Choosing the right health plan can be a daunting task, especially when it comes to navigating the complexities of Federal Employee Health Benefits (FEHB). The Office of Personnel Management (OPM) offers a variety of health plans to federal employees, retirees, and their families. Understanding the differences between these plans is crucial to making an informed decision that best suits your health needs and financial situation. This guide provides a detailed comparison of several OPM health plans to help you navigate your options effectively.
It’s important to remember that the information presented here is for comparative purposes and should not be considered the official statement of benefits. Always refer to the individual FEHB plan brochure for the official and comprehensive details before making your final enrollment decision. This comparison focuses on understanding the costs and network aspects of different High Deductible Health Plans (HDHPs) available through OPM.
Choosing between “Self,” “Self Plus One,” or “Self and Family” enrollment types is another important consideration. In some instances, the premium for “Self Plus One” might be higher than “Self and Family.” If you are looking to cover one eligible family member, it is advisable to compare premiums for both “Self Plus One” and “Self and Family” options on the official OPM website at www.opm.gov/fehbpremiums to ensure you select the most cost-effective enrollment type.
Understanding Self Enrollment: Choosing health coverage for yourself alone under OPM health plans.
Understanding Self Plus One Enrollment: Selecting health coverage for yourself and one eligible family member within OPM health plans.
Understanding Self and Family Enrollment: Choosing comprehensive health coverage for your entire eligible family under OPM health plans.
OPM Health Plan Comparison Table: Costs and Networks
This comparison tool provides a side-by-side look at key features of different OPM health plans, specifically focusing on High Deductible Health Plans (HDHPs). HDHPs are known for their lower premiums but higher deductibles, and they often come with Health Savings Accounts (HSAs) or Health Reimbursement Arrangements (HRAs) to help manage healthcare costs. Let’s dive into the comparison:
| Plans | Aetna HealthFund HDHP and Aetna Direct Plan (HDHP) | Blue Cross and Blue Shield Service Benefit Plan (Basic) | GEHA Benefit Plan (HDHP) | MHBP Consumer Option (HDHP) |
|---|---|---|---|---|
| Plan Links | ||||
| General Information – State | Alabama | Alabama | Alabama | Alabama |
| General Information – Enrollment Code – Self | 224 | 111 | 341 | 481 |
| General Information – Enrollment Code – Self & Family | 225 | 112 | 342 | 482 |
| General Information – Enrollment Code – Self Plus One | 226 | 113 | 343 | 483 |
| General Information – Carrier Code | 22 | 11 | 34 | 48 |
| General Information – Telephone Number | 877-459-6604 | 1-800-411-2583 | 800-821-6136 | 800-694-9901 |
| Biweekly Premium | $135.20 | $113.16 | $76.27 | $84.20 |
| Biweekly Premium | $287.01 | $274.14 | $163.99 | $186.33 |
| Biweekly Premium | $241.49 | $303.61 | $201.52 | $195.65 |
| Plans – Networks | Aetna HealthFund HDHP and Aetna Direct Plan (HDHP) – In-Network 1 | Aetna HealthFund HDHP and Aetna Direct Plan (HDHP) – Out-of-Network | Blue Cross and Blue Shield Service Benefit Plan (Basic) – In-Network 1 | Blue Cross and Blue Shield Service Benefit Plan (Basic) – In-Network 2 | Blue Cross and Blue Shield Service Benefit Plan (Basic) – Out-of-Network | GEHA Benefit Plan (HDHP) – In-Network 1 | GEHA Benefit Plan (HDHP) – Out-of-Network | MHBP Consumer Option (HDHP) – In-Network 1 | MHBP Consumer Option (HDHP) – Out-of-Network |
|---|---|---|---|---|---|---|---|---|---|
| Annual Deductible Annual Deductible: The amount you may have to pay for covered health care services before the plan begins to pay. Some plans have both an overall deductible for all or most covered items/services, but some also have separate deductibles for specific types of services (e.g. prescription services). | $1,800.00 | $2,600.00 | None | None | None | $1,650.00 | $3,300.00 | $2,000.00 | $2,000.00 |
| Annual Deductible Annual Deductible: The amount you may have to pay for covered health care services before the plan begins to pay. Some plans have both an overall deductible for all or most covered items/services, but some also have separate deductibles for specific types of services (e.g. prescription services). | $3,600.00 | $5,200.00 | None | None | None | $3,300.00 | $6,600.00 | $4,000.00 | $4,000.00 |
| Annual Deductible Annual Deductible: The amount you may have to pay for covered health care services before the plan begins to pay. Some plans have both an overall deductible for all or most covered items/services, but some also have separate deductibles for specific types of services (e.g. prescription services). | $3,600.00 | $5,200.00 | None | None | None | $3,300.00 | $6,600.00 | $4,000.00 | $4,000.00 |
| Type of Account | HSA/HRA | HSA/HRA | None | None | None | HSA/HRA | HSA/HRA | HSA/HRA | HSA/HRA |
| Medical Account Contribution The amount of funds available to you for paying your out-of-pocket qualified medical expenses through a premium pass-through contribution or a virtual account. | $800.00 | $800.00 | N/A | N/A | N/A | $1,000.00 | $1,000.00 | $1,200.00 | $1,200.00 |
| Medical Account Contribution The amount of funds available to you for paying your out-of-pocket qualified medical expenses through a premium pass-through contribution or a virtual account. | $1,600.00 | $1,600.00 | N/A | N/A | N/A | $2,000.00 | $2,000.00 | $2,400.00 | $2,400.00 |
| Medical Account Contribution The amount of funds available to you for paying your out-of-pocket qualified medical expenses through a premium pass-through contribution or a virtual account. | $1,600.00 | $1,600.00 | N/A | N/A | N/A | $2,000.00 | $2,000.00 | $2,400.00 | $2,400.00 |
| Net Deductible A net deductible is the sum of your deductible minus any medical account fund. | $1,000.00 | $1,800.00 | None | None | None | $650.00 | $2,300.00 | $800.00 | $800.00 |
| Net Deductible A net deductible is the sum of your deductible minus any medical account fund. | $2,000.00 | $3,600.00 | None | None | None | $1,300.00 | $4,600.00 | $1,600.00 | $1,600.00 |
| Net Deductible A net deductible is the sum of your deductible minus any medical account fund. | $2,000.00 | $3,600.00 | None | None | None | $1,300.00 | $4,600.00 | $1,600.00 | $1,600.00 |
| Annual Out-of-Pocket Maximum Annual Maximum Out of Pocket: Yearly amount the Federal government sets as the most each individual or family is required to pay in cost sharing (e.g. copayments, deductibles and coinsurance) during the plan year for covered, in-network services. This amount may be higher than the out of pocket limits the plan sets. | $6,900.00 | $9,000.00 | $7,500.00 | None | None | $6,000.00 | $8,500.00 | $6,000.00 | $7,500.00 |
| Annual Out-of-Pocket Maximum Annual Maximum Out of Pocket: Yearly amount the Federal government sets as the most each individual or family is required to pay in cost sharing (e.g. copayments, deductibles and coinsurance) during the plan year for covered, in-network services. This amount may be higher than the out of pocket limits the plan sets. | $13,800.00 | $18,000.00 | $15,000.00 | None | None | $12,000.00 | $17,000.00 | $12,000.00 | $15,000.00 |
| Annual Out-of-Pocket Maximum Annual Maximum Out of Pocket: Yearly amount the Federal government sets as the most each individual or family is required to pay in cost sharing (e.g. copayments, deductibles and coinsurance) during the plan year for covered, in-network services. This amount may be higher than the out of pocket limits the plan sets. | $13,800.00 | $18,000.00 | $15,000.00 | None | None | $12,000.00 | $17,000.00 | $12,000.00 | $15,000.00 |
| Member Cost with Medicare A & B Primary – Deductible Waiver with Parts A & B Member Cost with Medicare A & B Primary – This field will indicate either the amount of your annual deductible or that the deductible has been waived (forgiven) when Medicare A and B is the primary coverage. | $1800 | $2600 | N/A | N/A | N/A | $1650 $3300 | $3300 $6600 | Deductible Waived | Deductible Waived |
| Member Cost with Medicare A & B Primary – Out-of-Pocket Maximum with Parts A & B Member Cost with Medicare A & B Primary – This is the most you have to pay annually in cost-sharing (deductibles, copayments and coinsurance) for covered, in-network services in your FEHB plan when Medicare A and B is your primary coverage. | $6900 | $9000 | $7500 $15000 | N/A | N/A | $6000 $12000 | $8500 $17000 | $6000 $12000 | $7500 $15000 |
| Member Cost with Medicare A & B Primary – Primary Care Physician Office Visit with Medicare A & B Primary Member Cost with Medicare A & B Primary – This is the amount you pay for a primary care visit. When you have Medicare A and B, some plans will waive the copay. | 15% Coinsurance | 40% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | Copayment Waived | Coinsurance Waived |
| Member Cost with Medicare A & B Primary – Specialty Office Physician Visit with Parts A & B Member Cost with Medicare A & B Primary – This is the amount you pay for a Specialty care visit. When you have Medicare A and B, some plans will waive the copay. | 15% Coinsurance | 40% Coinsurance + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | Copayment Waived | Coinsurance Waived |
| Member Cost with Medicare A & B Primary – Inpatient Hospital Services with Parts A & B Member Cost with Medicare A & B Primary – This is the amount you pay for an inpatient hospital stay. When you have Medicare A and B, some plans waive this amount. | 15% Coinsurance | 40% Coinsurance + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | N/A | N/A | 5% Coinsurance | 35% Coinsurance + Difference Between Plan Allowance and Billed Amount | Coinsurance Waived | Coinsurance Waived |
| Member Cost with Medicare A & B Primary – Outpatient Hospital Services with Parts A & B Member Cost with Medicare A & B Primary – This is the amount you pay for an outpatient hospital visit when you have Medicare Parts A & B as your primary coverage.What is the amount a member with Medicare A and B pays for an outpatient hospital visit? | 15% Coinsurance | 40% Coinsurance + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | N/A | N/A | 5% Coinsurance | 35% Coinsurance + Difference Between Plan Allowance and Billed Amount | Coinsurance Waived | Coinsurance Waived |
| Member Cost with Medicare A & B Primary – Part B Premium Reimbursement with Parts A & B Member Cost with Medicare A & B Primary – If a plan reimburses you for your Part B premiums, this displays the maximum amount that you will be annually reimbursed. A ‘No” means that the premium will not be reimbursed. | No | No | $800 Max | N/A | N/A | $1000 Max | N/A | No | No |
| Member Cost with Medicare Advantage (Part C) Primary – Deductible Waiver with Part C Member Cost with Medicare Advantage (Part C) Primary – This field will indicate either the amount of your annual deductible or that the deductible has been waived (forgiven) when Medicare C is the primary coverage. | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A |
| Member Cost with Medicare Advantage (Part C) Primary – Out-of-Pocket Maximum with Part C Member Cost with Medicare Advantage (Part C) Primary – This is the most you have to pay annually in cost-sharing (deductibles, copayments and coinsurance) for covered, in-network services in your FEHB plan when Medicare C is your primary coverage. | N/A | N/A | $7500 $15000 | N/A | N/A | N/A | N/A | $6000 | $7500 |
| Member Cost with Medicare Advantage (Part C) Primary – Primary Care Physician Office Visit with Medicare Advantage (Part C) Primary Member Cost with Medicare Advantage (Part C) Primary – This is the amount you pay for a primary care visit. When you have Medicare C, some plans will waive the copay. | 15% | 40% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | N/A | N/A | N/A | N/A | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Member Cost with Medicare Advantage (Part C) Primary – Specialty Physician Office Visit with Part C Member Cost with Medicare Advantage (Part C) Primary – This is the amount you pay for a Specialty care visit. When you have Medicare C, some plans will waive the copay. | 15% | 40% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | N/A | N/A | N/A | N/A | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Member Cost with Medicare Advantage (Part C) Primary – Inpatient Hospital Services with Part C Member Cost with Medicare Advantage (Part C) Primary – This is the amount you pay for an inpatient hospital stay. When you have Medicare C, some plans waive this amount. | 15% | 40% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | N/A | N/A | N/A | N/A | $75 Per Day Up To $750 Per Admission | 40% + Difference Between Plan Allowance and Billed Amount |
| Member Cost with Medicare Advantage (Part C) Primary – Outpatient Hospital Services with Part C Member Cost with Medicare Advantage (Part C) Primary – This is the amount you pay for an outpatient hospital visit when you have Medicare Parts C as your primary coverage.What is the amount a member with Medicare C pays for an outpatient hospital visit? | 15% | 40% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | N/A | N/A | N/A | N/A | $75 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Member Cost with Medicare Advantage (Part C) Primary – Part B Premium Reimbursement with Part C Member Cost with Medicare Advantage (Part C) Primary – If a plan reimburses you for your Part B premiums, this displays the maximum amount that you will be annually reimbursed. A ‘No” means that the premium will not be reimbursed. | N/A | N/A | No | N/A | N/A | N/A | N/A | No | No |
| Member Cost with Medicare Part D EGWP – Prescription Drug Deductible Member Cost with Medicare Part D EGWP – Is the deductible waived for prescription drugs with Medicare Part D EGWP? | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A |
| Member Cost with Medicare Part D EGWP – Out-of-Pocket Maximum Member Cost with Medicare Part D EGWP – What is the maximum a member with Medicare Part D pays out-of-pocket for covered prescriptions? | N/A | N/A | $2000 | N/A | N/A | N/A | N/A | $2000 | $2000 |
| Member Cost with Medicare Part D EGWP – EGWP Tier 0 Member Cost with Medicare Part D EGWP – What is the member cost of Tier 0 prescriptions with Medicare Part D EGWP? | N/A | N/A | N/A | N/A | N/A | N/A | N/A | Member Pays Nothing | Member Pays Nothing |
| Member Cost with Medicare Part D EGWP – EGWP Tier 1 Member Cost with Medicare Part D EGWP – What is the member cost of Tier 1 prescriptions with Medicare Pard D EGWP? | N/A | N/A | $10 | N/A | Member Pays All Charges | N/A | N/A | $8 | $8 |
| Member Cost with Medicare Part D EGWP – EGWP Tier 2 Member Cost with Medicare Part D EGWP – What is the member cost of Tier 0 prescriptions with Medicare Part D EGWP? | N/A | N/A | $45 Copayment | N/A | Member Pays All Charges | N/A | N/A | $45 | $45 |
| Member Cost with Medicare Part D EGWP – EGWP Tier 3 Member Cost with Medicare Part D EGWP – What is the member cost of Tier 3 prescriptions with Medicare Part D EGWP? | N/A | N/A | 50% | N/A | Member Pays All Charges | N/A | N/A | $70 | $70 |
| Member Cost with Medicare Part D EGWP – EGWP Tier 4 Member Cost with Medicare Part D EGWP – What is the member cost of Tier 4 prescriptions with Medicare Pard D EGWP? | N/A | N/A | $75 Copayment | N/A | Member Pays All Charges | N/A | N/A | 25% | 25% |
| Member Cost with Medicare Part D EGWP – EGWP Tier 5 Member Cost with Medicare Part D EGWP – What is the member cost of Tier 5 prescriptions with Medicare Part D EGWP? | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A |
| Member Cost with Medicare Part D EGWP – EGWP Tier 6 Member Cost with Medicare Part D EGWP – What is the member cost of Tier 6 prescriptions with Medicare Part D EGWP? | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A |
| Primary/Specialty Care – Preventive Care Primary/Specialty Care – What is the member cost share for Preventive Care, as defined by the U.S. Preventive Services Task Force with a rating of A or B? | Member Pays Nothing | 40% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | N/A | N/A | Member Pays Nothing | 35% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | Member Pays All Charges |
| Primary/Specialty Care – Primary Care Office Visit Primary/Specialty Care – The amount you pay for a visit to a primary care practitioner (typically an M.D. or D.O., but can include other licensed providers). | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $35 Copayment | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Primary/Specialty Care – Specialist Office Visit Primary/Specialty Care – The amount you pay for a visit to a provider focusing on a specific area of medicine. Some plans require a referral from your primary care provider for you to see a specialist. You must get a referral, if required, or your plan may not pay for the services. | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $50 Copayment | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Primary/Specialty Care – Plan Requires Referral to See Certain Specialists Primary/Specialty Care – A written order from your primary care provider for you to see a specialist or get certain health care services. Some plans may require you need to get a referral before you can get health care services from anyone other than your primary care provider. In those plans, if you don’t get a referral first, the plan may not pay for the services | No | No | No | N/A | N/A | No | No | No | No |
| Emergency & Urgent Care – Emergency Care Emergency & Urgent Care – What is the member cost share for Emergency Care? | 15% | 15% | $0 Copayment + $350 | N/A | $0 + $350 | 5% | 5% | $50 Copayment | $50 Copayment + Difference Between Plan Allowance and Billed Amount |
| Emergency & Urgent Care – Urgent Care Emergency & Urgent Care – What is the member cost share for Urgent Care? | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $50 Copayment | N/A | $50 Or Member Pays All Charges | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $50 Copayment | $50 Copayment + Difference Between Plan Allowance and Billed Amount |
| Emergency & Urgent Care – Out-of-Pocket Waived Emergency & Urgent Care – Is a member’s Out-of-Pocket cost waived when the member is admitted to the hospital following ER treatment? Select “NA” if a member pays nothing for any medical emergency. | No | No | Yes | N/A | N/A | No | No | Yes | Yes |
| Surgery & Hospital Charges – Doctor Costs Inpatient Surgery Surgery & Hospital Charges – The amount you will pay for a doctor to perform inpatient surgery. | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $200 Copayment | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | 40% + Difference Between Plan Allowance and Billed Amount |
| Surgery & Hospital Charges – Hospital Inpatient Cost Per Admission Surgery & Hospital Charges – This is the amount you pay before the Plan pays benefits when you are admitted as an inpatient to a hospital. | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $350 Per Day Up To $1750 Per Admission | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $75 Per Day $750 Max | 40% + Difference Between Plan Allowance and Billed Amount |
| Surgery & Hospital Charges – Room & Board Charges Surgery & Hospital Charges – This is the amount you pay for covered Room & Board charges while an inpatient in a hospital. | 15% | 40% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | 40% + Difference Between Plan Allowance and Billed Amount |
| Surgery & Hospital Charges – Other Inpatient Costs Surgery & Hospital Charges – This is the amount you pay for other costs associated with inpatient surgery. | 15% | 40% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | 40% + Difference Between Plan Allowance and Billed Amount |
| Surgery & Hospital Charges – Doctor Costs Outpatient Surgery Surgery & Hospital Charges – This is the amount you pay for a doctor to perform surgery in an outpatient hospital setting or ambulatory surgery center. | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $150 Copayment Or $200 | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $150 | 40% + Difference Between Plan Allowance and Billed Amount |
| Surgery & Hospital Charges – Other Outpatient Costs Surgery & Hospital Charges – This is the amount you pay for other outpatient care at a hospital (not surgery or emergency room services). | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $250 Per Day Or $350 Per Day | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $75 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Lab, X-Ray & Other Diagnostic Tests – Simple Diagnostic Tests/Procedures Lab, X-Ray & Other Diagnostic Tests – What is the member cost share for Simple Diagnostic Tests/Procedures (e.g., blood tests, urinalysis, ultrasounds)? | 15% | 40% + Difference Between Plan Allowance and Billed Amount | 15% Or $40 Copayment Or $100 Copayment | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Lab, X-Ray & Other Diagnostic Tests – Complex Diagnostic Tests/Procedures Lab, X-Ray & Other Diagnostic Tests – What is the member cost share for Complex Diagnostic Tests/Procedures (e.g., CT scans, MRIs, PET scans, sleep labs)? | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $40 Or $100 | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Lab, X-Ray & Other Diagnostic Tests – Enhanced Lab Network Lab, X-Ray & Other Diagnostic Tests – What is the member cost share for Enhanced lab Network? | 15% | 40% + Difference Between Plan Allowance and Billed Amount | N/A | N/A | N/A | N/A | N/A | Member Pays Nothing | 40% + Difference Between Plan Allowance and Billed Amount |
| Prescription Drugs – Mail Service Pharmacy Benefit Prescription Drugs – This is the amount you pay for a mail order prescription. These are medications sent via mail for maintenance prescriptions, typically greater than a 30-day supply. | Yes | No | No | N/A | N/A | Yes | N/A | Yes | No |
| Prescription Drugs – Mail Order Pharmacy Restriction Prescription Drugs – Mail order drug dispensing may be restricted to a specific mail order pharmacy. For more details, refer to the medication pricing tool. | Yes | N/A | N/A | N/A | N/A | Yes | N/A | Yes | N/A |
| Prescription Drugs – Specialty Pharmacy Restriction Prescription Drugs – Specialty drug dispensing may be restricted to a specific specialty pharmacy. For more details, refer to the medication pricing tool. | Yes | N/A | Yes | N/A | N/A | Yes | N/A | Yes | N/A |
| Prescription Drugs – Hormone Therapy Prescription Drugs – Does the plan cover Hormone Therapy for the treatment of gender dysphoria? | Covered | Covered | Covered | Not Covered | Not Covered | Covered | Covered | Covered | Covered |
| Prescription Drugs – Tier 0 Prescription Prescription Drugs – Specifies formulary tier description and cost sharing for Tier 0 | Member Pays Nothing | 40% + Difference Between Plan Allowance and Billed Amount | N/A | N/A | N/A | Member Pays Nothing | $0 + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | Member Pays All Charges |
| Prescription Drugs – Tier 1 Prescriptions Prescription Drugs – Specifies formulary tier description and cost sharing for Tier 1 | $10 Copayment | 40% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | N/A | Member Pays All Charges | 25% | 25% + Difference Between Plan Allowance and Billed Amount | $10 | Member Pays All Charges |
| Prescription Drugs – Tier 2 Prescriptions Prescription Drugs – Specifies formulary tier description and cost sharing for Tier 2 | 50% $200 Max | 40% + Difference Between Plan Allowance and Billed Amount | $75 Copayment | N/A | Member Pays All Charges | 25% | 25% + Difference Between Plan Allowance and Billed Amount | 30% $200 Max | Member Pays All Charges |
| Prescription Drugs – Tier 3 Prescriptions Prescription Drugs – Specifies formulary tier description and cost sharing for Tier 3 | 50% $300 Max | 40% + Difference Between Plan Allowance and Billed Amount | 60% | N/A | Member Pays All Charges | 40% | 40% + Difference Between Plan Allowance and Billed Amount | 50% $200 Max | Member Pays All Charges |
| Prescription Drugs – Tier 4 Prescriptions Prescription Drugs – Specifies formulary tier description and cost sharing for Tier 4 | 50% $350 Max | 40% + Difference Between Plan Allowance and Billed Amount | $120 Copayment | N/A | Member Pays All Charges | 25% | N/A | 30% $225 Max | Member Pays All Charges |
| Prescription Drugs – Tier 5 Prescriptions Prescription Drugs – Specifies formulary tier description and cost sharing for Tier 5 | 50% $700 Max | 40% + Difference Between Plan Allowance and Billed Amount | $200 Copayment | N/A | Member Pays All Charges | 40% | N/A | 30% $225 Max | Member Pays All Charges |
| Prescription Drugs – Tier 6 Prescriptions Prescription Drugs – Specifies formulary tier description and cost sharing for Tier 6 | N/A | 40% + Difference Between Plan Allowance and Billed Amount | N/A | N/A | N/A | N/A | N/A | 30% $275 Max | Member Pays All Charges |
| Treatment, Devices, and Services – Applied Behavioral Analysis (ABA) Treatment, Devices, and Services – This is the amount you pay for Applied Behavior Analysis (ABA) coverage. | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $35 Copayment Or $50 Copayment | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Chiropractic Treatment, Devices, and Services – Your cost share for chiropractic care. | Member Pays All Charges | Member Pays All Charges | $35 Copayment | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Occupational Therapy Treatment, Devices, and Services – Your cost share for occupational therapy. | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $35 Copayment Or $50 Copayment | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Physical Therapy Treatment, Devices, and Services – Your cost share for physical therapy. | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $35 Copayment Or $50 Copayment | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Speech Therapy Treatment, Devices, and Services – Your cost share for speech therapy. | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $35 Copayment Or $50 Copayment | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Professional Services (Mental Health and Substance Use Disorder) Treatment, Devices, and Services – This is the member copayment for Professional Services Mental Health and Substance Use Disorder treatment | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $35 Copayment | Member Pays All Charges | Member Pays All Charges | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Inpatient Hospital (Mental Health and Substance Use Disorder Services) Treatment, Devices, and Services – This is the member copayment for Inpatient Hospital Mental Health and Substance Use Disorder Services | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $350 Copayment | Member Pays All Charges | Member Pays All Charges | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $75 Copayment $750 Max | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Outpatient Hospital (Mental Health and Substance Use Disorder Services) Treatment, Devices, and Services – This is the member copayment for Outpatient Hospital Mental Health and Substance Use Disorder Services | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $35 Copayment | Member Pays All Charges | Member Pays All Charges | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Infertility Services Treatment, Devices, and Services – Member cost for Diagnosis and Treatment Infertility Services | 15% | 40% + Difference Between Plan Allowance and Billed Amount | 30% | Member Pays All Charges | Member Pays All Charges | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Fertility Preservation Procedures (e.g., iatrogenic infertility) (Infertility Services) Treatment, Devices, and Services – Member Cost of Fertility Preservation Procedures (e.g., iatrogenic infertility) (Infertility Services) | 15% | 40% + Difference Between Plan Allowance and Billed Amount | 30% | Member Pays All Charges | Member Pays All Charges | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Artificial Insemination Services (e.g. ICI, IVI, IUI) Treatment, Devices, and Services – Specifies what coverage Carrier provides for artificial insemination procedures and services | 15% | 40% + Difference Between Plan Allowance and Billed Amount | 30% | Member Pays All Charges | Member Pays All Charges | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | Member Pays All Charges 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Assisted Reproductive Technology (ART) (e.g., IVF, GIFT, ZIFT) (Infertility Services) Treatment, Devices, and Services – Specifies what portion of the ART medical and pharmacy services the plan pays vs what portion of the medical services the member pays | Member Pays All Charges | Member Pays All Charges | Member Pays All Charges | Member Pays All Charges | Member Pays All Charges | Member Pays All Charges | Member Pays All Charges | Member Pays All Charges | Member Pays All Charges |
| Treatment, Devices, and Services – Surgical Procedures Treatment, Devices, and Services – Member cost associated with Surgical Procedures | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $150 Copayment | Member Pays All Charges | Member Pays All Charges | 5% | 35% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Reconstructive Surgery Treatment, Devices, and Services – Member cost associated with Reconstructive Surgery | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $150 Copayment | Member Pays All Charges | Member Pays All Charges | 5% | 35% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Gender Affirming Surgery Treatment, Devices, and Services – Member cost associated with Gender Affirming Surgery | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $150 Copayment | Member Pays All Charges | Member Pays All Charges | 5% | 35% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Hearing Services Treatment, Devices, and Services – Member cost Associated with Hearing Services | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $35 Copayment Or $50 Copayment | Member Pays All Charges | Member Pays All Charges | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Hearing Aids (External) Treatment, Devices, and Services – Member cost Associated with Hearing Aids (External) | Not Covered | Not Covered | Covered | Not Covered | Covered | Not Covered | Not Covered | Covered | Covered |
| Treatment, Devices, and Services – Maternity Care Treatment, Devices, and Services – Member cost associated with Prenatal Care, Screening for Gestational Diabetes, Delivery, and Postpartum Care (Maternity Care) | Member Pays Nothing | 40% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | Member Pays All Charges | Member Pays All Charges | 0% | 35% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Maternity Care – Hospital Stay Treatment, Devices, and Services – Member cost Associated with Hospital Stay–Vaginal Birth, Cesarean Birth (Maternity Care) | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $350 Copayment | Member Pays All Charges | Member Pays All Charges | 0% | 35% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Hospice Care Treatment, Devices, and Services – Member cost Associated with Hospice Care | 15% | 40% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | Member Pays All Charges | Member Pays Nothing | 5% $30000 Max | 35% + Difference Between Plan Allowance and Billed Amount $30000 Max | $5 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Home Health Services (Skilled Nursing Care) Treatment, Devices, and Services – Member Cost Associated with Home Health Services (Skilled Nursing Care) | 15% | 40% + Difference Between Plan Allowance and Billed Amount | Member Pays All Charges | Member Pays All Charges | Member Pays All Charges | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Durable Medical Equipment Treatment, Devices, and Services – Member cost Associated with Durable medical Equipment | 15% | 40% + Difference Between Plan Allowance and Billed Amount | 30% | Member Pays All Charges | Member Pays All Charges | 5% | 35% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Outpatient Rehabilitation (Skilled Nursing Care Facility) Treatment, Devices, and Services – Member Cost Associated with Outpatient Rehabilitation (Skilled Nursing Care Facility) | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $35 Copayment | Member Pays All Charges | Member Pays All Charges | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $75 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Diabetes Education Treatment, Devices, and Services – Member Cost Associated with Diabetes Education | Member Pays Nothing | Member Pays All Charges | $35 Copayment Or $50 Copayment | Member Pays All Charges | Member Pays All Charges | Member Pays Nothing | Member Pays Nothing | Member Pays Nothing | Member Pays All Charges |
| Treatment, Devices, and Services – Nutritional Counseling Treatment, Devices, and Services – Member Cost Associated with Nutritional Counseling | Member Pays Nothing | Member Pays All Charges | Member Pays Nothing | Member Pays All Charges | Member Pays All Charges | 0% | 35% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | 40% + Difference Between Plan Allowance and Billed Amount |
| Dental – Routine Dental Exams and Cleaning for Adults Dental – Does the plan cover Preventive Dental for Adults? | Yes | No | Yes | N/A | N/A | Yes | Yes | No | No |
| Dental – Routine Dental Exams and Cleaning for Children Dental – Does the plan cover Preventive Dental for Children? | Yes | No | Yes | N/A | N/A | Yes | Yes | No | No |
| Dental – Minor Restorative for Adults Dental – Does the plan cover Minor Restorative for Adults (e.g., fillings, local anesthesia)? | No | No | No | N/A | N/A | Yes | Yes | No | No |
| Dental – Minor Restorative for Children Dental – Does the plan cover Minor Restorative for Children (e.g., fillings, local anesthesia)? | No | No | No | N/A | N/A | Yes | Yes | No | No |
| Dental – Major Restorative for Adults Dental – Does the plan cover Major Restorative for Adults (e.g., endodontics, crowns, prosthodontics)? | No | No | No | N/A | N/A | No | No | No | No |
| Dental – Major Restorative for Children Dental – Does the plan cover Major Restorative for Children (e.g., endodontics, crowns, prosthodontics)? | No | No | No | N/A | N/A | No | No | No | No |
| Dental – Orthodontic Dental – Does the plan cover Orthodontics? | No | No | No | N/A | N/A | No | No | No | No |
| Vision – Routine Eye Exams Vision – Does the plan cover Routine Eye Exams? | Yes | Yes | No | N/A | N/A | Yes | Yes | No | No |
| Vision – Eye Exams for Medical Condition or Non-Surgical Treatment Vision – Does the plan cover Eye Exams for Medical Condition or Non-Surgical Treatment? | Yes | Yes | Yes | N/A | N/A | Yes | Yes | Yes | Yes |
| Vision – Eyeglass Frames & Lenses Vision – Does the plan cover Eyeglass Frames and Lenses? | Yes | Yes | No | N/A | N/A | Yes | Yes | Yes | Yes |
| Vision – Contacts Vision – Does the plan cover Contacts? | Yes | Yes | No | N/A | N/A | Yes | Yes | Yes | Yes |
| Alternative Care – Alternative Care Alternative Care – Your plan may cover some type of alternative care such as: acupuncture, massage therapy, hypnotherapy, holistic medicine, Yoga, herbal treatments, or naturopathic services. Please consult the plan brochure for more information. | Yes | Yes | Yes | N/A | N/A | Yes | Yes | Yes | Yes |
| Alternative Care – Chronic Disease Management: Asthma Alternative Care – Is Chronic Disease Management of Asthma covered? | Covered | Not Covered | Covered | Not Covered | Not Covered | Covered | Covered | Covered | Covered |
| Alternative Care – Chronic Disease Management: Heart Disease Alternative Care – Is Chronic Disease Management of Heart Disease covered? | Covered | Not Covered | Covered | Not Covered | Not Covered | Covered | Covered | Covered | Covered |
| Alternative Care – Chronic Disease Management: Hypertension Alternative Care – Is Chronic Disease Management of Hypertension covered? | Covered | Not Covered | Covered | Not Covered | Not Covered | Covered | Covered | Covered | Covered |
| Alternative Care – Chronic Disease Management: Obesity Alternative Care – Is Chronic Disease Management of Obesity covered? | Covered | Not Covered | Covered | Not Covered | Not Covered | Covered | Covered | Covered | Covered |
Key: Outstanding Excellent Good Fair Poor NA (NA is displayed if a plan did not report or is unable to report a result in this coverage area.)
| Plans | Aetna HealthFund HDHP and Aetna Direct Plan (HDHP) | Blue Cross and Blue Shield Service Benefit Plan (Basic) | GEHA Benefit Plan (HDHP) | MHBP Consumer Option (HDHP) |
|---|---|---|---|---|
| Quality – Controlling High Blood Pressure People with high blood pressure receive effective treatment. | ||||
| Quality – Hemoglobin A1c Control for Patients with Diabetes Do people with diabetes have their condition under control? | ||||
| Quality – Timeliness of Prenatal Care Pregnant women receive care in the first trimester. | ||||
| Quality – Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis Ages 18 to 64 Appropriate use of antibiotics for acute bronchitis. | ||||
| Quality – Asthma Medication Ratio Appropriate ratio of controller medications to total asthma medications. | ||||
| Quality – Breast Cancer Screening Do women who need screening mammograms get them? | ||||
| Quality – Follow Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence 30 day Follow-up appointment within 30 days of discharge. | ||||
| Quality – Follow Up After Emergency Department Visit for Mental Illness 30 day Follow-up appointment within 30 days of discharge. | ||||
| Quality – Childhood Immunization Status—Combination 10 Recommended well-child visits completed. | ||||
| Quality – Use of Imaging Studies for Low Back Pain Appropriate treatment of lower back pain. | ||||
| CustomerService – Overall Plan Satisfaction How pleased are customers with the plan overall? | ||||
| CustomerService – Claims Processing How quickly do customers say the plan handles claims? | NA | NA | NA | |
| CustomerService – Getting Needed Care Members report getting the care they need. | ||||
| CustomerService – Coordination of Care Members say that their doctors know about care from other providers. | NA |
Understanding High Deductible Health Plans (HDHPs)
All the plans compared in the table above are High Deductible Health Plans (HDHPs). HDHPs are characterized by lower premiums and higher deductibles compared to traditional health plans. This means you’ll generally pay less each pay period, but you’ll need to pay more out-of-pocket before your plan starts covering healthcare costs.
A key feature of many HDHPs is their compatibility with Health Savings Accounts (HSAs) or Health Reimbursement Arrangements (HRAs). HSAs and HRAs are tax-advantaged accounts that can help you save and pay for qualified medical expenses. Contributions to HSAs are tax-deductible, and funds grow tax-free. Withdrawals for qualified medical expenses are also tax-free. HRAs are typically funded by your employer.
Key Considerations for HDHPs:
- Lower Premiums: HDHPs generally have lower bi-weekly premiums, which can result in significant savings throughout the year, especially if you are generally healthy and don’t anticipate high healthcare costs.
- Higher Deductibles: You will need to meet a higher deductible before your plan starts to pay for most services. This means you’ll pay more out-of-pocket initially.
- Health Savings Account (HSA) or Health Reimbursement Arrangement (HRA): Take advantage of the HSA or HRA offered with many HDHPs. These accounts provide a tax-advantaged way to pay for healthcare expenses. The medical account contributions listed in the table are funds provided by the plan to help you with your deductible.
- Preventive Care: Typically, HDHPs cover preventive care services at 100%, meaning you won’t have to pay anything out-of-pocket for these services, even before meeting your deductible.
- Cost-Effectiveness: HDHPs can be cost-effective if you are healthy, don’t require frequent medical care, and are comfortable with a higher deductible in exchange for lower premiums and the benefits of an HSA or HRA.
How to Use This OPM Health Plan Comparison Tool
This comparison tool is designed to help you quickly evaluate and compare different OPM health plans based on costs and network features. Here’s how to effectively use it:
- Identify Your Needs: Consider your and your family’s healthcare needs. Do you anticipate needing frequent medical care? Do you prefer lower premiums or lower out-of-pocket costs when you need care? Are prescription drug costs a major concern?
- Compare Premiums: Look at the “Biweekly Premium” rows for “Self,” “Self Plus One,” and “Self & Family” to see the cost of each plan per pay period. Choose the enrollment type that fits your family situation.
- Evaluate Deductibles and Out-of-Pocket Maximums: Understand the “Annual Deductible,” “Net Deductible,” and “Annual Out-of-Pocket Maximum.” A lower deductible means you’ll start receiving plan benefits sooner, but premiums might be higher. The out-of-pocket maximum is the most you’ll pay for covered in-network services in a plan year.
- Check Medical Account Contributions: For HDHPs with HSAs/HRAs, note the “Medical Account Contribution.” This is essentially “free money” to help offset your deductible and healthcare costs. “Net Deductible” already factors in this contribution, giving you a clearer picture of your actual deductible responsibility.
- Review Coverage Details: While this table focuses on costs and networks, carefully review the plan brochures for detailed coverage information on services you frequently use, such as primary care visits, specialist visits, prescription drugs, mental health services, and specific treatments you may need.
- Consider Medicare Integration: If you are eligible for or have Medicare, pay close attention to the sections on “Member Cost with Medicare A & B Primary” and “Member Cost with Medicare Advantage (Part C) Primary.” These sections outline how the plans coordinate with Medicare and your potential costs.
- Utilize Plan Links and Contact Information: Use the provided “Plan Links” to visit each plan’s website for more detailed information and to access provider directories. The “Telephone Number” is also listed for direct inquiries.
Disclaimer: This comparison tool provides a simplified overview. Always consult the official plan brochures for complete benefit details and the most accurate information. Premiums and plan details can change, so verify the latest information on the OPM website and plan brochures before making your enrollment decision.
By carefully comparing these OPM health plan options and considering your personal healthcare needs, you can make an informed decision and select the best health coverage for you and your family.
