Maine Plan guide

Transcription

1 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Maine Plan guide The health of business, well planned. Plans effective October 1, 2012 For businesses with eligible employees ME (6/12)

2 ME (6/12) Team with Aetna for the health of your business Introducing a new suite of products and services designed specifically for companies with 2 to 100 eligible employees. Health benefits and health insurance, dental benefits/dental insurance, life insurance and disability insurance plans/policies are offered, underwritten or administered by Aetna Health Inc. and/or Aetna Life Insurance Company (Aetna). 2

3 You can count on Aetna to provide health plans that help simplify decision making and plan administration so you can focus on the health of your business ME (6/12) Aetna is committed to helping employers build healthy businesses. In today s rapidly changing economy, we recognize the need for less expensive, less complex health plan choices. Now, Aetna offers a variety of newly streamlined medical and dental benefits and insurance plans to provide more affordable options and to help simplify plan selection and administration. In this guide: 5 Small-business commitment 5 Benefits for every stage of life 6 Medical overview 8 Managing health care expenses 10 Medical plan options 24 Dental overview 26 Dental plan options 33 Life & disability overview 36 Life & disability plan options 38 Underwriting guidelines 48 Product specifications 58 Limitations and exclusions 3

4 Employers and their employees can benefit from Affordable plan options Online self-service tools and capabilities Enhanced services for consumer-directed health plans 24-hour access to Employee Assistance Program services Preventive care covered 100% Aetna disease management and wellness programs With Aetna, we know it s about... Options We provide a variety of health plan options to help meet your employees needs, including medical, dental, disability and life insurance. And, with access to a wide network of health care providers, you can be sure that employees have options in how they access their health care. Medical plans HSA-compatible plans Hospital plans Up-front plans Dental plans PPO Indemnity Life and disability plans* Basic life Supplemental life AD&D Ultra Supplemental AD&D Ultra Dependent life Short-term disability Long-term disability Simplicity We know that the health of your business is your top priority. Aetna s streamlined plans and variety of services make it easier for you to focus on your business by simplifying administration and management. Aetna makes it easy to manage health insurance benefits with simplified enrollment, billing and claims processing so you can focus on what matters most. Trust We work hard to provide health plan solutions you can trust. Our account executives, underwriters and customer service representatives are committed to providing businesses and their employees with service they can trust. Aetna resources are designed to fortify the health of your business Track medical claims and take advantage of online services with your Aetna Navigator secure member website. It features automated enrollment, personal health records and printable temporary member ID cards. Get real cost and health information to help make the right care decision with an online Cost of Care Estimator. Manage health records online with the Personal Health Record. Use the Aetna Health Connections SM Disease Management Program, which provides personal support to members to help them manage their conditions. Leverage 24/7 access to a nurse to help with personal health-related questions. Help members work toward health goals with wellness initiatives, such as the Simple Steps to a Healthier Life online program. Take advantage of discount programs for vision, dental, and general health care that encourage use of plan offerings. *For groups 51 to 100 please consult your sales representative for a plan design to meet your group needs. 4

5 Aetna is committed to the health of your business We understand that your business has unique needs. That s why we have streamlined our plan options for employers with 2 to 100 employees. We are committed to providing you with value and quality you can count on. Our variety of products and services allows you to focus on the health of your business. Aetna s health plan options are designed with the health of your business in mind Basic plans Basic benefits for your employees Limit the expense to your business Allow employees to buy up and share more of the cost --ME HNOnly 1000 HD 20/35 --ME HNOnly 3000 UD 25/45 --ME PPO 2500/80 Value plans Encourage employee responsibility in their health care decisions Tools and resources to support consumerism Innovative plan design --ME HNOnly 3000/90 HSA Compatible --ME HNOnly 5000/90 HSA Compatible --ME PPO 2500/80 HSA Compatible Standard plans Standard benefits plans Limit the financial impact on employees --ME HNOnly 500 HD 20/ ME PPO 1000/ ME PPO 1500/80 Health insurance benefits for every stage of life For young individuals and couples without children Lower monthly payments Modest out-of-pocket costs Quality preventive care Prescription drug coverage Financial protection HSA-compatible plans Hospital plans Up-front plans For married couples and single parents with teens and college-aged children Checkups and care for injuries and illness Preventive care and screenings that promote a healthy lifestyle National network of health care providers HSA-compatible plans Hospital plans For married couples and single parents with young children or teens Lower fees for office visits Lower monthly payments Caps on out-of-pocket expenses Quality preventive care for the entire family Hospital plans For men and women 55 years of age and over with no children at home Financial security Quality prescription drug coverage Hospital inpatient/outpatient services Emergency care HSA-compatible plans Hospital plans Up-front plans 5

6 Aetna Medical Overview At Aetna, we are committed to putting the employee at the center of everything we do. You can count on Aetna to provide health plans that help simplify decision making and plan administration so you can focus on the health of your business. 6

7 Medical Overview Maine Provider network All medical plans are available in the following counties: Androscoggin Hancock Oxford Somerset Aroostock Kennebec Penobscot Waldo Cumberland Knox Piscataquis Washington Franklin Lincoln Sagahadoc York Product Name Product Description PCP Required Referrals Required DocFind Plan Name PPO Aetna Health Network Only SM (HNOnly) Traditional Choice (TC) PPO plan members can see any recognized provider for covered services without a referral. Each time members seek health care, they have the freedom to choose either network providers at lower out-of-pocket costs, or non-network providers at higher out-of-pocket costs. Aetna Health Network Only (HNOnly) is a health maintenance organization plan that uses a network of participating providers. Each family member may select a primary care physician (PCP) participating in the Aetna network to provide routine and preventive care and help coordinate the member s total health care. Members never need a referral when visiting a participating specialist for covered services. Only services rendered by a participating provider are covered, except for emergency or urgently needed care. This indemnity plan option is available for employees who live outside the plan s network service area. Members coordinate their own health care and may see any recognized provider for covered services without a referral. No No Open Choice PPO Optional No Aetna Health Network Only SM (Open Access) No No N/A 7

8 Aetna High-Deductible HSA-Compatible Health Network Only and PPO plans Health Network Only and PPO health plans are compatible with a health savings account (HSA). HSA-compatible plans provide integrated medical and pharmacy benefits. Preventive care services are exempt from the. HSAs provide employers and their qualified employees with an affordable tax-advantaged solution that allows them to better manage their qualified medical and dental expenses. Employees can build a savings fund to help cover their future medical and dental expenses. HSAs can be funded by the employer or employee and are portable. Fund contributions may be tax (limits apply). When funds are used to cover qualified out-of-pocket medical and dental expenses, they are not taxed. It is completely at the discretion of the employer or employee whether or not to establish an HSA. Note: Employers and employees should consult with their tax advisor to determine eligibility requirements and tax advantages for participation in the HSA plan. No Cost Health Incentive Credit Members can earn $50 in just a few simple steps Members earn a $50 credit toward their out-of-pocket expenses when they: Complete or update their Health Assessment on Simple Steps To A Healthier Life. Complete one online wellness program. If the employee s spouse is covered under the plan, he or she is also eligible for the same incentive credit. So a family could save $100 in out-of-pocket expenses each year. Incentive rewards will be credited toward the and maximum out-of-pocket limit. This program is included at no additional cost, except with HSA-compatible plans. COBRA administration Aetna COBRA administration offers a full range of notification, documentation and record-keeping processes that can help employers manage the complex billing and notification processes required for COBRA compliance, while also helping to save them time and money. Health Savings Account (HSA) No set-up or administrative fees The Aetna HealthFund HSA, when coupled with an HSA-compatible high- health benefits and health insurance plan, is a tax-advantaged savings account. Once enrolled, either the employee or the employer can make account contributions. The HSA can be used to pay for qualified expenses tax free. Member s HSA plan You own your HSA Contribute tax free You choose how and when to use your dollars Roll it over each year and let it grow Earns interest, tax free Today Use for qualified expenses with tax-free dollars Future Plan for future and retiree health-related costs High- health plan Eligible in-network preventive care services will not be subject to the You pay 100% until is met, then only pay a share of the cost Meet out-of-pocket maximum, then plan pays 100% Not applicable to HSA-compatible plans. 8

9 Section 125 Cafeteria Plans and Section 132 Transit Reimbursement Accounts Employees can reduce their taxable income, and employers can pay less in payroll taxes. There are three ways to save: Premium-Only Plans (POP) Employees can pay for their portion of the group health insurance expenses on a pretax basis. First-year POP fees are waived with the purchase of medical coverage with five or more enrolled employees. Flexible Savings Account (FSA) FSAs give employees a chance to save for health expenses with pretax money. Health care spending accounts allow employees to set aside pretax dollars to pay for out-of-pocket expenses as defined by the IRS. Dependent care spending accounts allow participants to use pretax dollars to pay child or elder care expenses. Transit Reimbursement Account (TRA) TRAs allow participants to use pretax dollars to pay transportation and parking expenses for the purpose of commuting to and from work. Group Situs Medical and dental benefits and rates are based on the group s headquarters location, subject to applicable state laws. Eligible employees who live or work in CT and ME (the situs region) will receive the same rates and benefits as the headquarters location. Multi-State Solution We offer a multi-state solution to make it easier for businesses like yours to do business with us. We believe it brings more consistency across medical benefits offerings to employers with employees in multiple locations. Employers based in Maine can offer ME PPO plans to their employees who live and work outside of the situs region. The situs region comprises Maine and Connecticut. The rates and benefits will match those offered in Maine. If the out-of-situs employee lives in a non-network area, the employee will be enrolled in an indemnity plan. Plan sponsors will need to continue to meet underwriting guidelines, subject to all applicable state laws. In all instances, extraterritorial benefits that may apply on any of the out-of-situs employees will be implemented where required. Administrative Fees Fee description HSA Initial set-up $0 Monthly fees $0 POP Fee Initial set-up* $175 Renewal $100 HRA and FSA** Initial set-up* 1 25 employees $ employees $ employees $550 Renewal fee 1 25 employees $ employees $ employees $325 Monthly fees*** $5.25 per participant Additional set-up fee for stacked plans $150 (those electing an Aetna HRA and FSA simultaneously) Participation fee for stacked participants $10.25 per participant Minimum fees 1 25 employees $25 per month minimum employees $50 per month minimum TRA Annual fee $350 Transit monthly fees $4.25 per participant Parking monthly fees $3.15 per participant COBRA (federal) Annual fee employees $ employees $175 Per employee per month employees $ employees $1.02 Initial notice fee $1.50 per notice (includes notices at time of implementation and during ongoing administration) Monthly fee $0.88 per employee * Nondiscrimination testing provided annually after open enrollment for POP and FSA only. Additional off-cycle testing available at employer request for $100 fee. Nondiscrimination testing only available for FSA and POP products. ** Aetna FSA pricing is inclusive for POP. Debit cards are available for FSA only. Contact Aetna for further information. *** For HRA, if the employer opts out of Streamline, the fee is increased $1.50 per participant. For FSA, the debit card is available for an additional $1 per participant per month. Mailing reimbursement checks direct to employee homes is an additional $1 per participant per month. Aetna HRAs are subject to employer-defined use and forfeiture rules. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Information subject to change. Aetna reserves the right to change any of the above fees and to impose additional fees upon prior written notice. 9

10 Aetna Health Network Only (HNOnly) HSA Compatible Plan Options* Plan Options ME HNOnly 2500/90 HSA Compatible ME HNOnly 3000/90 HSA Compatible ME HNOnly 4000/90 HSA Compatible ME HNOnly 5000/90 HSA Compatible Member Benefits In-network In-network In-network In-network Member Coinsurance 10% after 10% after 10% after 10% after Calendar Year Deductible** (Embedded) $2,500 Individual $5,000 Family $3,000 Individual $6,000 Family $4,000 Individual $8,000 Family $5,000 Individual $10,000 Family Calendar Year Out-of-Pocket Maximum** (Embedded) $3,500 Individual $7,000 Family $5,000 Individual $10,000 Family $5,500 Individual $11,000 Family $ 6,050 Individual $12,100 Family Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Primary Care Physician Office Visit 0% after 0% after 0% after 0% after Specialist Office Visit 10% after 10% after 10% after 10% after Preventive Care Well-Child Exams, Immunizations, Adult Physicals, 0%; Routine Gyn Exams, Routine Mammograms, Routine DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply) 0%; 0%; 0%; Vision Eyewear $100 every 24 months $100 every 24 months $100 every 24 months $100 every 24 months Aetna Vision SM Discount Program Included Included Included Included Outpatient Services (Lab and X-ray) Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) 10% after 10% after 10% after 10% after 10% after 10% after 10% after 10% after Inpatient Hospital 10% after 10% after 10% after 10% after Outpatient Surgery 10% after 10% after 10% after 10% after Emergency Room 10% after 10% after 10% after 10% after Urgent Care 10% after 10% after 10% after 10% after Outpatient Rehabilitation Therapy (50 combined visits per calendar year for physical, occupational and speech therapy) Chiropractic Services (36 visits per calendar year) Durable Medical Equipment ($2,500 calendar year maximum) 10% after 10% after 10% after 10% after 10% after 10% after 10% after 10% after 10% after 10% after 10% after 10% after Prescription Drugs Retail and Mail Order (MOD) (1x copay up to a 30-day retail supply 2x copay up to 31- to 90-day retail/mod supply) After integrated is met, $10/$35/$50 After integrated is met, $10/$35/$50 After integrated is met, $10/$35/$50 After integrated is met, $10/$35/$50 Specialty Care Drugs After integrated is met, 50% up to a maximum of After integrated is met, 50% up to a maximum of After integrated is met, 50% up to a maximum of After integrated is met, 50% up to a maximum of See pages for footnotes. 10

11 Aetna Health Network Only (HNOnly) HSA Compatible Plan Options* Plan Options ME HNOnly 2500/90 HSA Compatible 51+ ME HNOnly 3000/90 HSA Compatible 51+ ME HNOnly 4000/90 HSA Compatible 51+ ME HNOnly 5000/90 HSA Compatible 51+ Member Benefits In-network In-network In-network In-network Member Coinsurance 10% after 10% after 10% after 10% after Calendar Year Deductible** (Embedded) $2,500 Individual $5,000 Family $3,000 Individual $6,000 Family $4,000 Individual $8,000 Family $5,000 Individual $10,000 Family Calendar Year Out-of-Pocket Maximum** (Embedded) $3,500 Individual $7,000 Family $5,000 Individual $10,000 Family $5,500 Individual $11,000 Family $6,050 Individual $12,100 Family Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Primary Care Physician Office Visit 10% after 10% after 10% after 10% after Specialist Office Visit 10% after 10% after 10% after 10% after Preventive Care Well-Child Exams, Immunizations, Adult Physicals, 0%; Routine Gyn Exams, Routine Mammograms, Routine DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply) 0%; 0%; 0%; Vision Eyewear $100 every 24 months $100 every 24 months $100 every 24 months $100 every 24 months Aetna Vision SM Discount Program Included Included Included Included Outpatient Services (Lab and X-ray) Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) 10% after 10% after 10% after 10% after 10% after 10% after 10% after 10% after Inpatient Hospital 10% after 10% after 10% after 10% after Outpatient Surgery 10% after 10% after 10% after 10% after Emergency Room 10% after 10% after 10% after 10% after Urgent Care 10% after 10% after 10% after 10% after Outpatient Rehabilitation Therapy (50 combined visits per calendar year for physical, occupational and speech therapy) Chiropractic Services (36 visits per calendar year) Durable Medical Equipment ($2,500 calendar year maximum) 10% after 10% after 10% after 10% after 10% after 10% after 10% after 10% after 10% after 10% after 10% after 10% after Prescription Drugs Retail and Mail Order (MOD) (1x copay up to a 30-day retail supply 2x copay up to 31- to 90-day retail/mod supply) After Integrated is met, $10/$35/$50 After Integrated is met, $10/$35/$50 After Integrated is met, $10/$35/$50 After Integrated is met, $10/$35/$50 Specialty Care Drugs After Integrated is met, 50% up to a maximum of After Integrated is met, 50% up to a maximum of After Integrated is met, 50% up to a maximum of After Integrated is met, 50% up to a maximum of See pages for footnotes. 11

12 Aetna Health Network Only (HNOnly) Plan Options* Plan Options ME HNOnly 1000 HD 20/35 ME HNOnly 2000 UD 25/45 ME HNOnly 3000 UD 25/45 ME HNOnly 4000 UD 25/50 ME HNOnly 7500 UD 30/50 Member Benefits In-network In-network In-network In-network In-network Member Coinsurance N/A 30% after 30% after 30% after 30% after Calendar Year Deductible** (Embedded) $1,000 Individual $2,000 Family $2,000 Individual $4,000 Family $3,000 Individual $6,000 Family $4,000 Individual $8,000 Family $7,500 Individual $15,000 Family Calendar Year Out-of-Pocket Maximum** (Embedded) $2,500 Individual $5,000 Family $4,000 Individual $8,000 Family $5,000 Individual $10,000 Family $6,000 Individual $12,000 Family $9,500 Individual $19,000 Family Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Unlimited Primary Care Physician Office Visit $20 copay; $25 copay; $25 copay; $25 copay; $30 copay; Specialist Office Visit $35 copay; $45 copay; $45 copay; $50 copay; $50 copay; Preventive Care Well-Child Exams, Immunizations, Adult Physicals, $0 copay; Routine Gyn Exams, Routine Mammograms, Routine DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply) $0 copay; $0 copay; $0 copay; $0 copay; Vision Eyewear $100 every 24 months $100 every 24 months $100 every 24 months $100 every 24 months $100 every 24 months Aetna Vision SM Discount Program Included Included Included Included Included Outpatient Services (Lab and X-ray) $35 copay; $35 copay after $45 copay after $50 copay after $50 copay after Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) 20%; 30% after 30% after 30% after 30% after Inpatient Hospital 20% after 30% after 30% after 30% after 30% after Outpatient Surgery 20% after 30% after 30% after 30% after 30% after Emergency Room (Copay waived if admitted) $150 copay; $150 copay; $200 copay; $200 copay; $200 copay; Urgent Care $150 copay; $150 copay; $200 copay; $200 copay; $200 copay; Outpatient Rehabilitation Therapy (50 combined visits per calendar year for physical, occupational and speech therapy) $35 copay; 30% after 30% after 30% after 30% after Chiropractic Services (36 visits per calendar year) $35 copay; 30% after 30% after 30% after 30% after Durable Medical Equipment ($2,500 calendar year maximum) 20%; 30% after 30% after 30% after 30% after Prescription Drugs Retail and Mail Order (MOD) (1x copay up to a 30-day retail supply 2x copay up to 31- to 90-day retail/mod supply) Specialty Care Drugs $10/$35/$50 $10/$35/$50 $10/$35/$50 $10/$35/$50 $10/$35/$50 50% up to a maximum of $200 per scrip for up to a 30-day supply and up to a maximum of $400 per scrip for up to a 31- to 50% up to a maximum of $200 per scrip for up to a 30-day supply and up to a maximum of $400 per scrip for up to a 31- to 50% up to a maximum of $200 per scrip for up to a 30-day supply and up to a maximum of $400 per scrip for up to a 31- to 50% up to a maximum of $200 per scrip for up to a 30-day supply and up to a maximum of $400 per scrip for up to a 31- to 50% up to a maximum of $200 per scrip for up to a 30-day supply and up to a maximum of $400 per scrip for up to a 31- to See pages for footnotes. 12

13 Aetna Health Network Only (HNOnly) Plan Option* Plan Options Member Benefits Member Coinsurance Calendar Year Deductible** (Embedded) Calendar Year Out-of-Pocket Maximum** (Embedded) Lifetime Maximum Benefit Primary Care Physician Office Visit Specialist Office Visit ME HNOnly 500 HD 20/ In-network N/A $500 Individual $1,000 Family $2,500 Individual $5,000 Family Unlimited $20 copay; $30 copay; Preventive Care Well-Child Exams, Immunizations, Adult Physicals, $0 copay; Routine Gyn Exams, Routine Mammograms, Routine DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply) Vision Eyewear $100 every 24 months Aetna Vision SM Discount Program Outpatient Services (Lab and X-ray) Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) Inpatient Hospital Outpatient Surgery Emergency Room (Copay waived if admitted) Urgent Care Outpatient Rehabilitation Therapy (50 combined visits per calendar year for physical, occupational and speech therapy) Chiropractic Services (36 visits per calendar year) Durable Medical Equipment ($2,500 calendar year maximum) Included $30 copay; 20%; 20% after 20% after $125 copay; $125 copay; $30 copay; $30 copay; 20%; Prescription Drugs Retail and Mail Order (MOD) (1x copay up to a 30-day retail supply 2x copay up to 31- to 90-day retail/mod supply) Specialty Care Drugs $10/$35/$50 50% up to a maximum of $200 per scrip for up to a 30-day supply and up to a maximum of $400 per scrip for up to a 31- to See pages for footnotes. 13

14 Aetna Open Choice PPO HSA Compatible Plan Options* Plan Options ME PPO 2500/80 HSA Compatible ME PPO 3500/80 HSA Compatible Member Benefits Network Out-of-network Network Out-of-network Member Coinsurance 20% after 40% after 20% after 40% after Calendar Year Deductible** (Embedded) $2,500 Individual $5,000 Family $5,000 Individual $10,000 Family $3,500 Individual $7,000 Family $7,000 Individual $14,000 Family Calendar Year Maximum Out-of-Pocket Limit** (Embedded) $5,000 Individual $10,000 Family $10,000 Individual $20,000 Family $5,500 Individual $11,000 Family $11,000 Individual $22,000 Family Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Non-Specialist Office Visit 20% after 40% after 20% after 40% after Specialist Office Visit 20% after 40% after 20% after 40% after Preventive Care Well-Child Exams, Immunizations, Adult Physicals, 0%; Routine Gyn Exams, Routine Mammograms, Routine DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply) 40% after 0%; 40% after Vision Eyewear (Network and out-of-network combined) $100 every 24 months $100 every 24 months Aetna Vision SM Discount Program Included Included Outpatient Services (Lab and X-ray) Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) 20% after 40% after 20% after 40% after 20% after 40% after 20% after 40% after Inpatient Hospital 20% after 40% after 20% after 40% after Outpatient Surgery 20% after 40% after 20% after 40% after Emergency Room 20% after Paid as network 20% after Paid as network Urgent Care 20% after Paid as network 20% after Paid as network Outpatient Rehabilitation Therapy (50 combined visits per calendar year for physical, occupational and speech therapy; network and out-of-network combined) Chiropractic Services (36 visits per calendar year; network and out-of-network combined) Durable Medical Equipment ($2,500 calendar year maximum; network and out-of-network combined) 20% after 40% after 20% after 40% after 20% after 40% after 20% after 40% after 20% after 40% after 20% after 40% after Prescription Drugs Retail and Mail Order (MOD) (1x copay up to a 30-day retail supply 2x copay up to 31- to 90-day retail/mod supply) After integrated is met, $10/$35/$50 After integrated is met, 20% of submitted cost after $10/$35/ $50 After integrated is met, $10/$35/$50 After integrated is met, 20% of submitted cost after $10/$35/ $50 Specialty Care Drugs After integrated is met, 50% up to a maximum of After integrated is met, 50% up to a maximum of After integrated is met, 50% up to a maximum of After integrated is met, 50% up to a maximum of See pages for footnotes. 14

15 Aetna Open Choice PPO HSA Compatible Plan Options* Plan Options ME PPO 4500/80 HSA Compatible Member Benefits Network Out-of-network Member Coinsurance 20% after 40% after Calendar Year Deductible** (Embedded) Calendar Year Maximum Out-of-Pocket Limit** (Embedded) $4,500 Individual $9,000 Family $6,050 Individual $12,100 Family $9,000 Individual $18,000 Family $18,000 Individual $36,000 Family Lifetime Maximum Benefit Unlimited Unlimited Non-Specialist Office Visit 20% after 40% after Specialist Office Visit 20% after 40% after Preventive Care Well-Child Exams, Immunizations, Adult Physicals, 0%; Routine Gyn Exams, Routine Mammograms, Routine DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply) 40% after Vision Eyewear (Network and out-of-network combined) Aetna Vision SM Discount Program Outpatient Services (Lab and X-ray) Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) $100 every 24 months Included 20% after 40% after 20% after 40% after Inpatient Hospital 20% after 40% after Outpatient Surgery 20% after 40% after Emergency Room 20% after Paid as network Urgent Care 20% after Paid as network Outpatient Rehabilitation Therapy (50 combined visits per calendar year for physical, occupational and speech therapy; network and out-of-network combined) Chiropractic Services (36 visits per calendar year; network and out-of-network combined) Durable Medical Equipment ($2,500 calendar year maximum; network and out-of-network combined) 20% after 40% after 20% after 40% after 20% after 40% after Prescription Drugs Retail and Mail Order (MOD) (1x copay up to a 30-day retail supply 2x copay up to 31- to 90-day retail/mod supply) After integrated is met, $10/$35/$50 After integrated is met, 20% of submitted cost after $10/$35/ $50 Specialty Care Drugs After integrated is met, 50% up to a maximum of After integrated is met, 50% up to a maximum of See pages for footnotes. 15

16 Aetna Open Choice PPO HSA Compatible Plan Options* Plan Options ME PPO 2500/80 HSA Compatible 51+ ME PPO 3000/100 HSA Compatible 51+ Member Benefits Network Out-of-network Network Out-of-network Member Coinsurance 20% after 40% after 0% after 20% after Calendar Year Deductible** (Embedded) $2,500 Individual $5,000 Family $5,000 Individual $10,000 Family $3,000 Individual $6,000 Family $4,500 Individual $9,000 Family Calendar Year Maximum Out-of-Pocket Limit** (Embedded) $5,000 Individual $10,000 Family $10,000 Individual $20,000 Family $3,500 Individual $7,000 Family $7,000 Individual $14,000 Family Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Non-Specialist Office Visit 20% after 40% after 0% after 20% after Specialist Office Visit 20% after 40% after 0% after 20% after Preventive Care Well-Child Exams, Immunizations, Adult Physicals, Routine Gyn Exams, Routine Mammograms, Routine DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply) 0%; 40% after 0%; 20% after Vision Eyewear (Network and out-of-network combined) $100 every 24 months $100 every 24 months Aetna Vision SM Discount Program Included Included Outpatient Services (Lab and X-ray) Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) 20% after 40% after 0% after 20% after 20% after 40% after 0% after 20% after Inpatient Hospital 20% after 40% after 0% after 20% after Outpatient Surgery 20% after 40% after 0% after 20% after Emergency Room 20% after Paid as network 0% after Paid as network Urgent Care 20% after Paid as network 0% after Paid as network Outpatient Rehabilitation Therapy (50 combined visits per calendar year for physical, occupational and speech therapy; network and out-of-network combined) Chiropractic Services (36 visits per calendar year; network and out-of-network combined) Durable Medical Equipment ($2,500 calendar year maximum; network and out-of-network combined) 20% after 40% after 0% after 20% after 20% after 40% after 0% after 20% after 20% after 40% after 0% after 20% after Prescription Drugs Retail and Mail Order (MOD) (1x copay up to a 30-day retail supply 2x copay up to 31- to 90-day retail/mod supply) After Integrated is met, $10/$35/$50 After Integrated is met, 20% of submitted cost after $10/$35/$50 After Integrated is met, $10/$35/$50 After Integrated is met, 20% of submitted cost after $10/$35/$50 Specialty Care Drugs After Integrated is met, 50% up to a maximum of After Integrated is met, 50% up to a maximum of After Integrated is met, 50% up to a maximum of After Integrated is met, 50% up to a maximum of See pages for footnotes. 16

17 Aetna Open Choice PPO HSA Compatible Plan Options* Plan Options ME PPO 3500/80 HSA Compatible 51+ ME PPO 4500/80 HSA Compatible 51+ Member Benefits Network Out-of-network Network Out-of-network Member Coinsurance 20% after 40% after 20% after 40% after Calendar Year Deductible** (Embedded) $3,500 Individual $7,000 Family $7,000 Individual $14,000 Family $4,500 Individual $9,000 Family $9,000 Individual $18,000 Family Calendar Year Maximum Out-of-Pocket Limit** (Embedded) $5,500 Individual $11,000 Family $11,000 Individual $22,000 Family $6,050 Individual $12,100 Family $18,000 Individual $36,000 Family Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Non-Specialist Office Visit 20% after 40% after 20% after 40% after Specialist Office Visit 20% after 40% after 20% after 40% after Preventive Care Well-Child Exams, Immunizations, Adult Physicals, Routine Gyn Exams, Routine Mammograms, Routine DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply) 0%; 40% after 0%; 40% after Vision Eyewear (Network and out-of-network combined) $100 every 24 months $100 every 24 months Aetna Vision SM Discount Program Included Included Outpatient Services (Lab and X-ray) Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) 20% after 40% after 20% after 40% after 20% after 40% after 20% after 40% after Inpatient Hospital 20% after 40% after 20% after 40% after Outpatient Surgery 20% after 40% after 20% after 40% after Emergency Room 20% after Paid as network 20% after Paid as network Urgent Care 20% after Paid as network 20% after Paid as network Outpatient Rehabilitation Therapy (50 combined visits per calendar year for physical, occupational and speech therapy; network and out-of-network combined) Chiropractic Services (36 visits per calendar year; network and out-of-network combined) Durable Medical Equipment ($2,500 calendar year maximum; network and out-of-network combined) 20% after 40% after 20% after 40% after 20% after 40% after 20% after 40% after 20% after 40% after 20% after 40% after Prescription Drugs Retail and Mail Order (MOD) (1x copay up to a 30-day retail supply 2x copay up to 31- to 90-day retail/mod supply) After Integrated is met, $10/$35/$50 After Integrated is met, 20% of submitted cost after $10/$35/$50 After Integrated is met, $10/$35/$50 After Integrated is met, 20% of submitted cost after $10/$35/$50 Specialty Care Drugs After Integrated is met, 50% up to a maximum of After Integrated is met, 50% up to a maximum of After Integrated is met, 50% up to a maximum of After Integrated is met, 50% up to a maximum of See pages for footnotes. 17

18 Aetna Open Choice PPO Plan Options* Plan Options ME PPO 1500/80 ME PPO 2500/80 Member Benefits Network Out-of-network Network Out-of-network Member Coinsurance 20% after 40% after 20% after 40% after Calendar Year Deductible** (Embedded) $1,500 Individual $3,000 Family $3,000 Individual $6,000 Family $2,500 Individual $5,000 Family $4,000 Individual $8,000 Family Calendar Year Maximum Out-of-Pocket Limit** (Embedded) $4,000 Individual $8,000 Family $6,000 Individual $12,000 Family $5,000 Individual $10,000 Family $6,500 Individual $13,000 Family Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Non-Specialist Office Visit $30 copay; 40% after $30 copay; 40% after Specialist Office Visit $45 copay; 40% after $45 copay; 40% after Preventive Care Well-Child Exams, Immunizations, Adult Physicals, $0 copay; Routine Gyn Exams, Routine Mammograms, Routine DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply) 40% after $0 copay; 40% after Vision Eyewear (Network and out-of-network combined) $100 every 24 months $100 every 24 months Aetna Vision SM Discount Program Included Included Outpatient Services (Lab and X-ray) $45 copay after 40% after $45 copay after 40% after Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) 20% after 40% after 20% after 40% after Inpatient Hospital 20% after 40% after 20% after 40% after Outpatient Surgery 20% after 40% after 20% after 40% after Emergency Room (Copay waived if admitted) $150 copay; Paid as network $150 copay; Paid as network Urgent Care $150 copay; Paid as network $150 copay; Paid as network Outpatient Rehabilitation Therapy (50 combined visits per calendar year for physical, occupational and speech therapy; network and out-of-network combined) Chiropractic Services (36 visits per calendar year; network and out-of-network combined) Durable Medical Equipment ($2,500 calendar year maximum; network and out-of-network combined) 20% after 40% after 20% after 40% after 20% after 40% after 20% after 40% after 20% after 40% after 20% after 40% after Prescription Drugs Retail and Mail Order (MOD) (1x copay up to a 30-day retail supply 2x copay up to 31- to 90-day retail/mod supply) $10/$35/$50 20% of submitted cost after $10/$35/$50 $10/$35/$50 20% of submitted cost after $10/$35/$50 Specialty Care Drugs 50% up to a maximum of 50% up to a maximum of 50% up to a maximum of 50% up to a maximum of See pages for footnotes. 18

19 Aetna Open Choice PPO Plan Options* Plan Options ME PPO 3500/80 ME PPO 5000/80 Member Benefits Network Out-of-network Network Out-of-network Member Coinsurance 20% after 40% after 20% after 40% after Calendar Year Deductible** (Embedded) $3,500 Individual $7,000 Family $5,000 Individual $10,000 Family $5,000 Individual $10,000 Family $7,500 Individual $15,000 Family Calendar Year Maximum Out-of-Pocket Limit** (Embedded) $6,000 Individual $12,000 Family $7,500 Individual $15,000 Family $7,000 Individual $14,000 Family $10,000 Individual $20,000 Family Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Non-Specialist Office Visit $30 copay; 40% after $30 copay; 40% after Specialist Office Visit $45 copay; 40% after $50 copay; 40% after Preventive Care Well-Child Exams, Immunizations, Adult Physicals, $0 copay; Routine Gyn Exams, Routine Mammograms, Routine DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply) 40% after $0 copay; 40% after Vision Eyewear (Network and out-of-network combined) $100 every 24 months $100 every 24 months Aetna Vision SM Discount Program Included Included Outpatient Services (Lab and X-ray) $45 copay after 40% after $50 copay after 40% after Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) 20% after 40% after 20% after 40% after Inpatient Hospital 20% after 40% after 20% after 40% after Outpatient Surgery 20% after 40% after 20% after 40% after Emergency Room (Copay waived if admitted) $150 copay; Paid as network $150 copay; Paid as network Urgent Care $150 copay; Paid as network $150 copay; Paid as network Outpatient Rehabilitation Therapy (50 combined visits per calendar year for physical, occupational and speech therapy; network and out-of-network combined) Chiropractic Services (36 visits per calendar year; network and out-of-network combined) Durable Medical Equipment ($2,500 calendar year maximum; network and out-of-network combined) 20% after 40% after 20% after 40% after 20% after 40% after 20% after 40% after 20% after 40% after 20% after 40% after Prescription Drugs Retail and Mail Order (MOD) (1x copay up to a 30-day retail supply 2x copay up to 31- to 90-day retail/mod supply) $10/$35/$50 20% of submitted cost after $10/$35/$50 $10/$35/$50 20% of submitted cost after $10/$35/$50 Specialty Care Drugs 50% up to a maximum of 50% up to a maximum of 50% up to a maximum of 50% up to a maximum of See pages for footnotes. 19

20 Aetna Open Choice PPO Plan Option* Plan Option ME PPO 1000/ Member Benefits Network Out-of-network Member Coinsurance 10% after 30% after Calendar Year Deductible** (Embedded) Calendar Year Maximum Out-of-Pocket Limit** (Embedded) $1,000 Individual $2,000 Family $2,500 Individual $5,000 Family $2,000 Individual $4,000 Family $5,000 Individual $10,000 Family Lifetime Maximum Benefit Unlimited Unlimited Non-Specialist Office Visit Specialist Office Visit Preventive Care $20 copay; $30 copay; 30% after 30% after Well-Child Exams, Immunizations, Adult Physicals, $0 copay; Routine Gyn Exams, Routine Mammograms, Routine DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply) 30% after Vision Eyewear (Network and out-of-network combined) Aetna Vision SM Discount Program $100 every 24 months Included Outpatient Services (Lab and X-ray) $30 copay after 30% after Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) 10% after 30% after Inpatient Hospital 10% after 30% after Outpatient Surgery 10% after 30% after Emergency Room (Copay waived if admitted) Urgent Care $100 copay; $100 copay; Paid as network Paid as network Outpatient Rehabilitation Therapy (50 combined visits per calendar year for physical, occupational and speech therapy; network and out-of-network combined) Chiropractic Services (36 visits per calendar year; network and out-of-network combined) Durable Medical Equipment ($2,500 calendar year maximum; network and out-of-network combined) 10% after 30% after 10% after 30% after 10% after 30% after Prescription Drugs Retail and Mail Order (MOD) (1x copay up to a 30-day retail supply 2x copay up to 31- to 90-day retail/mod supply) Specialty Care Drugs $10/$35/$50 20% of submitted cost after $10/$35/$50 50% up to a maximum of 50% up to a maximum of See pages for footnotes. 20

21 Aetna Traditional Choice Plan Option* Plan Option ME Traditional Choice 2500/80 Member Benefits Member Coinsurance Calendar Year Deductible** (Embedded) Calendar Year Out-of-Pocket Maximum** (Embedded) Lifetime Maximum Benefit Non-Specialist Office Visit Specialist Office Visit 20% after $2,500 Individual $5,000 Family $4,500 Individual $9,000 Family Unlimited 20% after 20% after Preventive Care Well-Child Exams, Immunizations, Adult Physicals, 0%; Routine Gyn Exams, Routine Mammograms, Routine DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply) Vision Eyewear Aetna Vision SM Discount Program Outpatient Services (Lab and X-ray) Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) Inpatient Hospital Outpatient Surgery Emergency Room Urgent Care Outpatient Rehabilitation Therapy (50 combined visits per calendar year for physical, occupational and speech therapy) Chiropractic Services (36 visits per calendar year) Durable Medical Equipment ($2,500 Calendar Year Maximum) $100 every 24 months Included 20% after 20% after 20% after 20% after 20% after 20% after 20% after 20% after 20% after Prescription Drugs Retail and Mail Order (MOD) (1x copay up to a 30-day retail supply 2x copay up to 31- to 90-day retail/mod supply) Specialty Care Drugs $10/$35/$50 50% up to a maximum of See pages for footnotes. 21

22 Medical Plans for Eligible Enrolling Footnotes * This is a partial description of benefits available. For more information, refer to the specific plan design summary. Dollar amount copayments and percentage coinsurance amounts indicate what the member is required to pay. ** HNOnly HSA Compatible plans: Only those out-of-pocket expenses resulting from the application of, coinsurance percentage and copays, including prescription drug copays, may be used to satisfy the out-of-pocket maximum. Once the family /maximum out-of-pocket limit is met, all family members will be considered as having met their /maximum out-of-pocket limit for the remainder of the calendar year. No one family member may contribute more than the individual /maximum out-of-pocket limit to the family /maximum out-of-pocket limit. Deductible carryover is not included. PPO HSA Compatible plans: All covered expenses, including prescription drugs, accumulate separately toward the network and out-of-network and maximum out-of-pocket limit; only those out-of-pocket expenses resulting from the application of, coinsurance percentage and copays, including prescription drug copays, may be used to satisfy the maximum out-of-pocket limit; and certain services may not apply toward the or maximum out-of-pocket limit. Once the family /maximum out-of-pocket limit is met, all family members will be considered as having met their /maximum out-of-pocket limit for the remainder of the calendar year. No one family member may contribute more than the individual /maximum out-of-pocket limit to the family /maximum out-of-pocket limit. Deductible carryover is not included. HNOnly plans: Only those out-of-pocket expenses resulting from the application of and coinsurance percentage may be used to satisfy the out-of-pocket maximum; and certain services may not apply toward the or out-of-pocket maximum. Once the family /out-of-pocket maximum is met, all family members will be considered as having met their / out-of-pocket maximum for the remainder of the calendar year. No one family member may contribute more than the individual /out-of-pocket maximum amount to the family /out-of-pocket maximum. Deductible carryover is not included. PPO: All covered expenses accumulate separately toward the network and out-of-network and maximum out-of-pocket limit. Only those out-of-pocket expenses resulting from the application of and coinsurance percentage may be used to satisfy the maximum out-of-pocket limit; and certain services may not apply toward the or maximum out-of-pocket limit. Once the family /maximum out-of-pocket limit is met, all family members will be considered as having met their /maximum out-of-pocket limit for the remainder of the calendar year. No one family member may contribute more than the individual /maximum out-of-pocket limit to the family /maximum out-of-pocket limit. Deductible carryover is not included. Traditional Choice plan: All covered expenses accumulate toward the and maximum out-of-pocket limit. Only those out-of-pocket expenses resulting from the application of and coinsurance percentage may be used to satisfy the maximum out-of-pocket limit; and certain services may not apply toward the or maximum out-of-pocket limit. Once the family / maximum out-of-pocket limit is met, all family members will be considered as having met their /maximum out-of-pocket limit for the remainder of the calendar year. No one family member may contribute more than the individual /maximum out-of-pocket limit to the family /maximum out-of-pocket limit. Deductible carryover is not included. 22

23 Based upon United States Treasury guidance available as of the print date. Pharmacy plans include prior authorization and step-therapy. 90-Day transition of coverage (TOC) for prior authorization and step-therapy included on pharmacy plans. Transition of coverage for prior authorization and step-therapy helps members of new groups to transition to Aetna by providing a 90-calendar-day opportunity, beginning on the group s initial effective date, during which time prior authorization and step-therapy requirements will not apply to certain drugs. Once the 90 calendar days has expired, prior authorization and step-therapy edits will apply to all drugs requiring prior authorization and step-therapy as listed in the formulary guide. Members who have claims paid for a drug requiring prior authorization and step-therapy during the transition of coverage period may continue to receive this drug after the 90 calendar days and will not be required to obtain a prior authorization or approval for a medical exception for this drug. NOTE: step-therapy and TOC for step-therapy are not included on HSA Compatible plans. The integrated is waived for certain preventive medications. Please refer to for the Preventive Medications listing. Some benefits are subject to limitations or visit maximums. Members or providers may be required to precertify or obtain prior approval for certain services such as non-emergency hospital care. We cover the cost of services based on whether doctors are in network or out of network. We want to help you understand how much Aetna pays for your out-of-network care. At the same time, we want to make it clear how much more you will need to pay for this out-of-network care. You may choose a provider (doctor or hospital) in our network. You may choose to visit an out-of-network provider. If you choose a doctor who is out of network, your Aetna health plan may pay some of that doctor s bill. Most of the time, you will pay a lot more money out of your own pocket if you choose to use an out-of-network doctor or hospital. When you choose out-of-network care, Aetna limits the amount it will pay. This limit is called the recognized or allowed amount. When you choose out-of-network care, Aetna recognizes an amount based on what Medicare pays for these services. The government sets the Medicare rate. Your doctor sets his or her own rate to charge you. It may be higher sometimes much higher than what your Aetna plan recognizes. Your doctor may bill you for the dollar amount that Aetna doesn t recognize. You must also pay any copayments, coinsurance and s under your plan. No dollar amount above the recognized charge counts toward your or out-of-pocket maximums. To learn more about how we pay out-of-network benefits visit Type how Aetna pays in the search box. You can avoid these extra costs by getting your care from Aetna s broad network of health care providers. Go to and click on Find a Doctor on the left side of the page. If you are already a member, sign on to your Aetna Navigator member site. This applies when you choose to get care out of network. When you have no choice (for example: emergency room visit after a car accident, or for other emergency services), we will pay the bill as if you got care in network. You pay cost sharing and s for your in-network level of benefits. Contact Aetna if your provider asks you to pay more. You are not responsible for any outstanding balance billed by your providers for emergency services beyond your cost sharing and s. Women s Preventive Health Benefits: The following Women s Preventive Health Benefits generally are covered at no cost share, when provided in network: Well-woman visits (annually and now including prenatal visits) Screening for gestational diabetes Human papillomavirus (HPV) DNA testing Counseling for sexually transmitted infections Counseling and screening for human immunodeficiency virus (HIV) Screening and counseling for interpersonal and domestic violence Breastfeeding support, supplies and counseling Generic formulary contraceptives are covered without member cost-share (for example, no copayment). Certain religious organizations or religious employers may be exempt from offering contraceptive services. Note: For a summary list of Limitations and Exclusions, refer to pages