatives, except blood
clotting factors and the patient's own blood for later
administration

All charges All charges

Extended care benefits/ skilled nursing care facility benefits
Extended care benefit: All necessary services during
confinement in an skilled nursing facility with no dollar or day
limit when full-time nursing care is necessary and the
confinement is medically appropriate as determined by a Plan
doctor and approved by the Plan.

Nothing Nothing

Not covered: custodial care All charges All charges
Hospice care
Supportive and palliative care for a terminally ill member in
the home or hospice facility, including inpatient and
outpatient care and family counseling, when provided under
the direction of a Plan doctor, who certifies the patient is in
the terminal stages of illness, with a life expectancy of
approximately 6 months or less.

Nothing Nothing 29
29 Page 30 31
2001 Aetna U. S. Healthcare HMO 30 Section 5( c)
Ambulance You Pay Standard Option You Pay High Option
Ambulance service ordered or authorized by a Plan doctor. See Section 5( d) Emergency Care for more
details.
Nothing Nothing

Not covered: Ambulance services for routine transportation
to receive outpatient or inpatient services.
All charges All charges 30
30 Page 31 32
2001 Aetna U. S. Healthcare HMO 31 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
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A N
T

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure.

Be sure to read Section 4, Your costs for covered services for valuable
information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.

I M
P O
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A N
T

What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe
endangers your life or could result in serious injury or disability, and requires immediate medical or surgical
care. Some problems are emergencies because, if not treated promptly, they might become more serious;
examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening,
such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There
are many other acute conditions that we may determine are medical emergencies what they all have in
common is the need for quick action.

What to do in case of emergency:
If you need emergency care, you are covered 24 hours a day, 7 days a week, anywhere in the world. An
emergency medical condition is one manifesting itself by acute symptoms of sufficient severity such that a
prudent layperson, who possesses average knowledge of health and medicine, could reasonably expect the
absence of immediate medical attention to result in serious jeopardy to the person's health, or with respect to a
pregnant woman, the health of the woman and her unborn child.

Whether you are in or out of an Aetna U. S. Healthcare HMO service area, we simply ask that you follow the
guidelines below when you believe you need emergency care.

Call the local emergency hotline (ex. 911) or go to the nearest emergency facility. If a delay would not be detrimental to your health, call your primary care provider. Notify your primary care provider as soon as

possible after receiving treatment.
After assessing and stabilizing your condition, the emergency facility should contact your primary care physician so they can assist the treating physician by supplying information about your medical history.

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

What to Do Outside Your Aetna U. S. Healthcare HMO Service Area
Members who are traveling outside their HMO service area or students who are away at school are covered
for emergency and urgently needed care. Urgent care may be obtained from a private practice physician, a
walk-in clinic, an urgent care center or an emergency facility. Certain conditions, such as severe vomiting,
earaches, sore throats or fever, are considered "urgent care" outside your Aetna U. S. Healthcare HMO service
area and are covered in any of the above settings.

If, after reviewing information submitted to us by the provider that supplied care, the nature of the urgent or
emergency problem does not qualify for coverage, it may be necessary to provide us with additional
information. We will send you an Emergency Room Notification Report to complete, or a Member Services
representative can take this information by telephone. 31
31 Page 32 33
2001 Aetna U. S. Healthcare HMO 32 Section 5( d)
Follow-up Care after Emergencies All follow-up care should be coordinated by your PCP. Follow-up care with nonparticipating providers is only
covered with a referral from your primary care physician and pre-approval from Aetna U. S. Healthcare. Whether
you were treated inside or outside your Aetna U. S. Healthcare service area, you must obtain a referral before any
follow-up care can be covered. Suture removal, cast removal, X-rays and clinic and emergency room revisits are
some examples of follow-up care.

What to do in case of emergency:
Emergencies within our service area: If you are in an emergency situation, call you primary care doctor. In extreme emergencies or if you are unable to contact your doctor, contact the local emergency system (e. g. the

911 telephone system) or go to the nearest hospital emergency room. Be sure to tell the emergency room
personnel that you are a Plan member so they can notify your primary care doctor. You or a family member must
notify your primary care doctor as soon as possible after receiving emergency care. It is your responsibility to
ensure that your primary care doctor has been timely notified.

If you need to be hospitalized, the Plan must be notified as soon as possible. If you are hospitalized in non-Plan
facilities and a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when
medically feasible with any ambulance charges covered in full.

To be covered by this Plan, any follow-up care recommended by non-participating providers must be approved by
us or provided by plan providers.

Emergencies outside our service area: Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.

If you need to be hospitalized, the Plan must be notified as soon as possible. If a Plan doctor believes care can be
better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges
covered in full.

To be covered by this Plan, any follow-up care recommended by non-participating providers must be approved by
us or provided by plan providers.

Benefit Description You pay
Emergency within our service area Standard Option High Option
Emergency care at a doctor's office $15 per PCP visit $20 per specialist
visit
$10 per PCP visit
$15 per specialist
visit

Emergency care as an outpatient in a hospital or an urgent care center

NOTE: If the emergency results in admission to a hospital,
the copay is waived.

$35 per visit $35 per visit

Not covered: Elective care or non-emergency care All charges All charges 32
32 Page 33 34
2001 Aetna U. S. Healthcare HMO 33 Section 5( d)
Emergency outside our service area Standard Option High Option
Emergency care at a doctor's office $15 per PCP visit $20 per specialist
visit
$10 per PCP visit
$15 per specialist
visit

Emergency care as an outpatient in a hospital or an urgent care center

NOTE: If the emergency results in admission to a hospital,
the copay is waived.

$35 per visit $35 per visit

Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the

service area
Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area exclusion

All charges All charges

Ambulance
Professional ambulance service when medically appropriate.
See 5( c) for non-emergency service.
Nothing Nothing

Not covered: air ambulance All charges All charges 33
33 Page 34 35
2001 Aetna U. S. Healthcare HMO 34 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
Network Benefit

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Parity
Beginning in 2001, all FEHB plans' mental health and substance abuse benefits will
achieve "parity" with other benefits. This means that we will provide mental health
and substance abuse benefits differently than in the past.

When you get our approval for services and follow a treatment plan we approve,
cost-sharing and limitations for participating mental health and substance abuse
benefits will be no greater than for similar benefits for other illnesses and conditions.

Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in this brochure.

Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

I M
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Description You pay
Mental health and substance abuse
benefits Standard Option High Option

Diagnostic and treatment services recommended
by a Plan provider and contained in a treatment
plan that we approve. The treatment plan may
include services, drugs, and supplies described
elsewhere in this brochure.

NOTE: Plan benefits are payable only when we
determine the care is clinically appropriate to treat
your condition and only when you receive the
care as part of a treatment plan that we approve.

Your cost sharing
responsibilities are
no greater than for
other illness or
conditions.

Same as Standard
Option

Professional services, including individual or group therapy by providers such as
psychiatrists, psychologists, or clinical social
workers

Medication management

$20 per visit $15 per visit

Diagnostic tests $20 per visit $15 per visit
Services provided by a hospital or other facility

Services in approved alternative care settings such as partial hospitalization, residential
treatment, full-day hospitalization, facility
based intensive outpatient treatment.

$240 per admission Nothing

Mental health and substance abuse benefits Continued on the next page 34
34 Page 35 36
2001 Aetna U. S. Healthcare HMO 35 Section 5( e)
Mental health and substance abuse benefits (Continued) You Pay Standard Option You Pay High Option
Not covered:
Services we have not approved.
Out of Network mental health and substance abuse services.

NOTE: OPM will base its review of disputes
about treatment plans on the treatment plan's
clinical appropriateness. OPM will generally not
order us to pay or provide one clinically
appropriate treatment plan in favor of another.

All charges All charges

Preauthorization To be eligible to receive these benefits you must follow your treatment plan and all the following authorization processes:
Contact Customer Services at 1-800-537-9384 to identify providers and
obtain information on the referral process.

Special transitional benefit If a mental health or substance abuse professional provider is treating you under our plan as of January 1, 2001, you will be eligible for continued
coverage with your provider for up to 90 days under the following
conditions:

If your mental health or substance abuse professional provider with whom you are currently in treatment leaves the plan at our request for

other than cause.
If this condition applies to you, we will allow you reasonable time to
transfer your care to a participating mental health or substance abuse
professional provider. During the transitional period, you may continue to
see your treating provider and will not pay any more out-of-pocket than
you did in the year 2000 for services. This transitional period will begin
with our notice to you of the change in coverage and will end 90 days
after you receive our notice. If we write to you before October 1, 2000,
the 90-day period ends before January 1 and this transitional benefit does
not apply.

Network limitation We may limit your benefits if you do not follow your treatment plan.
How to submit network claims Mail your itemized bills to Aetna U. S. Healthcare, P. O. Box 1125, Blue Bell, PA 19422. 35
35 Page 36 37
2001 Aetna U. S. Healthcare HMO 36 Section 5( f)
Section 5 (f). Prescription drug benefits
I
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T
A
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T

Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.

All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are a medically
necessary.
Certain drugs require your doctor to get precertification from the Plan before they can be prescribed under the Plan. Upon approval by the Plan, the

prescription is good for the current calendar year or a specified time period,
whichever is less.

Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about

coordinating benefits with other coverage, including with Medicare.

I
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There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician or dentist must write the prescription.
Where you can obtain them. You must fill non-emergency prescriptions at a Plan pharmacy for up to a 30-day supply, or by mail for a 31-90 day supply of medication (if authorized by your physician). Please

call Member Services at 1-800-537-9384 for more details on how to use the mail order program. In an
emergency or urgent care situation, you may fill your covered prescription at any retail pharmacy. If you
obtain your prescription at a pharmacy that does not participate with the plan, you will need to pay the
pharmacy the full price of the prescription and submit a claim for reimbursement subject to the terms and
conditions of the plan.

We use a formulary. Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary. The Plan's formulary does not exclude medications from coverage, but requires a higher

copayment for nonformulary drugs. Nonformulary drugs will be covered when prescribed by a Plan
doctor. Certain drugs require your doctor to get precertification from the Plan before they can be
prescribed under the Plan. Visit our website at www. aetnaushc. com/ feds to review our Formulary Guide
or call 1-800-537-9384.

Precertification. Your pharmacy benefits plan includes our precertification program. Precertification helps encourage the appropriate and cost-effective use of certain drugs. These drugs must be pre-authorized by

our Pharmacy Management Precertification Unit before they will be covered. Only your physician or
pharmacist in the case of an antibiotic or analgesic can request prior authorization for a drug.

The precertification program is based upon current medical findings, manufacturer labeling, FDA
guidelines and cost information.

The drugs requiring precertification are subject to change. Visit our website for the current Precertification
List.

These are the dispensing limitations. Covered prescription drugs prescribed by a licensed physician or dentist and obtained at a Participating Plan Pharmacy may be dispensed for up to a 30-day supply.

Members must obtain a 31-to 90-day supply of covered prescription of covered prescription
medication through mail order.

When you have to file a claim. Send your itemized bill( s) to: Aetna U. S. Healthcare, P. O. Box 1125, Blue Bell, PA 19422.

Prescription drug benefits Begin on the next page. 36
36 Page 37 38
2001 Aetna U. S. Healthcare HMO 37 Section 5( f)
Benefit Description You pay
Covered medications and supplies Standard Option High Option
We cover the following medications and supplies prescribed
by the physician or dentist and obtained from a Plan or
through our mail order program:

Drugs for which a prescription is required by Federal law.
Oral contraceptive drugs.
Insulin
Disposable needles and syringes needed to inject covered prescribed medication, including insulin.

Diabetic supplies limited to lancets, alcohol swabs, urine test strips/ tablets, and blood glucose test strips
Oral fertility drugs
Nutritional formulas for the treatment of phenylketonuria, branched-chain ketonuria, galectosemia, and

homocystinuria when administered under the direction of
a Plan doctor.

Intravenous fluids and medications for home use, implantable drugs, such as Norplant, IUDs, and some

injectable drugs are covered. See Section 5A for details.

Limited benefits
Drugs to treat sexual dysfunction are limited. Contact the Plan for dose limits.

Depo Provera is limited to 5 vials per calendar year.
One diaphragm per calendar year

$10 per covered
generic formulary
prescription/ refill
(up to a 30 day
supply) or $20 for
a 31-to 90-day
supply through
mail order

$15 per covered
brand name
formulary
prescription/ refill
(up to a 30 day
supply) or $30 for
a 31-to 90-day
supply through
mail order

$30 per covered
non-formulary
(generic or brand)
prescription/ refill
(up to a 30 day
supply) or $60 for
a 31-to 90-day
supply through
mail order

50%
$15 copay per vial
$15 per diaphragm

$5 per covered
generic formulary
prescription/ refill
(up to a 30 day
supply) or $10 for
a 31-to 90-day
supply through
mail order

$10 per covered
brand name
formulary
prescription/ refill
(up to a 30 day
supply) or $20 for
a 31-to 90-day
supply through
mail order

$25 per covered
non-formulary
(generic or brand)
prescription/ refill
(up to a 30 day
supply) or $50 for
a 31-to 90-day
supply through
mail order

50%
$10 copay per vial
$10 per diaphragm

Covered medications and supplies Continued on the next page 37
37 Page 38 39
2001 Aetna U. S. Healthcare HMO 38 Section 5( f)
Covered medications and supplies (Continued) You Pay Standard Option You Pay High Option
Here are some things to keep in mind about our prescription
drug program:

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

To request a copy of the Aetna U. S. Healthcare Medication Formulary Guide, call 1-800-537-9384 or
visit out website at www. aetnaushc. com/ feds.

Not covered:
Drugs available without a prescription or for which there is a nonprescription equivalent available, (i. e., an over-the-counter

(OTC) drug)
Drugs obtained at a non-Plan pharmacy, except when related to out-of-area emergency care

Vitamins and nutritional substances that can be purchased without prescription.
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance.
Smoking-cessation drugs and medication, including, but not limited to, nicotine patches and sprays.

Injectable fertility drugs
Drugs used for the purpose of weight reduction (i. e., appetite suppressants).

All charges All charges 38
38 Page 39 40
2001 Aetna U. S. Healthcare HMO 39 Section 5( g)
Section 5 (g). Special Features
Feature Description
Services for the deaf and
hearing-impaired

1-800-628-3323

Reciprocity benefit If you need to visit a participating primary care physician for a covered service, and you are 50 mile or more away from home you may visit a
primary care physician from our Plan's approved network.
Call 1-800-537-9384 for provider information and location
Select a doctor from 3 primary care doctors in that area
The Plan will authorize you for one visit and any tests or X-rays ordered by that primary care physician.

You must coordinate all subsequent visits through your own participating care physician.

High risk pregnancies Our L'il Appleseed (r) Program provides risk screening and assistance for all pregnant members. We also offer special benefits, such as educational
literature about pregnancy and childbirth, $40 reimbursement for
attending prenatal classes, nurse visits, and discounts on baby products.

Centers of excellence for
transplants/ heart
surgery/ etc

Our National Medical Excellence Program (r) coordinates services for
complicated or rare illnesses and transplants. The National Medical
Excellence Program is unique to Aetna U. S. Healthcare and has been created
for members with particularly difficult conditions such as rare cancers and
other complicated diseases and disorders.

Usually, the recommended treatment can be found in your area. But if your
needs extend beyond your region, the National Medical Excellence Program
may be available to send you to out-of-area experts.

The first priority is to determine an appropriate treatment program. If your
treatment program cannot be provided in the local area, we will arrange and
pay for covered care as well as related travel expenses to wherever the
necessary care is available. Prior approval is required.

Travel benefit/ services
overseas

Our National Medical Excellence Program is a case management program
that provides consistency in the coordination of care for life threatening
and complex illnesses. This includes bone marrow and solid organ
transplants, investigational and new technology (when covered), and
unique services that are offered at a limited number of medical facilities.
We also coordinate care for members if they need covered care that is not
available in their local area and if they become ill when traveling
temporarily outside the Continental United States. 39
39 Page 40 41
2001 Aetna U. S. Healthcare HMO 40 Section 5( h)
Section 5 (h). Dental benefits
I M
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T

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are

medically necessary.
Plan dentists must provide or arrange covered care.
We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the

health of the patient; we do not cover the dental procedure unless it is described
below.

Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about

coordinating benefits with other coverage, including with Medicare.

I M
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Accidental injury benefit
No benefits other than those listed on the following schedule.

Dental Benefits
Service Standard Option You Pay High Option You Pay

Diagnostic
Office visit for oral evaluation limited to 2 visits per year
Bitewing x-rays limited to 2 sets of bitewing x-rays per year
Entire x-ray series limited to 1 entire x-ray series in any 3 year
period

Periapical x-rays and other dental x-rays as necessary
Diagnostic models

Preventive
Prophylaxis (cleaning of teeth) limited to 2 treatments per year
Topical fluoride limited to 2 courses of treatment per year and
to children under age 18

Oral hygiene instruction

Restorative (Fillings)
Amalgam (primary) 1 surface
Amalgam (primary) 2 surfaces
Amalgam (primary) 3 surfaces
Amalgam (primary) 4 surfaces
Amalgam (permanent) 1 surface
Amalgam (permanent) 2 surfaces
Amalgam (permanent) 3 surfaces
Amalgam (permanent) 4 surfaces

$5
$5

$5
$5
$5

$5
$5
$5

$5
$5
$5
$5
$5
$5
$5
$5

$5
$5

$5
$5
$5

$5
$5
$5

$5
$5
$5
$5
$5
$5
$5
$5

Dental benefits Continued on next page 40
40 Page 41 42
2001 Aetna U. S. Healthcare HMO 41 Section 5( h)
Dental Benefits (Continued)
Service Standard Option You Pay High Option You Pay

Prosthodontics Removable
Denture adjustments (complete or partial/ upper or lower)

Endodontics
Pulp cap direct
Pulp cap indirect

$5
$5
$5

$5
$5
$5

NOTE: The above services are only covered when provided
by your participating primary care dentist in accordance with
the terms of your Plan. If rendered by a participating
specialist, they are provided at reduced fees. Pediatric
dentists are considered specialists. Certain other services will
be provided by your primary care dentist at reduced fees. A
partial list appears below. Ask your primary care dentist for a
complete schedule of current reduced member fees. All
member fees must be paid directly to the participating dentist.

Each employee and dependent must select a primary care
dentist from the directory and include the dentist's name on
the enrollment or provider selection form.

The following procedures are also available from your
participating primary care dentist up to the maximum fee
shown. These same services received from a participating
specialist may require you to pay a fee that is higher than the
stated maximum. Call your participating primary care dentist
or participating dental specialist for the specific fee in your
area. 41
41 Page 42 43
2001 Aetna U. S. Healthcare HMO 42 Section 5( h)
Dental Benefits (Continued)
Service Standard Option You Pay up to

a maximum fee of
High Option
You Pay up to
a maximum fee of

Diagnostic
Sealant per permanent tooth
Space maintainer

Restorative (Fillings)
Resin (anterior) 1 surface
Resin (anterior) 2 surfaces
Resin (anterior) 3 surfaces
Resin (anterior) 4 or more surfaces or incisal angle
Metallic inlay

$ 35
$445

$ 85
$115
$140
$150
$580

$ 35
$445

$ 85
$115
$140
$150
$580

Prosthodontics, removable
Complete denture, (upper or lower)
Immediate denture (upper or lower)
Partial denture resin base (upper or lower)
Partial denture cast metal framework with resin base (upper
or lower)

Denture repairs
Add tooth to existing partial
Add clasp to existing partial
Denture rebase
Denture relines
Interim denture (complete or partial/ upper or lower)
Tissue conditioning

Prosthodontics, fixed
Bridge pontic
Metallic inlay/ onlay
Cast metal retainer for resin bonded prosthesis
Crown porcelain
Crown cast
Recement bridge
Post and core

Oral surgery
Extractions (nonsurgical and tissue impacted)
Anesthesia (general in office, first half-hour session)

$820
$885
$630
$955

$120
$105
$120
$300
$260
$370
$ 85

$685
$650
$250
$685
$690
$ 65
$250

$380
$215

$820
$885
$630
$955

$120
$105
$120
$300
$260
$370
$ 85

$685
$650
$250
$685
$690
$ 65
$250

$380
$215

Dental benefits Continued on next page 42
42 Page 43 44
2001 Aetna U. S. Healthcare HMO 43 Section 5( h)
Dental Benefits (Continued)
Service Standard Option You Pay up to

a maximum fee of
High Option
You Pay up to
a maximum fee of

Periodontics (Gum treatment)
Gingivectomy per quadrant
Gingival curretage per quadrant
Periodontal surgery
Provisional splinting
Scaling and root planing per quadrant
Periodontal maintenance procedure

Endodontics (Root canal)
Therapeutic pulpotomy
Root canals (anterior, bicuspid, molar) excluding final
restoration

Apicoectomy anterior

Orthodontics
Pre-orthodontic treatment visit
Fully banded case (adult age 19 and over)
Fully banded case (child age 18 and under)

$250
$120
$605
$125
$120
$ 85

$100
$605

$405

$280
$4,400
$4,400

$250
$120
$605
$125
$120
$ 85

$100
$605

$405

$280
$4,400
$4,400

Specific fees vary by area of the country up to the stated
maximum. Ask your primary care dentist for a complete
schedule of reduced fees.

Services not received from a participating dental provider
are not covered. We offer no other dental benefits than those
shown above.

All charges All charges 43
43 Page 44 45
2001 Aetna U. S. Healthcare HMO 44 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits and programs on this page are not part of the FEHB contract or premium, and you cannot file an FEHB
disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket
maximums.

Member Health Education With our programs, Aetna U. S. Healthcare offers special health education, preventive care and wellness programs. We
provide our members with materials that promote a healthy lifestyle and good health.
The Healthy Eating Program is an easy-to-follow approach to better health through good nutrition. It's designed to
provide members and their families with information to develop a long-term healthy eating plan that is also realistic.
Members will also understand how to reduce their risk of illness and disease, manage their weight, increase their energy
level and boost their ability to fight illness.

Our Healthy Breathing (r) Smoking-Cessation Program will help you safely quit smoking with educational materials,
phone support and discounts on over-the-counter smoking-cessation products. The member may also enroll in an eight-to-
twelve week smoking-cessation program.

Intelihealth (r) We offer InteliHealth, our affiliate website (www. intelihealth. com) that provides timely, relevant, reliable and easy-to-understand
health information online. Established in 1996, InteliHealth has received international acclaim for the
second straight year by being named the "People's Choice" in the Webby Awards health category. The Webby awards
are presented annually by the International Academy of Digital Arts and Sciences.

Vision One (r) 1 You are eligible to receive significant discounts on eyeglasses, contact lenses and nonprescription items including

sunglasses and eyewear products through the Vision One Program (1-800-793-8616) at more than 4,000 locations
across the country.

The discount enriches our routine vision care coverage provided in your health plan, which includes an eye exam from a
participating provider. If your health plan also includes coverage for eyewear such as prescription eyeglasses or contact
lenses, your out-of-pocket expenses can be reduced when you use your Vision One discount.

Informed Health (r) Line Provides eligible members with telephone access to registered nurses experienced in providing information on a variety
of health topics. Informed Health Line is available 24 hours a day, 7 days a week. You may call Informed Health Line at
1-800-556-1555, Informed health Line nurses cannot diagnose, prescribe medication or give medical advice.

Medicare Managed Care Plan Enrollment This Plan offers Medicare recipients (those enrolled only in codes P3, SU and parts of KL) the opportunity to enroll in
the Plan through Medicare. As indicated on page 51, annuitants and former spouses with FEHB coverage and Medicare
Part B may elect to drop their FEHB coverage and enroll in a Medicare managed care plan when one is available in
their area. They may then later reenroll in the FEHB Program. Most Federal annuitants have Medicare Part A. Those
without Medicare Part A may join this Medicare managed care plan but will probably have to pay for hospital coverage
in addition to the Part B premium. Before you join the plan, ask whether the plan covers hospital benefits and, if so,
what you will have to pay. Contact your retirement system for information on dropping your FEHB enrollment and
changing to a Medicare managed care plan. Contact us at 1-800-282-5366 for information on the Medicare managed
care plan and the cost of that enrollment.

If you are Medicare eligible and are interested in enrolling in a Medicare HMO sponsored by this Plan without dropping
your enrollment in this Plan's FEHB plan, call 1-800-282-5366 for information on the benefits available under the
Medicare HMO.

1 Vision One is a registered trademark of Cole Vision. 44
44 Page 45 46
2001 Aetna U. S. Healthcare HMO 45 Section 6
Section 6. General exclusions things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we
will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat
your illness, disease, injury or condition and we agree, as discussed under What Services Require Our Prior
Approval on page 14.

We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies (See Emergency Benefits);
Services, drugs or supplies that are not medically necessary;
Services not required according to accepted standards of medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Procedures, services, drugs, and supplies related to abortions except when the life of the mother would be endangered
if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest;

Procedures, services, drugs and supplies related to sex transformations;
Services or supplies you receive from a provider or facility barred from the FEHB Program; and
Expenses you incurred while you were not enrolled in this plan. 45
45 Page 46 47
2001 Aetna U. S. Healthcare HMO 46 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan
pharmacies, you will not have to file claims. Just present your identification card and pay your copayment, coinsurance,
or deductible.

You will only need to file a claim when you receive emergency services from non-Plan providers. Sometimes these
providers bill us directly. Check with the provider. If you need to file the claim, here is the process:

Medical, Hospital and
Drug benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form. Facilities

will file on the UB-92 form. For claims questions and assistance, call us
at 1-800-537-9384.

When you must file a claim such as for out-of-area care submit it on
the HCFA-1500 or a claim form that includes the information shown
below. Bills and receipts should be itemized and show:

Covered member's name and ID number;
Name and address physician or facility that provided the service or supply;

Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from any primary payer such as the Medicare Summary Notice (MSN); and

Receipts, if you paid for your services.
Submit your claims to: Aetna U. S. Healthcare, Inc., 1425 Union Meeting
Road, P. O. Box 1125, Blue Bell, PA 19422

Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received
the service, unless timely filing was prevented by administrative operations
of Government or legal incapacity, provided the claim was submitted as
soon as reasonably possible.

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 46
46 Page 47 48
2001 Aetna U. S. Healthcare HMO 47 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on
your claim or request for services, drugs, or supplies including a request for preauthorization:

Step Description

1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: Aetna U. S. Healthcare, Inc., 1425 Union Meeting Road, P. O. Box 1125, Blue
Bell, PA 19422; and

(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit
provisions in this brochure; and

(d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills,
medical records, and explanation of benefits (EOB) forms.

2 We have 30 days from the date we receive your request to: (a) Pay the claim (or if applicable arrange for the health care provider to give you the care); or
(b) Write to you and maintain our denial go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider, we will send you a copy of our
request go to step 3.

3 You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.
If we do not receive the information within 60 days, we will decide within 30 days of the date the
information was due. We will base our decision on the information we already have.

We will write to you with our decision.

4 If you do not agree with our decision, you may ask OPM to review it. You must write to OPM within:

90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us if we did not answer that request in some way within 30 days; or
120 days after we asked for additional information.

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division III,
P. O. Box 436, Washington, D. C. 20044-0436.

Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this
brochure;

Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical
records, and explanation of benefits (EOB) forms;

Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.

NOTE: If you want OPM to review different claims, you must clearly identify which documents apply to
which claim. 47
47 Page 48 49
2001 Aetna U. S. Healthcare HMO 48 Section 8
NOTE: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must provide a copy of your specific written consent with the
review request.

NOTE: The above deadlines may be extended if you show that you were unable to meet the deadline
because of reasons beyond your control.

5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no
other administrative appeals.

6 If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs or supplies. This is the only deadline that may not
be extended.
OPM may disclose the information it collects during the review process to support their disputed claim
decision. This information will become part of the court record.

You may not sue until you have completed the disputed claims process. Further, Federal law governs your
lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of
benefits in dispute.

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of
bodily functions or death if not treated as soon as possible), and a) If we haven't responded yet to you initial request for care or preauthorization/ prior approval, then call us at

1-800-537-9384 and we will expedite our review; or
b) We denied your initial request for care or preauthorization/ prior approval, then
If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim
expedited treatment too, or
You can call OPM's health Benefits Contracts Division III at 202-606-0737 between 8 a. m. and 5 p. m.
eastern time.
External Review If this Plan denied your claim for payment or services, you can ask us to reconsider your claim. If we still deny your

claim, you can seek an independent external review, before asking OPM to review it, if:
1. The amount of your claim or service is more than $500; and
2. The Plan denied your claim because it did not consider the treatment medically necessary or considered it
experimental or investigational.

The independent external review will use a neutral, independent physician with related expertise to conduct the review.
The Plan will cover the professional fee for the review and you will pay the cost to compile and send your submission
to the Plan.

To request an External Review Form call 1-800-537-9384 within 60 days after receiving the Plan's written notification
that it will uphold its original decision to deny your claim.

The external reviewer will make a decision within 30 days after you send us all the necessary information with the
External Review Request Form. Your primary care doctor can request an expedited review in cases of "clinical
urgency" where your health would be seriously jeopardized if you waited the full 30 days. In this case, the external
review organization or physician will make a decision within 72 hours.

To request a detailed description of the external review requirements, call the Plan's Member Relations Office at
1-800-537-9384. 48
48 Page 49 50
2001 Aetna U. S. Healthcare HMO 49 Section 9
Section 9. Coordinating benefits with other coverage
When you have other
health coverage You must tell us if you are covered or a family member is covered under another group health plan or have automobile insurance that pays health

care expenses without regard to fault. This is called "double coverage."

When you have double coverage, one plan normally pays its benefits in full
as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is
primary according to the National Association of Insurance
Commissioners' guidelines.

When we are the primary payer, we will pay the benefits described in this
brochure.

When we are the secondary payer, we will determine our allowance. After
the primary plan pays, we will pay what is left of our allowance, up to our
regular benefit. We will not pay more than our allowance.

What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.

Some people with disabilities, under 65 years of age.
People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).

Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A.
Part B (Medical Insurance). Most people pay monthly for Part B.
If you are eligible for Medicare, you may have choices in how you get your
health care. Medicare managed care is the term used to describe the various
health plan choices available to Medicare beneficiaries. The information in
the next few pages shows how we coordinate benefits with Medicare,
depending on the type of Medicare managed care plan you have.

The Original Medicare Plan The Original Medicare Plan is available everywhere in the United States. It is the way most people get their Medicare Part A and Part
B benefits. You may go to any doctor, specialist, or hospital that
accepts Medicare. Medicare pays its share and you pay your share.
Some things are not covered under Original Medicare, like
prescription drugs.

When you are enrolled in this Plan and Original Medicare, you still need to
follow the rules in this brochure for us to cover your care. Your must
continue to be authorized by your PCP, or precertified as required.

We will not waive any of our copayments and coinsurance.
(Primary payer chart begins on next page.) 49
49 Page 50 51
2001 Aetna U. S. Healthcare HMO 50 Section 9
The following chart illustrates whether Original Medicare or this Plan should be the primary payer for you according to
your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered
family member has Medicare coverage so we can administer these requirements correctly.

Primary Payer Chart
Then the primary payer is A. When either you or your covered spouse are age 65 or over
and Original Medicare This Plan

1) Are an active employee with the Federal government (including
when you or a family member are eligible for Medicare solely
because of a disability),

!! ! !

2) Are an annuitant, !! ! !
3) Are a reemployed annuitant with the Federal government when
a) The position is excluded from FEHB, or............................................................. .................. !! ! !

b) The position is not excluded from FEHB............................................................
Ask your employing office which of these applies to you.
....................................... ............ !! ! !

4) Are a Federal judge who retired under title 28, U. S. C., or a Tax
Court judge who retired under Section 7447 of title 26, U. S. C.
(or if your covered spouse is this type of judge),

!! ! !

5) Are enrolled in Part B only, regardless of your employment status, !! ! !
(for Part B
services)

!! ! !
(for other
services)

6) Are a former Federal employee receiving Workers' Compensation and
the Office of Workers' Compensation Programs has determined that
you are unable to return to duty,

!! ! !
(except for claims
related to Workers'
Compensation.)

B. When you or a covered family member have Medicare
based on end stage renal disease (ESRD) and

1) Are within the first 30 months of eligibility to receive Part A benefits
solely because of ESRD,
!! ! !

2) Have completed the 30-month ESRD coordination period and are still
eligible for Medicare due to ESRD,
!! ! !

3) Become eligible for Medicare due to ESRD after Medicare became
primary for you under another provision,
!! ! !

C. When you or a covered family member have FEHB and
1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or .............................................................................................. ............................. !! ! !

b) Are an active employee ........................................................................................ ....................................... ............ !! ! !
Please note, if your Plan physician does not participate in Medicare, you will have to file a claim with
Medicare. 50
50 Page 51 52
2001 Aetna U. S. Healthcare HMO 51 Section 9
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are health
care choices (like HMOs) in some areas of the country. In most Medicare
managed care plans, you can only go to doctors, specialists, or hospitals
that are part of the plan. Medicare managed care plans cover all Medicare
Part A and B benefits. To learn more about enrolling in a Medicare
managed care plan, contact Medicare at 1-800-MEDICARE (1-800-633-
4227) or at www. medicare. gov. If you enroll in a Medicare managed care
plan, the following options are available to you:

This Plan and our Medicare managed care plan: You may enroll in our
Medicare managed care plan and also remain enrolled in our FEHB plan.
In this case, we do not waive any of our copayments or coinsurance for
your FEHB coverage.

This Plan and another Plan's Medicare managed care plan: You may
enroll in another plan's Medicare managed care plan and also remain
enrolled in our FEHB plan. We will still provide benefits when your
Medicare managed care plan is primary, even out of the managed care
Plan's network and/ or service area (if you use our Plan Providers), but we
will not waive any of our copayments or coinsurance.

Suspended FEHB coverage and a Medicare managed care plan: If you
are an annuitant or former spouse, you can suspend your FEHB coverage
to enroll in a Medicare managed care plan, eliminating your FEHB
premium. (OPM does not contribute to your Medicare managed care plan
premium.) For information on suspending your FEHB enrollment, contact
your retirement office. If you later want to re-enroll in the FEHB Program,
generally you may do so only at the next open season unless you
involuntarily lose coverage or move out of the Medicare managed care
plan service area.

Enrollment in Note: If you choose not to enroll in Medicare Part B, you can still be Medicare Part B covered under the FEHB Program. We cannot require you to enroll in
Medicare.

TRICARE TRICARE is the health care program for members, eligible dependents of military persons and retirees of the military. TRICARE includes the
CHAMPUS program. If both TRICARE and this Plan cover you, we pay
first. See your TRICARE Health Benefits Advisor if you have questions
about TRICARE coverage.

Workers' Compensation We do not cover services that:
you need because of a workplace-related disease or injury that the Office of Workers' Compensation Programs (OWCP) or a similar

Federal or State agency determines they must provide; or
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed

under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your
treatment, we will cover your benefits. You must use our providers.

Medicaid When you have this Plan and Medicaid, we pay first. 51
51 Page 52 53
2001 Aetna U. S. Healthcare HMO 52 Section 9
When other Government agencies
are responsible for your care We do not cover services and supplies when a local, State, or Federal Government agency directly or indirectly pays for them.

When others are responsible
for injuries When you receive money to compensate you for medical or hospital care for injuries or illness caused by another person, you must reimburse us for

any expenses we paid. However, we will cover the cost of treatment that
exceeds the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our subrogation
procedures.

The Member specifically acknowledges our right of subrogation. When we
provide health care benefits for injuries or illnesses for which a third party
is or may be responsible, we shall be subrogated to your rights of recovery
against any third party to the extent of the full cost of all benefits provided
by us, to the fullest extent permitted by law. We may proceed against any
third party with or without your consent.

You also specifically acknowledge our right of reimbursement. This right
of reimbursement attaches, to the fullest extent permitted by law, when we
have provided health care benefits for injuries or illness for which a third
party is or may be responsible and you and/ or your representative has
recovered any amounts from the third party or any party making payments
on the third party's behalf. By providing any benefit under this Plan, we
are granted an assignment of the proceeds of any settlement, judgment or
other payment received by you to the extent of the full cost of all benefits
provided by us. Our right of reimbursement is cumulative with and not
exclusive of our subrogation right and we may choose to exercise either or
both rights of recovery.

You and your representatives further agree to:
Notify us promptly and in writing when notice is given to any third party of the intention to investigate or pursue a claim to recover

damages or obtain compensation due to injuries or illness sustained by
us that may be the legal responsibility of a third party; and

Cooperate with us and do whatever is necessary to secure our rights of subrogation and/ or reimbursement under this Plan; and

Give us a first-priority lien on any recovery, settlement or judgment or other source of compensation which may be had from a third party to
the extent of the full cost of all benefits associated with injuries or
illness provided by us for which a third party is or may be responsible
(regardless of whether specifically set forth in the recovery, settlement,
judgment or compensation agreement); and 52
52 Page 53 54
2001 Aetna U. S. Healthcare HMO 53 Section 9
Pay, as the first priority, from any recovery, settlement or judgment or other source of compensation, any and all amounts due us as
reimbursement for the full cost of all benefits associated with injuries or
illness provided by us for which a third party is or may be responsible
(regardless of whether specifically set forth in the recovery, settlement,
judgment, or compensation agreement), unless otherwise agreed to by
us in writing; and

Do nothing to prejudice our rights as set forth above. This includes, but is not limited to, refraining from making any settlement or recovery

which specifically attempts to reduce or exclude the full cost of all
benefits provided by us.

We may recover the full cost of all benefits provided by us under this Plan
without regard to any claim of fault on the part of you, whether by
comparative negligence or otherwise. No court costs or attorney fees may
be deducted from our recovery without the prior express written consent of
us. In the event you or your representative fails to cooperate with us, you
shall be responsible for all benefits paid by us in addition to costs and
attorney's fees incurred by us in obtaining repayment. 53
53 Page 54 55
2001 Aetna U. S. Healthcare HMO 54 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on

December 31 of the same year.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 15.

Coinsurance Coinsurance is the percentage of expenses that you must pay for your care. See page 15.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Any type of care provided in accordance with Medicare guidelines, including room and board, that a) does not require the skills of technical or
professional personnel; b) is not furnished by or under the supervision of
such personnel or does not otherwise meet the requirements of post-hospital
Skilled Nursing Facility care; or c) is a level such that you have
reached the maximum level of physical or mental function and such person
is not likely to make further significant improvement. Custodial Care
includes, but is not limited to, any type of care where the primary purpose
of the type of care provided is to attend to your daily living activities which
do not entail or require the continuing attention of trained medical or
paramedical personnel. Examples of this includes, but is not limited to,
assistance in walking, getting in and out of bed, bathing, dressing, feeding,
using the toilet, changes of dressings of non infected, post operative or
chronic conditions, preparation of special diets, supervision of medication
which can be self-administered by the you, general maintenance care of
colostomy or ileostomy, routine services to maintain other service which,
in the sole determination of us, based on medically accepted standards, can
be safely and adequately self-administered or performed by the average
non-medical person without the direct supervision of trained medical or
paramedical personnel, regardless of who actually provides the service,
residential care and adult day care, protective and supportive care including
educational services, rest cures, convalescent care

Detoxification The process whereby an alcohol or drug intoxicated or alcohol or drug dependent person is assisted, in a facility licensed by the appropriate
regulatory authority, through the period of time necessary to eliminate, by
metabolic or other means, the intoxicating alcohol or drug, alcohol or drug
dependent factors or alcohol in combination with drugs as determined by a
licensed Physician, while keeping the physiological risk to the patient at a
minimum. 54
54 Page 55 56
2001 Aetna U. S. Healthcare HMO 55 Section 10
Experimental or
investigational services Services or supplies that are, as determined by us, experimental. A drug, device, procedure or treatment will be determined to be experimental if:

There is not sufficient outcome data available from controlled clinical trials published in the peer reviewed literature to substantiate its safety
and effectiveness for the disease or injury involved; or
Required FDA approval has not been granted for marketing; or
A recognized national medical or dental society or regulatory agency has determined, in writing, that it is experimental or for research

purposes; or
The written protocol or protocol( s) used by the treating facility or the protocol or protocol( s) of any other facility studying substantially the

same drug, device, procedure or treatment or the written informed
consent used by the treating facility or by another facility studying the
same drug, device, procedure or treatment states that it is experimental
or for research purposes; or

It is not of proven benefit for the specific diagnosis or treatment of your particular condition; or

It is not generally recognized by the Medical Community as effective or appropriate for the specific diagnosis or treatment of your particular
condition; or
It is provided or performed in special settings for research purposes.

Medical necessity Also known as medically necessary or medically necessary services. Services that are appropriate and consistent with the diagnosis in
accordance with accepted medical standards as described in this document.
Medical Necessity, when used in relation to services, shall have the same
meaning as Medically Necessary Services. This definition applies only to
the determination by us of whether health care services are Covered
Benefits under this Plan. 55
55 Page 56 57
2001 Aetna U. S. Healthcare HMO 56 Section 10
Reasonable Charge The charge for a Covered Benefit which is determined by us to be the prevailing charge level made for the service or supply in the
geographic area where it is furnished. We may take into account
factors such as the complexity, degree of skill needed, type or
specialty of the Provider, range of services provided by a facility,
and the prevailing charge in other areas in determining the
Reasonable Charge for a service or supply that is unusual or is not
often provided in the area or is provided by only a small number of
providers in the area.

Referral Specific directions or instructions from your PCP, in conformance with our policies and procedures, that direct you to a participating provider for
medically necessary care.

Respite Care Care furnished during a period of time when your family or usual caretaker cannot, or will not, attend to the your needs.

Urgent Care Covered benefits required in order to prevent serious deterioration of a your health that results from an unforeseen illness or injury if you are
temporarily absent from the our service area and receipt of the health care
service cannot be delayed until your return to the service area.

Us/ We Us and we refer to Aetna U. S. Healthcare, Inc.
You You refers to the enrollee and each covered family member. 56
56 Page 57 58
2001 Aetna U. S. Healthcare HMO 57 Section 11
Section 11. FEHB facts
No pre-existing condition
limitation We will not refuse to cover the treatment of a condition that you had before you enrolled in this Plan solely because you had the condition

before you enrolled.

Where you can get information about enrolling in the
FEHB Program See www. opm. gov/ insure. Also, your employing or retirement office can answer your questions, and give you a Guide to Federal Employee Health
Benefits Plans, brochures for other plans, and other materials you need to
make an informed decision about:

When you may change your enrollment;
How you can cover your family members;
What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire;

When your enrollment ends; and
When the next open season for enrollment begins.
We don't determine who is eligible for coverage and, in most cases, cannot
change your enrollment status without information from your employing or
retirement office.

Types of coverage available
for you and your family Self Only coverage is for you alone. Self and Family coverage is for you, your spouse, and your unmarried dependent children under age 22,

including any foster children or stepchildren your employing or retirement
office authorizes coverage for. Under certain circumstances, you may also
continue coverage for a disabled child 22 years of age or older who is
incapable of self-support.

If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You may
change your enrollment 31 days before to 60 days after that event. The Self
and Family enrollment begins on the first day of the pay period in which
the child is born or becomes an eligible family member. When you change
to Self and Family because you marry, the change is effective on the first
day of the pay period that begins after your employing office receives your
enrollment form, benefits will not be available to your spouse until you
marry.

Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we. Please
tell us immediately when you add or remove family members from your
coverage for any reason, including divorce, or when your child under age
22 marries or turns 22.

If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB plan. 57
57 Page 58 59
2001 Aetna U. S. Healthcare HMO 58 Section 11
When benefits and
premiums start The benefits in this brochure are effective on January 1. If you are new to this Plan, your coverage and premiums begin on the first day of your first

pay period that starts on or after January 1. Annuitants' premiums begin on
January 1.

Your medical and claims
records are confidential We will keep your medical and claims information confidential. Only the following will have access to it:

OPM, this Plan, and subcontractors when they administer this contract;
This Plan, and appropriate third parties, such as other insurance plans and the Office of Workers' Compensation Programs (OWCP), when

coordinating benefit payments and subrogating claims;
Law enforcement officials when investigating and/ or prosecuting alleged civil or criminal actions;

OPM and the General Accounting Office when conducting audits;
Individuals involved in bona fide medical research or education that does not disclose your identity; or

O P M, w hen r eview ing a dis puted claim or def ending litigation about a claim.

When you retire When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years
of your Federal service. If you do not meet this requirement, you may be
eligible for other forms of coverage, such as Temporary Continuation of
Coverage (TCC).

When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:

Your enrollment ends, unless you cancel your enrollment, or You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary
Continuation of Coverage.

Spouse equity coverage If you are divorced from a Federal employee or annuitant, you may not continue to get benefits under your former spouse's enrollment. But, you

may be eligible for your own FEHB coverage under the spouse equity law.
If you are recently divorced or are anticipating a divorce, contact your ex-spouse's
employing or retirement office to get RI 70-5, the Guide to
Federal Employees Health Benefits Plans for Temporary Continuation of
Coverage and Former Spouse Enrollees, or other information about your
coverage choices.

TCC If you leave Federal service, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary

Continuation of Coverage (TCC). For example, you can receive TCC if
you are not able to continue your FEHB enrollment after you retire. 58
58 Page 59 60
2001 Aetna U. S. Healthcare HMO 59 Section 11
You may not elect TCC if you are fired from your Federal job due to gross
misconduct.

Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to
Federal Employees Health Benefits Plans for Temporary Continuation of
Coverage and Former Spouse Enrollees, from your employing or
retirement office or from www. opm. gov/ insure.

Converting to individual coverage You may convert to a non-FEHB individual policy if:

Your coverage under TCC or the spouse equity law ends. If you canceled your coverage or did not pay your premium, you cannot
convert;
You decided not to receive coverage under TCC or the spouse equity law; or

You are not eligible for coverage under TCC or the spouse equity law.

If you leave Federal service, your employing office will notify you of your
right to convert. You must apply in writing to us within 31 days after you
receive this notice. However, if you are a family member who is losing
coverage, the employing or retirement office will not notify you. You must
apply in writing to us within 31 days after you are no longer eligible for
coverage.

Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and we
will not impose a waiting period or limit your coverage due to pre-existing
conditions.

Getting a Certificate of
Group Health Plan Coverage If you leave the FEHB Program, we will give you a Certificate of Group Health Plan Coverage that indicates how long you have been enrolled with

us. You can use this certificate when getting health insurance or other
health care coverage. Your new plan must reduce or eliminate waiting
periods, limitations, or exclusions for health related conditions based on
the information in the certificate, as long as you enroll within 63 days of
losing coverage under this Plan.

If you have been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may also request a certificate
from those plans.

Inspector General Advisory Stop health care fraud! Fraud increases the cost of health care for everyone. If you suspect that a physician, pharmacy, or hospital has
charged you for services you did not receive, billed you twice for the same
service, or misrepresented any information, do the following:

Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 1-800-537-9384 and explain the situation.

If we do not resolve the issue, call THE HEALTH CARE FRAUD HOTLINE 202-418-3300 or write to: The United States Office of
Personnel Management, Office of the Inspector General Fraud Hotline,
1900 E Street, NW, Room 6400, Washington, DC 20415. 59
59 Page 60 61
2001 Aetna U. S. Healthcare HMO 60 Section 11
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud. Also, the Inspector General may investigate anyone
who uses an ID card if the person tries to obtain services for a person who
is not an eligible family member, or is no longer enrolled in the Plan and
tries to obtain benefits. Your agency may also take administrative action
against you. 60
60 Page 61 62
2001 Aetna U. S. Healthcare HMO 61 DoD/ FEHB Demonstration Project
Department of Defense/ FEHB Demonstration Project
What is it? The Department of Defense/ FEHB Demonstration Project allows some active and retired uniformed service members and their dependents to

enroll in the FEHB Program. The demonstration will last for three years
and began with the 1999 open season for the year 2000. Open season
enrollments will be effective January 1, 2001. DoD and OPM have set up
some special procedures to implement the Demonstration Project, noted
below. Otherwise, the provisions described in this brochure apply.

Who is eligible DoD determines who is eligible to enroll in the FEHB Program. Generally, you may enroll if:
You are an active or retired uniformed service member and are eligible for Medicare;
You are a dependent of an active or retired uniformed service member and are eligible for Medicare;
You are a qualified former spouse of an active or retired uniformed service member and you have not remarried; or
You are a survivor dependent of a deceased active or retired uniformed service member; and
You live in one of the geographic demonstration areas.
If you are eligible to enroll in a plan under the regular Federal Employees
Health Benefits Program, you are not eligible to enroll under the
DoD/ FEHBP Demonstration Project.

The demonstration areas Dover AFB, DE Commonwealth of Puerto Rico
Fort Knox, KY G r eens bor o/ Wins ton S alem/ H igh P oint, N C
Dallas, TX Humboldt County, CA area
New Orleans, LA Naval Hospital, Camp Pendleton, CA
Adair County, IA Coffee County, GA

When you can join You may enroll under the FEHB/ DoD Demonstration Project during the 2000 open season, November 13, 2000, through December 11, 2000. Your
coverage will begin January 1, 2001. DoD has set-up an Information
Processing Center (IPC) in Iowa to provide you with information about
how to enroll. IPC staff will verify your eligibility and provide you with
FEHB Program information, plan brochures, enrollment instructions and
forms. The toll-free phone number for the IPC is 1-877-DOD-FEHB
(1-877-363-3342).

You may select coverage for yourself (Self Only) or for you and your
family (Self and Family) during the 2000 and 2001 open seasons. Your
coverage will begin January 1 of the year following the open season during
which you enrolled.

If you become eligible for the DoD/ FEHB Demonstration Project outside
of open season, contact the IPC to find out how to enroll and when your
coverage will begin. 61
61 Page 62 63
2001 Aetna U. S. Healthcare HMO 62 DoD/ FEHB Demonstration Project
DoD has a web site devoted to the Demonstration Project. You can view
information such as their Marketing/ Beneficiary Education Plan,
Frequently Asked Questions, demonstration area locations and zip code
lists at www. tricare. osd. mil/ fehbp. You can also view information about
the demonstration project, including "The 2001 Guide to Federal
Employees Health Benefits Plans Participating in the DoD/ FEHB
Demonstration Project," on the OPM web site at www. opm. gov.

TCC eligibility See Section 11, FEHB Facts; it explains temporary continuation of coverage (TCC). Under this DoD/ FEHB Demonstration Project the only
individual eligible for TCC is one who ceases to be eligible as a "member
of family" under your self and family enrollment. This occurs when a child
turns 22, for example, or if you divorce and your spouse does not qualify to
enroll as an unremarried former spouse under title 10, United States Code.
For these individuals, TCC begins the day after their enrollment in the
DoD/ FEHB Demonstration Project ends. TCC enrollment terminates after
36 months or the end of the Demonstration Project, whichever occurs first.
You, your child, or another person must notify the IPC when a family
member loses eligibility for coverage under the DoD/ FEHB Demonstration
Project.

TCC is not available if you move out of a DoD/ FEHB Demonstration
Project area, you cancel your coverage, or your coverage is terminated for
any reason. TCC is not available when the demonstration project ends.

Other features The 31-day extension of coverage and right to convert do not apply to the DoD/ FEHB Demonstration Project. 62
62 Page 63 64
2001 Aetna U. S. Healthcare HMO 63 Index
Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage.

Accidental injury, 26, 40
Alternative treatment, 23
Ambulance, 14, 28, 30, 32, 33
Anesthesia, 25, 27, 29, 42
Autologous bone marrow
transplant, 21, 27

Blood and blood plasma, 29
Casts, 28, 29
Chemotherapy, 21
Childbirth, 24, 39
Claims, 7, 12, 35, 46, 47, 48, 50,
58

Coinsurance, 5, 10, 12, 15, 46,
49, 51, 54

Colorectal cancer screening, 18
Congenital anomalies, 25, 26
Deductible, 46
Definitions, 17, 25, 28, 31, 34,
36, 40, 54, 65

Dental care, 26, 65
Dressings, 28, 29, 38, 54
Durable medical equipment
(DME), 23

Educational classes and
programs, 24

Emergency, 5, 30, 31, 32, 33, 36,
38, 45, 46, 65

Experimental or investigational,
45, 48

Eyeglasses, 22, 44, 65
Family planning, 20
Fecal occult blood test, 18
General exclusions, 45

Hearing services, 22
Home health services, 23
Hospice care, 29
Hospital, 5, 10, 11, 13, 15, 17, 19,
21, 23, 25, 26, 27, 28, 29, 32,
33, 34, 44, 46, 49, 52, 59, 61,
65

Immunizations, 5, 18, 19
Infertility, 14, 20
Insulin, 37
Mammograms, 11, 17
Medicaid, 51
Medically necessary, 6, 14, 17,
19, 25, 28, 32, 36, 40, 45, 48,
55, 56

Medicare, 6, 17, 23, 25, 28, 31,
34, 36, 40, 44, 46, 49, 50, 51,
54, 61

Members, 6, 7, 12, 24, 25, 31, 36,
39, 44, 51, 57, 61, 67

Non-FEHB Benefits, 44
Nurse, 24, 39
Nurse Anesthetist, 28
Registered Nurse, 44
Occupational therapy, 21

Office visits, 5
Oral and maxillofacial surgery,
26

Orthopedic devices, 23
Out-of-pocket expenses, 44
Oxygen, 23, 28, 29
Pap test, 17, 18
Physical therapy, 21

Physician, 5, 6, 7, 12, 13, 14, 15,
17, 19, 23, 25, 27, 31, 32, 36,
37, 39, 46, 48, 50, 54, 59

Precertification, 6, 7, 14, 36
Prescription drugs, 15, 36, 46, 49,
65, 66

Preventive care, adult, 18
Preventive care, children, 19, 22
Preventive services, 11
Prior approval, 14, 39, 45, 48
Prosthetic devices, 22, 23, 25, 26
Radiation therapy, 21
Room and board, 28, 54
Second surgical opinion, 17
Speech therapy, 21
Splints, 28
Subrogation, 52
Substance abuse, 6, 10, 11, 14,
34, 35, 65

Surgery, 6, 10, 14, 19, 21, 22, 23,
25, 26, 27, 28, 39, 43, 65

Oral, 26, 42
Outpatient, 7, 14, 15, 29, 65
Reconstructive, 25, 26
Syringes, 37

Temporary continuation of
coverage, 58, 59, 62

Transplants, 21, 27, 39, 65
Treatment therapies, 21
Vision services, 22
Wheelchairs, 23
X-rays, 17, 28, 29, 32, 39, 40 63
63 Page 64 65
2001 Aetna U. S. Healthcare HMO 64
NOTES: 64
64 Page 65 66
2001 Aetna U. S. Healthcare HMO 65 Summary of Benefits
Summary of benefits for Aetna U. S. Healthcare 2001
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we
cover; for more detail, look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.

We only cover services provided or arranged by participating physicians, except in emergencies.
Benefits You Pay-High
Option
You Pay-Standard
Option
Page

Medical services provided by physicians:
Diagnostic and treatment services
provided in the office..................................

Office visit copay: $10
primary care; $15 specialist
Office visit copay: $15
primary care; $20 specialist 17

Services provided by a hospital:
Inpatient ........................................................

Outpatient......................................................
Nothing

Nothing
$240 per admission copay
$50 copay per outpatient
surgical visit

28
29

Emergency benefits:
In-area ...........................................................
Out-of-area....................................................
$35 per visit
$35 per visit
$35 per visit
$35 per visit

32
33

Mental health and substance abuse treatment ... Same as medical and
hospital benefits
Same as medical and
hospital benefits
34

Prescription drugs............................................... 30 day supply:
$5 per generic formulary
$10 per brand name
formulary
$25 per non-formulary
2 times copay for 31-90 day
supply

30 day supply:
$10 per generic formulary
$15 per brand name
formulary
$30 per non-formulary
2 times copay for 31-90 day
supply

36

Dental Care......................................................... Variable copays Variable copays 40
Vision Care......................................................... $15 copay per visit. Up to
$100 reimbursement for
eyeglasses or contacts per
24 month period

$20 copay per visit. Up to
$100 reimbursement for
eyeglasses or contacts per
24 month period

22

Special features: Services for the deaf
and hearing-impaired, and Center of
Excellence for transplants/ heart
surgery/ etc.

Contact Plan Contact Plan 39 65
65 Page 66 67
2001 Aetna U. S. Healthcare HMO 66 Summary of Benefits
Benefits You Pay-High
Option
You Pay-Standard
Option
Page

Protection against catastrophic costs
(your out-of-pocket maximum) .........................

Nothing after $1,500/ Self
Only or $3,000/ Family
enrollment per year in
copayments.

Copayments towards
prescription drugs,
behavioral health and dental
services do not count
towards these limits.

Nothing after $1,500/ Self
Only or $3,000/ Family
enrollment per year in
copayments

Copayments towards
prescription drugs,
behavioral health and dental
services do not count
towards these limits

15 66
66 Page 67 68
2001 Aetna U. S. Healthcare HMO 67 Rates
2001 Rate Information for Aetna U. S. Healthcare
Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category, refer to the FEHB
Guide for that category or contact the agency that maintains your health benefits enrollment.

Postal rates apply to career Postal Service employees. Most employees should refer to the FEHB Guide for United
States Postal Service Employees, RI 70-2. Different postal rates apply and special FEHB guides are published for Postal
Service Nurses and Tool & Die employees (see RI 70-2B); and for Postal Service Inspectors and Office of Inspector
General (OIG) employees (see RI 70-2IN).

Postal rates do not apply to non-career postal employees, postal retirees, or associate members of any postal employee
organization. Refer to the applicable FEHB Guide.

Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type of
Enrollment Code
Gov't
Share
Your
Share
Gov't
Share
Your
Share
USPS
Share
Your
Share

Southeastern Pennsylvania and Delaware
High Option
Self Only SU1 $86.59 $36.29 $187.61 $78.63 $102.22 $20.66

High Option
Self and Family SU2 $195.82 $119.29 $424.28 $258.46 $231.17 $83.94

Standard Option
Self Only SU4 $80.99 $27.00 $175.49 $58.49 $95.84 $12.15

Standard Option
Self and Family SU5 $195.82 $82.95 $424.28 $179.72 $231.17 $47.60

Southwestern, Central and Northeastern Pennsylvania
High Option
Self Only KL1 $68.67 $22.89 $148.79 $49.59 $81.26 $10.30

High Option
Self and Family KL2 $181.72 $60.57 $393.72 $131.24 $215.03 $27.26

Standard Option
Self Only KL4 $59.63 $19.88 $129.20 $43.07 $70.57 $8.94

Standard Option
Self and Family KL5 $158.65 $52.88 $343.74 $114.58 $187.73 $23.80 67
67 Page 68
2001 Aetna U. S. Healthcare HMO 68 Rates
2001 Rate Information for Aetna U. S. Healthcare continued
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type of
Enrollment Code
Gov't
Share
Your
Share
Gov't
Share
Your
Share
USPS
Share
Your
Share

New Jersey
High Option
Self Only P31 $86.59 $49.89 $187.61 $108.10 $102.22 $34.26

High Option
Self and Family P32 $195.82 $156.20 $424.28 $338.43 $231.17 $120.85

Standard Option
Self Only P34 $86.59 $34.17 $187.61 $74.04 $102.22 $18.54

Standard Option
Self and Family P35 $195.82 $121.86 $424.28 $264.03 $231.17 $86.51

Washington, DC, North and Central Maryland and Northern Virginia
High Option
Self Only JN1 $85.69 $28.56 $185.66 $61.88 $101.40 $12.85

High Option
Self and Family JN2 $195.82 $68.43 $424.28 $148.26 $231.17 $33.08

Standard Option
Self Only JN4 $62.37 $20.79 $135.14 $45.04 $73.80 $9.36

Standard Option
Self and Family JN5 $145.95 $48.65 $316.22 $105.41 $172.71 $21.89

Central, Richmond and Tri-Cities Virginia
High Option
Self Only XE1 $73.29 $24.43 $158.80 $52.93 $86.73 $10.99

High Option
Self and Family XE2 $190.15 $63.38 $411.99 $137.33 $225.01 $28.52

Standard Option
Self Only XE4 $65.21 $21.74 $141.29 $47.10 $77.17 $9.78

Standard Option
Self and Family XE5 $169.45 $56.48 $367.14 $122.38 $200.51 $25.42

15986-9/00 68

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