Nevada plan guide. Creating the right health benefits package starts with you and your employees

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1 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Nevada plan guide Creating the right health benefits package starts with you and your employees Plans effective January 1, 2015 For businesses with employees XX.XX.XXX.X NV (X/14) B (8/14)

2 Choosing the right health plan Every company has its own particular needs, driven in part by the health of its employees, by its commitment to health and wellness and, of course, by its financial resources. We believe creating the right health benefits and insurance plan means combining these four options to meet a company s specific needs: benefits, network, cost sharing, funding. Experience matters We take the time to listen and learn about your needs. Our experience allows us to share knowledge and provide tools to help achieve the right balance of cost and coverage. Our approach makes all the difference in the value you get from your plan, and in the satisfaction of your employees. Today s health care environment demands a new set of solutions to meet new challenges. Together, we can create a healthy future for your company and your employees. Health/Dental benefits, health/dental insurance, life and disability insurance plans/policies are offered by Aetna Health Inc., Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). Each insurer has sole financial responsibility for its own products.

3 We want to make choosing the right benefits as easy as possible. So we ve organized information in this easy-to-understand guide. M D V L&D U Health care reform 4 Plans, tools and extras 6 7 Network options, cost sharing and premiums 8 Health and wellness programs 9 Medical plans overview 10 Medical plan options 11 PPO plans 16 HMO plans 23 HNOption plans 24 Indemnity plan 25 Dental plans overview 28 Aetna standard 2 9 dental plans 30 Aetna voluntary 3 9 dental plans 32 Aetna dental plans 34 Vision plans overview 39 Aetna Vision SM Preferred 41 Life and disability plans overview 44 Life 47 Short-Term Disability 48 Long-Term Disability 49 Packaged Life and Disability 50 Underwriting guidelines 51 Limitations and exclusions 77 New business checklist 80 3

4 Information about your plan due to health care reform Signed into law in March 2010, the Affordable Care Act is the most life-changing law since the passing of Medicare in the 1960s. We are committed to following the new health care law and to helping you understand its impact. We have outlined below key changes that may impact your health care benefits. Essential health benefits package Aetna plans must offer standard coverage known as essential health benefits. This includes all plans inside and outside of the health insurance exchanges. These benefits provide your employees with essential health benefits, and limit cost sharing. Here are the broad categories of essential benefits that will be included in your employees coverage: Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance abuse services Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric dental Pediatric vision Out-of-pocket (OOP) maximum mandate All cost sharing must apply toward the OOP maximum, including in-network medical, behavioral health and pharmacy cost sharing. This does not include premiums, out-of-network bills for amounts over the plan s recognized charges or spending for non-covered services. The out-of-pocket maximum must include: Copays Deductibles Coinsurance Fees These fees are included in your premium: Health Insurer Fee Annual fee to offset premium subsidies and tax credit related expenses Transitional Reinsurance Program Contribution Helps finance the cost of high-risk individuals in the individual market Patient-Centered Outcomes Research Fee (also known as the Comparative Effectiveness Fee) Fee to fund clinical outcomes effectiveness research Guaranteed issue Guaranteed issue of health insurance coverage applies to individual, small group and large group markets. Guaranteed issue is available for: Group health plans/insurance coverage (insured only) Individual health insurance coverage (including medical conversion) Pharmacy (insured only) Behavioral health (insured only)* Please note that guaranteed issue is not available for: Self-funded plans Standalone/separate dental or vision Hospital indemnity/fixed indemnity Medicare and Medicare Supplement Medicaid Retiree-only plans Grandfathered plans Association/MEWA plans Waiting period Plans may not have any waiting periods longer than 90 days. The maximum 90-day waiting period applies to fully insured and self-funded plans. We will update our policies and will work with employers that have waiting periods exceeding 90 days. *No standalone insured behavioral health. 4

5 Pediatric dental/vision for children up to age 19 (2 to 50) Pediatric dental and vision mandates are a separate essential health benefit category and are included with your medical benefits. We will cover those services in 2015 according to the benchmark plan coverage. Pediatric dental Plan name PPO plans PPO HSA plans PPO 100% plan Participating Nonparticipating Participating Nonparticipating Participating Nonparticipating Dental checkup (a/k/a preventive/diagnostic) 0%; deductible 30% after deductible 0% after deductible 30% after deductible 0%; deductible 30% after deductible Dental basic 30% after deductible 50% after deductible 30% after deductible 50% after deductible 0% after deductible 50% after deductible Dental major 50% after deductible 50% after deductible 50% after deductible 50% after deductible 0% after deductible 50% after deductible Dental ortho (after 24 months of continuous coverage) 50% after deductible 50% after deductible 50% after deductible 50% after deductible 0% after deductible 50% after deductible Plan Name HMO plans with deductible HMO plans with no deductible Indemnity Participating Participating No network Dental checkup (a/k/a preventive/diagnostic) 0%; deductible 0% 0%; deductible Dental basic 30% after deductible 30% 30% after deductible Dental major 50% after deductible 50% 50% after deductible Dental ortho (after 24 months of continuous coverage) 50% after deductible 50% 50% after deductible Pediatric vision Plan name PPO plans PPO HSA plans HMO plans with deductible HMO plans with no deductible Indemnity Participating Nonparticipating Participating Nonparticipating Participating Participating No network Vision exam (one exam per 12 months) 0%; deductible 50% after deductible 0%; deductible 50% after deductible 0%; deductible 0% 20%; deductible Frames, lenses or contacts (per 12 months) 0%; deductible 50% after deductible 0% after deductible 50% after deductible 0%; deductible 0% 0%; deductible These plans do not cover all vision or dental expenses and have exclusions and limitations. Members should refer to their plan documents to determine which services are covered and to what extent. 5

6 Choosing the right plan for your business Our product portfolio includes a range of coverage and cost combinations. You ll find choices for different budgets and benefits strategies. And you ll see that we re more than medical. You can round out your benefits offering with dental as well as life and disability offerings. Take a look at what s available. Medical plans HSA-compatible plans HMO plans PPO plans Indemnity plans Plan levels You can choose up to four levels of health plans. These levels are named using metals bronze, silver, gold and platinum. Each level includes the same essential health benefits. But the levels differ in how much the health plan pays. Health plan levels Bronze 60% Silver 70% Gold 80% Platinum 90% Average amount the plan pays for covered services Visit the health care reform section on for more information. Or talk with your broker. Tools to help your employees stay healthy, informed and productive With Aetna health plans, your employees get online tools and helpful resources that let them make the most of their benefits. Our most popular tools include: Secure member website. Your employees get self-service tools, plus health plan and health information through their Aetna Navigator website. Think of it as the key that unlocks the full value of their health benefits package. Encourage them to sign up at Member Payment Estimator. With an Aetna health plan, your employees can compare and estimate costs* for office visits, tests, surgeries and more. This means they can save money** and avoid surprises. This online tool factors in their deductible, coinsurance and copays, plus contracted rates. They can see how much they have to pay and how much the plan will pay. They can log in to their Aetna Navigator member website to use the tool. Online provider directory. Finding doctors, specialists, hospitals and more in the Aetna network is easy with our DocFind search tool. It s available at and the Aetna Navigator member website. My Life Values. Your employees get 24/7 online services and support for managing their everyday personal and work matters. itriage ( employees). This is a free mobile app that lets members research symptoms and diseases, find a medical provider and even book an appointment all from the convenience of their mobile device. itriage will guide them to network doctors, hospitals and facilities based on your company health plan. It can help direct your employees to the most appropriate, cost-effective care. * Estimated costs not available in all markets. The tool gives you an estimate of what you would owe for a particular service based on your plan at that very point in time. Actual costs may differ from the estimate if, for example, claims for other services are processed after you get your estimate but before the claim for this service is submitted. Or, if the doctor or facility performs a different service at the time of your visit. ** In 2011, members who used Member Payment Estimator before receiving care saved an average of $170 out of pocket on 34 common procedures, according to the Member Payment Estimator Study, Aetna Informatics and Product Development, August

7 Dental plans Dental Maintenance Organization or DMO plan (2 9 enrolled employees) PPO Dental plan extras There s extra value built into our dental portfolio: Dental-medical integration. Our program encourages preventive dental care among employees who have diabetes or heart disease, or who are pregnant. This can lead to more of your employees taking steps to stay healthy. Vision plans Aetna Vision SM Preferred plans Vision plan extras Choice and convenience and flexibility. Members have the choice to go to any vision provider. Plus, for added convenience, members can easily schedule an eye exam online with some participating providers. Our plans help members fit vision care in to their lifestyle and our bundled plan options provide the administrative ease of having one bill, one renewal and one trusted company to work for you. The value of a balanced network. We offer a balanced network of independent eye care providers as well as in-network retail providers that include most preferred national optical retail chains offering flexible evening and weekend hours. Discounts. Aetna Vision Preferred plan offers additional savings on contact lenses, eyeglasses, prescription sunglasses, LASIK vision correction and more at most in-network locations. Availability varies by state. Life and disability plans* Basic term life insurance Packaged life and disability Life and disability plan extras Aetna Life Essentials SM. Through our program, your employees get access to expert advice on legal and financial matters at no added cost. Plus, they get discounts on health products and services, like fitness and vision care.** Funeral planning and concierge service. Through our partnership with Everest, we offer our life members pre-planning and at-need services. Aetna Return to Work Solutions SM Program. Our returnto-work solutions provide customers with the support and resources they need to help get valued employees back to work safely and as soon as possible. *For groups 51 to 100, please consult your sales representative for a plan design to meet your group needs. **These services are discount programs, not insurance. 7

8 Choose from a wide range of health benefits and insurance options to fit your needs About our benefits Choose from numerous, integrated benefits options that can lead to improved employee engagement and health, while helping you manage your costs. This includes medical, pharmacy, dental, life, disability and vision. Plus, online tools that help employees use their benefits wisely and get help when they need it. About our network We have many full-network and tiered-network options to lower employer costs while still providing employees with access to quality care. Our doctor networks prioritize quality and efficiency to improve the health care experience and make it easy for individuals to get the care they need. About our cost sharing Some of our cost-sharing arrangements encourage employees to become more involved in their own health care and become better health care consumers. Employees with these plans receive more preventive care, have lower overall costs and use online tools more frequently. Cost sharing and premiums for every budget Your focus is on lower costs. Increasingly, that means greater levels of employee cost sharing. With Aetna in your corner, you can map out a strategy based on your employee base and price point. And you can choose from the full spectrum of health plan types. 8

9 Health and wellness programs Having a happier, healthier workforce is important to you. So is cost management. We ve found that helping your employees get more involved in managing their health and well-being is a great way to meet these goals. Talk to your broker or Aetna representative to learn more about our programs. Wellness on us Wellness for employees means a healthier business for employers. As always, our business health benefits and insurance plans offer $0 copays for in-network preventive care. It s one more way to help employees get a step closer to better health. Preventive care benefits with no copay Immunizations Routine physicals Child wellness visits Routine mammogram Routine OB/GYN visits 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 Simple Steps To A Healthier Life health assessment, and Complete one online health program Women s preventive health benefits These services are generally 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, certain brand formulary contraceptives are covered without member copayment; certain religious organizations or religious employers may be exempt from offering contraceptive services We make things easy for you Health plan management and administration is our specialty, which makes it easier for you to manage health insurance benefits with: eenrollment. Handle enrollments, terminations and other changes online, with less paperwork and greater efficiency. ebilling. Save time and simplify reconciliation and payment, anytime, anywhere, with our secure system. It lets you get, view and pay all your medical and dental bills online. 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 deductible and maximum out-of-pocket limit. This program is included at no additional cost on all plans except HMO and HSA-compatible plans. Wellness programs can make health and fitness part of everyday living Women s health and preventive health reminders Simple Steps To A Healthier Life program Informed Health 24-hour nurse line** Aetna discount programs Personal Health Record *Does not apply to plans without a deductible, HSA-compatible plans or HMO plans. ** While only your doctor can diagnose, prescribe or give medical advice, the Informed Health Line nurses can provide information on more than 5,000 health topics. Contact your doctor first with any questions or concerns regarding your health care needs. 9

10 10 Aetna medical overview Medical coverage can be a deal-breaker in recruiting and keeping talented employees. Our medical plan portfolio was designed with the needs of businesses like yours in mind. You ll find flexible options, from traditional indemnity to consumer-directed plans. You can choose the plan design and benefits level that fits your budget and achieve the right balance of cost and coverage for your business.

11 Medical overview M We offer the in-state portfolio (MC) and rating structure to out-of-state employees who live in an out-of-state network area. Out-of-state employees who do not live in an out-of-state network area will be eligible for an indemnity plan. Product name Product description PCP required Referrals required Network name PPO Aetna Value Network SM (AVN) HMO Members can access any participating provider for covered services without a referral. When 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. Members are able to receive emergency services at the in-network/ participating coinsurance/copay level. A health maintenance organization (HMO) uses a network of participating providers. Each family member must select a primary care physician (PCP) from the Aetna network to provide routine and preventive care and help coordinate the member s total health care. Only services rendered by a participating provider are covered, except for emergency or urgently needed care. No No Open Choice PPO Yes Yes Aetna Value Network (AVN) HMO HNOption Indemnity Members have the benefits of a point of service plan with two easy ways to access care. They may visit any network doctor or hospital of their choice for covered services or they may choose to visit a provider outside the network. Best of all, members do not need referrals and receive lower out-of-pocket costs when using network providers. In addition, members are able to receive emergency services at the in-network coinsurance/copay level. Employees who live outside the plan s network service area are eligible. Members coordinate their own health care and may access any recognized provider for covered services without a referral. Optional No Aetna Health Network Option SM No No N/A (Open Access) 11

12 M Aetna high-deductible, HSA-compatible PPO plans Aetna high-deductible, HSA-compatible 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 deductible. 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. HSA accounts can be funded by the employer or employee and are portable. Fund contributions may be tax-deductible (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. Health savings account (HSA) No set-up or administrative fees The Aetna HealthFund HSA, when coupled with a high-deductible health benefits and health insurance plan, is a tax-advantaged savings account. Once enrolled, account contributions can be made by the employee and/or employer. The HSA can be used to pay for qualified expenses tax free. HSA account Member owns the HSA Contributions are tax free Member chooses how and when to use HSA dollars Roll it over each year and let it grow Earns interest, tax free Today or in the future Use now for qualified expenses with tax-free dollars Plan for future and retiree health-related costs High-deductible health plan Eligible in-network preventive care services will not be subject to the deductible You pay 100 percent until deductible is met, then only pay a share of the cost Meet out-of-pocket maximum, then plan pays 100 percent Health reimbursement arrangement (HRA)* The Aetna HealthFund HRA combines the protection of a deductible-based health plan with a health fund that pays for eligible health care services. The member cannot contribute to the HRA, and employers have control over HRA plan designs and fund rollover. The fund is available to an employee for qualified expenses on the plan s effective date. The HRA and the HSA provide members with financial support for higher out-of-pocket health care expenses. Our consumer-directed health products and services give members the information and resources they need to help make informed health care decisions for themselves and their families while helping lower employers costs.** 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. Section 125 cafeteria plans and Section 132 transit reimbursement accounts You can pay less in payroll taxes and employees can reduce their taxable income. 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. 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. *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. 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. 12

13 Administrative fees M Fee description Fee Premium-only plan (POP) Health reimbursement arrangement (HRA) and flexible spending account (FSA)** Initial set-up* $190 $125 Initial set-up 2 25 employees $360 $ employees $460 $ employees $560 $335 Monthly fees*** Additional set-up fee for stacked plans (those electing an Aetna HRA and FSA simultaneously) Participation fee for stacked participants Minimum fees $5.45 per participant $150 $10.45 per participant 0 25 employees $25 per month minimum employees $50 per month minimum COBRA services Annual fee employees $ employees $230 Per employee per month employees $ employees $1.05 Initial notice fee Minimum fees Renewal fee Renewal fee $3.00 per notice (includes notices at time of implementation and during ongoing administration) employees $25 per month minimum employees $50 per month minimum Transit reimbursement account (TRA) Annual fee $350 Transit monthly fees Parking monthly fees $4.25 per participant $3.15 per participant * 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 us for more 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. HRAs are subject to employer-defined use and forfeiture rules, and are unfunded liabilities of your employer. Fund balances are not vested benefits. Aetna reserves the right to change any of the above fees and to impose additional fees upon prior written notice. 13

14 M Nevada provider network* County Aetna Open Choice PPO Aetna HNOption Aetna Value Network HMO County Aetna Open Choice PPO Aetna HNOption Aetna Value Network HMO Carson City + Churchill + Clark Douglas + Elko + Eureka + Humboldt + Lander + Mineral + Nye (Southern) + + Nye (Northern) + Pershing + Storey + Washoe (Southern) + + Washoe (Northern) + White Pine + Lyon + Large health care professional network* including more than 5,771 providers and 42 hospitals statewide Differences between 2 50 and Market Segments Plan benefit 2 50 Market Segment Market Segment Bariatric Surgery HMO/HNOption Included Included Bariatric Surgery PPO Included Not Included Hearing Exam/Hearing Aids Included Not Included Pediatric Dental Included Optional Vision Rider Pediatric Vision Vision exam and hardware included Optional Vision Rider Private Duty Nursing for Home Health Care Included Not Included Rx accumulates to OOP Max Included Included *Network subject to change. 14

15 Pick-A-Plan 3* M Pick-A-Plan 3 is our suite of plans designed specifically with small businesses in mind. These plans provide choice, flexibility and simplicity. Greater employee choice Employers can offer any of the three available plans.** Flexibility and affordability Employers can create a customized benefits package from any of our plan types and plan designs. We offer a variety of plans at different price points. Employers may designate a level of contribution that meets their budget. Pick-A-Plan 3 Target audience Plan choices Minimum participation 2 4 enrolled employees Every small business with 5+ enrolled employees Up to 3 of the available plans Choice of 1 or 2 plans Total freedom We offer plan choices that range in price and benefits to meet each individual employee s needs, whether they are lower premiums or lower out-of-pocket costs at the time services are received. Easy administration Setting up this program is simple: 1. The employer chooses up to three plans to offer on the employer application 2. The employer chooses how much to contribute 3. Each employee chooses the plan that s right for him or her 5 or more enrolled employees Employer contribution Pick-A-Plan 3 available 50 percent of the employee rate or $120 defined contribution or the actual cost of the plans picked, whichever is less. Teladoc benefits*** Teladoc benefits provide members and their eligible dependents with 24/7/365 access to U.S. board-certified doctors and pediatricians by phone or online. They can also get prescriptions, when appropriate, for medications to treat many medical issues. Speak with U.S. board-certified doctors Our national network includes the highest quality, state-licensed doctors who will call members back within 22 minutes, on average. Use it anywhere/anytime Whether on vacation or home with sick kids, your employees can reach Teladoc doctors anytime, 24/7/365 by phone and online video consultations. Save money Teladoc is $40 or less per consultation. That s less than an urgent care or ER visit, and Teladoc never costs more than a doctor visit. *Available with five or more enrolled employees. **One person must enroll in each plan chosen. *** Teladoc and Teladoc physicians are independent contractors and are neither agents nor employees of Aetna. Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescription will be written. Teladoc operates subject to state regulation and may not be available in certain states. Teladoc does not prescribe DEA controlled substances, nontherapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. Teladoc physicians reserve the right to deny care for potential misuse of services. 15

16 M PPO plans (2 100) Plan name Gold PPO 250 Copay Plan (2 50) PPO 250 Copay Plan (51 100) Gold PPO /50 (2 50) PPO /50 (51 100) Network available Open Choice PPO N/A Open Choice PPO N/A PCP/referrals required No N/A No N/A Member benefits Participating providers Nonparticipating providers1 Calendar year deductible Calendar year out-of-pocket limit $250 individual $500 family $6,000 individual $12,000 family $1,000 individual $2,000 family $12,000 individual $24,000 family Participating providers $500 individual $1,000 family $5,000 individual $10,000 family Deductible & out-of-pocket limit accumulation Embedded2 Embedded2 Not included in out-of-pocket limit Primary care physician office visit3 Specialist office visit3 Walk-in clinics3 Chiropractic (12 visits per calendar year) $25 copay; deductible $50 copay; deductible $25 copay; deductible $50 copay; deductible Amounts over allowable charges and failure to precertify penalty. 30% after deductible $25 copay; deductible 30% after deductible $50 copay; deductible 30% after deductible $25 copay; deductible 30% after deductible $50 copay; deductible Nonparticipating providers1 $1,000 individual $2,000 family $10,000 individual $20,000 family Amounts over allowable charges and failure to precertify penalty. 50% after deductible 50% after deductible 50% after deductible 50% after deductible Preventive care/screenings/immunizations No charge 30% after deductible No charge 50% after deductible Diagnostic testing3 (X-ray, blood work) Imaging (CT/PET scans MRIs) Lab: $25 copay; deductible X-ray: $25 copay; deductible $150 copay after deductible 30% after deductible Lab: $25 copay; deductible X-ray: $25 copay; deductible 50% after deductible 30% after deductible 20% after deductible 50% after deductible Pharmacy plan type Aetna Value Plus Four Tier formulary* Aetna Value Plus Four Tier formulary* Prescription drug deductible None None Prescription drugs Tier 1: preferred generic Tier 2: preferred brand Tier 3: nonpreferred generic & brand Retail: 30-day supply Mail order: 2.5 times retail copay, up to 90-day supply Tier 4: Aetna Specialty CareRx SM Includes preferred and nonpreferred self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin) Outpatient surgery OP hospital department & freestanding facility Inpatient hospital facility Rehabilitation services (PT/OT/ST) (2 50: 60 visits per calendar year combined : 30 visits per calendar year combined) $10/$50/$100 30% plus $10/$50/$100 $15/$50/$100 30% plus $15/$50/$100 30% up to $500 per prescription $500 copay after deductible $1,000 copay after deductible $25 copay; deductible Not covered 30% up to $500 per prescription Not covered 30% after deductible 20% after deductible 50% after deductible 30% after deductible 20% after deductible 50% after deductible 30% after deductible 20% after deductible 50% after deductible Emergency room $150 copay; deductible $200 copay; deductible Urgent care $50 copay; deductible $50 copay; deductible $50 copay; deductible Adult routine vision Available as a rider Available as a rider $50 copay; deductible Refer to page 26 for footnotes. 16

17 PPO plans (2 100) M Plan name Silver PPO /50 (2 50) PPO /50 (51 100) Silver PPO /50 (2 50) PPO /50 (51 100) Network available Open Choice PPO N/A Open Choice PPO N/A PCP/referrals required No N/A No N/A Member benefits Participating providers Nonparticipating providers1 Calendar year deductible Calendar year out-of-pocket limit $1,000 individual $2,000 family $6,000 individual $12,000 family $2,000 individual $4,000 family $12,000 individual $24,000 family Participating providers $1,500 individual $3,000 family $6,350 individual $12,700 family Deductible & out-of-pocket limit accumulation Embedded2 Embedded2 Not included in out-of-pocket limit Primary care physician office visit3 Specialist office visit3 Walk-in clinics3 Chiropractic (12 visits per calendar year) $30 copay; deductible $60 copay; deductible $30 copay; deductible $60 copay; deductible Amounts over allowable charges and failure to precertify penalty. 50% after deductible $30 copay; deductible 50% after deductible $60 copay; deductible 50% after deductible $30 copay; deductible 50% after deductible $60 copay; deductible Nonparticipating providers1 $3,000 individual $6,000 family $12,700 individual $25,400 family Amounts over allowable charges and failure to precertify penalty. 50% after deductible 50% after deductible 50% after deductible 50% after deductible Preventive care/screenings/immunizations No charge 50% after deductible No charge 50% after deductible Diagnostic testing3 (X-ray, blood work) Lab: $30 copay; deductible X-ray: $60 copay; deductible 50% after deductible Lab: $30 copay; deductible X-ray: $30 copay; deductible 50% after deductible Imaging (CT/PET scans MRIs) 20% after deductible 50% after deductible 25% after deductible 50% after deductible Pharmacy plan type Aetna Value Plus Four Tier formulary* Aetna Value Plus Four Tier formulary* Prescription drug deductible None None Prescription drugs Tier 1: preferred generic Tier 2: preferred brand Tier 3: nonpreferred generic & brand Retail: 30-day supply Mail order: 2.5 times retail copay, up to 90-day supply Tier 4: Aetna Specialty CareRx SM Includes preferred and nonpreferred self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin) Outpatient surgery OP hospital department & freestanding facility $25/$55/$100 30% plus $25/$55/$100 $20/$50/$100 30% plus $20/$50/$100 30% up to $500 per prescription Not covered 30% up to $500 per prescription Not covered 20% after deductible 50% after deductible 25% after deductible 50% after deductible Inpatient hospital facility 20% after deductible 50% after deductible 25% after deductible 50% after deductible Rehabilitation services (PT/OT/ST) (2 50: 60 visits per calendar year combined : 30 visits per calendar year combined) $30 copay; deductible 50% after deductible 25% after deductible 50% after deductible Emergency room $300 copay; deductible $300 copay; deductible Urgent care $50 copay; deductible $50 copay; deductible $50 copay; deductible Adult routine vision Available as a rider Available as a rider $50 copay; deductible Refer to page 26 for footnotes. 17

18 M PPO plans (2 100) Plan name Silver PPO /50 (2 50) PPO /50 (51 100) Silver PPO /50 (2 50) PPO /50 (51 100) Network available Open Choice PPO N/A Open Choice PPO N/A PCP/referrals required No N/A No N/A Member benefits Participating providers Nonparticipating providers1 Calendar year deductible Calendar year out-of-pocket limit $2,000 individual $4,000 family $6,350 individual $12,700 family $4,000 individual $8,000 family $12,700 individual $25,400 family Participating providers $2,500 individual $5,000 family $6,350 individual $12,700 family Deductible & out-of-pocket limit accumulation Embedded2 Embedded2 Not included in out-of-pocket limit Primary care physician office visit3 Specialist office visit3 Walk-in clinics3 Chiropractic (12 visits per calendar year) $30 copay; deductible $60 copay; deductible $30 copay; deductible $60 copay; deductible Amounts over allowable charges and failure to precertify penalty. 50% after deductible $30 copay; deductible 50% after deductible $60 copay; deductible 50% after deductible $30 copay; deductible 50% after deductible $60 copay; deductible Nonparticipating providers1 $5,000 individual $10,000 family $12,700 individual $25,400 family Amounts over allowable charges and failure to precertify penalty. 50% after deductible 50% after deductible 50% after deductible 50% after deductible Preventive care/screenings/immunizations No charge 50% after deductible No charge 50% after deductible Diagnostic testing3 (X-ray, blood work) Lab: $30 copay; deductible X-ray: $30 copay; deductible 50% after deductible Lab: $30 copay; deductible X-ray: $60 copay; deductible 50% after deductible Imaging (CT/PET scans MRIs) 20% after deductible 50% after deductible 30% after deductible 50% after deductible Pharmacy plan type Aetna Value Plus Four Tier formulary* Aetna Value Plus Four Tier formulary* Prescription drug deductible None None Prescription drugs Tier 1: preferred generic Tier 2: preferred brand Tier 3: nonpreferred generic & brand Retail: 30-day supply Mail order: 2.5 times retail copay, up to 90-day supply Tier 4: Aetna Specialty CareRx SM Includes preferred and nonpreferred self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin) Outpatient surgery OP hospital department & freestanding facility $15/$50/$100 30% plus $15/$50/$100 $10/$50/$100 30% plus $10/$50/$100 30% up to $500 per prescription Not covered 30% up to $500 per prescription Not covered 20% after deductible 50% after deductible 30% after deductible 50% after deductible Inpatient hospital facility 20% after deductible 50% after deductible 30% after deductible 50% after deductible Rehabilitation services (PT/OT/ST) (2 50: 60 visits per calendar year combined : 30 visits per calendar year combined) 20% after deductible 50% after deductible 30% after deductible 50% after deductible Emergency room $300 copay; deductible $300 copay; deductible Urgent care $50 copay; deductible $50 copay; deductible $50 copay; deductible Adult routine vision Available as a rider Available as a rider $50 copay; deductible Refer to page 26 for footnotes. 18

19 PPO plans (2 100) M Plan name Silver PPO /50 (2 50) PPO /50 (51 100) Silver PPO /50 (2 50) PPO /50 (51 100) Network available Open Choice PPO N/A Open Choice PPO N/A PCP/referrals required No N/A No N/A Member benefits Participating providers Nonparticipating providers1 Calendar year deductible Calendar year out-of-pocket limit $2,500 individual $5,000 family $6,350 individual $12,700 family $5,000 individual $10,000 family $12,700 individual $25,400 family Participating providers $3,000 individual $6,000 family $6,350 individual $12,700 family Deductible & out-of-pocket limit accumulation Embedded2 Embedded2 Not included in out-of-pocket limit Amounts over allowable charges and failure to precertify penalty. Primary care physician office visit3 50%; deductible 50% after deductible $30 copay; deductible Specialist office visit3 50%; deductible 50% after deductible $60 copay; deductible Walk-in clinics3 50%; deductible 50% after deductible $30 copay; deductible Chiropractic (12 visits per calendar year) 50%; deductible 50% after deductible $60 copay; deductible Nonparticipating providers1 $6,000 individual $12,000 family $12,700 individual $25,400 family Amounts over allowable charges and failure to precertify penalty. 50% after deductible 50% after deductible 50% after deductible 50% after deductible Preventive care/screenings/immunizations No charge 50% after deductible No charge 50% after deductible Diagnostic testing3 (X-ray, blood work) Lab: 50% after deductible X-ray: 50% after deductible 50% after deductible Lab: $30 copay; deductible X-ray: $60 copay; deductible 50% after deductible Imaging (CT/PET scans MRIs) 50% after deductible 50% after deductible 30% after deductible 50% after deductible Pharmacy plan type Aetna Value Plus Four Tier formulary* Aetna Value Plus Four Tier formulary* Prescription drug deductible $250 per individual None Prescription drugs Tier 1: preferred generic Tier 2: preferred brand Tier 3: nonpreferred generic & brand Retail: 30-day supply Mail order: 2.5 times retail copay, up to 90-day supply Tier 4: Aetna Specialty CareRx SM Includes preferred and nonpreferred self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin) Outpatient surgery OP hospital department & freestanding facility $10; deductible $50 after deductible $100 after deductible 50% up to $500 per prescription after deductible 30% plus $10; deductible 30% plus $50 after deductible 30% plus $100 after deductible Not covered $10/$50/$100 30% plus $10/$50/$100 30% up to $500 per prescription Not covered 50% after deductible 50% after deductible 30% after deductible 50% after deductible Inpatient hospital facility 50% after deductible 50% after deductible 30% after deductible 50% after deductible Rehabilitation services (PT/OT/ST) (2 50: 60 visits per calendar year combined : 30 visits per calendar year combined) 50% after deductible 50% after deductible 30% after deductible 50% after deductible Emergency room 50% after deductible $300 copay; deductible Urgent care $50 copay; deductible $50 copay; deductible $50 copay; deductible Adult routine vision Available as a rider Available as a rider $50 copay; deductible Refer to page 26 for footnotes. 19

20 M PPO plans (2 100) Plan name Silver PPO /50 (2 50) PPO /50 (51 100) Silver PPO Saver /70 (2 50) PPO Saver /70 (51 100) Network available Open Choice PPO N/A Open Choice PPO N/A PCP/referrals required No N/A No N/A Member benefits Participating providers Nonparticipating providers1 Calendar year deductible Calendar year out-of-pocket limit $4,000 individual $8,000 family $6,350 individual $12,700 family $8,000 individual $16,000 family $12,700 individual $25,400 family Participating providers $5,000 individual $10,000 family $6,350 individual $12,700 family Deductible & out-of-pocket limit accumulation Embedded2 Embedded2 Not included in out-of-pocket limit Primary care physician office visit3 Specialist office visit3 Walk-in clinics3 Chiropractic (12 visits per calendar year) $30 copay; deductible $60 copay; deductible $30 copay; deductible $60 copay; deductible Amounts over allowable charges and failure to precertify penalty. 50% after deductible $25 copay; deductible Nonparticipating providers1 $10,000 individual $20,000 family $12,700 individual $25,400 family Amounts over allowable charges and failure to precertify penalty. 30% after deductible 50% after deductible 0% after deductible 30% after deductible 50% after deductible $25 copay; deductible 30%after deductible 50% after deductible 0% after deductible 30% after deductible Preventive care/screenings/immunizations No charge 50% after deductible No charge 30%after deductible Diagnostic testing3 (X-ray, blood work) Lab: $30 copay; deductible X-ray: $60 copay; deductible 50% after deductible Lab: $25 copay; deductible X-ray: $25 copay; deductible 30% after deductible Imaging (CT/PET scans MRIs) 40% after deductible 50% after deductible 0% after deductible 30% after deductible Pharmacy plan type Aetna Value Plus Four Tier formulary* Aetna Value Plus Four Tier formulary* Prescription drug deductible None None Prescription drugs Tier 1: preferred generic Tier 2: preferred brand Tier 3: nonpreferred generic & brand Retail: 30-day supply Mail order: 2.5 times retail copay, up to 90-day supply Tier 4: Aetna Specialty CareRx SM Includes preferred and nonpreferred self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin) Outpatient surgery OP hospital department & freestanding facility $10/$50/$100 30% plus $10/$50/$100 $10/$50/$100 30% plus $10/$50/$100 30% up to $500 per prescription Not covered 30% up to $500 per prescription Not covered 40% after deductible 50% after deductible 0% after deductible 30% after deductible Inpatient hospital facility 40% after deductible 50% after deductible 0% after deductible 30% after deductible Rehabilitation services (PT/OT/ST) (2 50: 60 visits per calendar year combined : 30 visits per calendar year combined) 40% after deductible 50% after deductible 0% after deductible 30% after deductible Emergency room $300 copay; deductible 0% after deductible Urgent care $50 copay; deductible $50 copay; deductible $50 copay; deductible Adult routine vision Available as a rider Available as a rider $50 copay; deductible Refer to page 26 for footnotes. 20

21 PPO plans (2 100) M Plan name Bronze PPO /70 (2 50) PPO /70 (51 100) Silver PPO HSA /70 (2 50) PPO HSA /70 (51 100) Network available Open Choice PPO N/A Open Choice PPO N/A PCP/referrals required No N/A No N/A Member benefits Participating providers Nonparticipating providers1 Calendar year deductible Calendar year out-of-pocket limit $6,350 individual $12,700 family $6,350 individual $12,700 family $12,700 individual $25,400 family $15,875 individual $31,750 family Participating providers $2,500 individual $5,000 family $6,350 individual $12,700 family Nonparticipating providers1 $5,000 individual $10,000 family $12,700 individual $25,400 family Deductible & out-of-pocket limit accumulation Embedded2 True integrated family (TIF)4 Not included in out-of-pocket limit Primary care physician office visit3 Specialist office visit3 Walk-in clinics3 Chiropractic (12 visits per calendar year) $25 copay; deductible $75 copay; deductible $25 copay; deductible $75 copay; deductible Amounts over allowable charges and failure to precertify penalty. Amounts over allowable charges and failure to precertify penalty. 30% after deductible 0% after deductible 30% after deductible 30% after deductible 0% after deductible 30% after deductible 30% after deductible 0% after deductible 30% after deductible 30% after deductible 0% after deductible 30% after deductible Preventive care/screenings/immunizations No charge 30% after deductible No charge 30% after deductible Diagnostic testing3 (X-ray, blood work) Lab: 0% after deductible X-ray: 0% after deductible 30% after deductible 0% after deductible 30% after deductible Imaging (CT/PET scans MRIs) 0% after deductible 30% after deductible 0% after deductible 30% after deductible Pharmacy plan type Aetna Value Plus Four Tier formulary* Aetna Value Plus Four Tier formulary* Prescription drug deductible Integrated Medical/Rx deductible Integrated Medical/Rx deductible Prescription drugs Tier 1: preferred generic Tier 2: preferred brand Tier 3: nonpreferred generic & brand Retail: 30-day supply Mail order: 2.5 times retail copay, up to 90-day supply Tier 4: Aetna Specialty CareRx SM Includes preferred and nonpreferred self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin) Outpatient surgery OP hospital department & freestanding facility $25; deductible 0% after deductible 0% after deductible 30% plus $20; deductible 50% after deductible 50% after deductible $10 after deductible $50 after deductible $100 after deductible 0% after deductible Not covered 30% up to $500 per prescription after deductible 30% plus $10 after deductible 30% plus $50 after deductible 30% plus $100 after deductible Not covered 0% after deductible 30% after deductible 0% after deductible 30% after deductible Inpatient hospital facility 0% after deductible 30% after deductible 0% after deductible 30% after deductible Rehabilitation services (PT/OT/ST) (2 50: 60 visits per calendar year combined : 30 visits per calendar year combined) 0% after deductible 30% after deductible 0% after deductible 30% after deductible Emergency room 0% after deductible 0% after deductible Urgent care $50 copay; deductible $50 copay; deductible 0% after deductible 0% after deductible Adult routine vision Available as a rider Available as a rider Refer to page 26 for footnotes. 21

22 M PPO plans (2 100) Plan name Silver PPO HSA /60 (2 50) PPO HSA /60 (51 100) Bronze PPO HSA /50 (2 50) PPO HSA /50 (51 100) Network available Open Choice PPO N/A Open Choice PPO N/A PCP/referrals required No N/A No N/A Member benefits Participating providers Nonparticipating providers1 Calendar year deductible Calendar year out-of-pocket limit $3,000 individual $6,000 family $4,250 individual $8,500 family $6,000 individual $12,000 family $8,500 individual $17,000 family Participating providers $4,000 individual $8,000 family $6,350 individual $12,700 family Deductible & out-of-pocket limit accumulation Embedded2 Embedded2 Not included in out-of-pocket limit Amounts over allowable charges and failure to precertify penalty. Nonparticipating providers1 $8,000 individual $16,000 family $12,700 individual $25,400 family Amounts over allowable charges and failure to precertify penalty. Primary care physician office visit3 10% after deductible 40% after deductible 20% after deductible 50% after deductible Specialist office visit3 10% after deductible 40% after deductible 20% after deductible 50% after deductible Walk-in clinics3 10% after deductible 40% after deductible 20% after deductible 50% after deductible Chiropractic (12 visits per calendar year) 10% after deductible 40% after deductible 20% after deductible 50% after deductible Preventive care/screenings/immunizations No charge 40% after deductible No charge 50% after deductible Diagnostic testing3 (X-ray, blood work) 10% after deductible 40% after deductible 20% after deductible 50% after deductible Imaging (CT/PET scans MRIs) 10% after deductible 40% after deductible 20% after deductible 50% after deductible Pharmacy plan type Aetna Value Plus Four Tier formulary* Aetna Value Plus Four Tier formulary* Prescription drug deductible Integrated Medical/Rx deductible Integrated Medical/Rx deductible Prescription drugs Tier 1: preferred generic Tier 2: preferred brand Tier 3: nonpreferred generic & brand Retail: 30-day supply Mail order: 2.5 times retail copay, up to 90-day supply Tier 4: Aetna Specialty CareRx SM Includes preferred and nonpreferred self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin) Outpatient surgery OP hospital department & freestanding facility 10% after deductible 10% after deductible 10% after deductible 10% up to $500 per prescription after deductible 50% after deductible 50% after deductible 50% after deductible Not covered $10 after deductible $50 after deductible $100 after deductible 30% up to $500 per prescription after deductible 30% plus $10 after deductible 30% plus $50 after deductible 30% plus $100 after deductible Not covered 10% after deductible 40% after deductible 20% after deductible 50% after deductible Inpatient hospital facility 10% after deductible 40% after deductible 20% after deductible 50% after deductible Rehabilitation services (PT/OT/ST) (2 50: 60 visits per calendar year combined : 30 visits per calendar year combined) 10% after deductible 40% after deductible 20% after deductible 50% after deductible Emergency room 10% after deductible 20% after deductible Urgent care 10% after deductible 40% after deductible 20% after deductible 50% after deductible Adult routine vision Available as a rider Available as a rider Refer to page 26 for footnotes. 22