The Texas EPO plans are available statewide and also with many local networks. Refer to the network and county availability page for full details.

Transcription

1 ElectChoiceOpenAccess EPO TX 01/01/2017 Member benefits Plan name TX Gold EPO %* TX Silver EPO % TX Silver EPO % TX Silver EPO % Value IRX (Individual/Family) The Texas EPO plans are available statewide and also with many local networks. Refer to the network and county availability page for full details. $1,500/$3,000 $2,000/$4,000 $2,500/$5,000 $3,000/$6,000 TX Silver EPO % $4,000/$8,000 Out-of-pocket limit (Individual/Family) and out-of-pocket limit accumulation Primary care physician office visit Specialist office visit Walk-in clinics Diagnostic testing: Lab Diagnostic testing: X-ray Complex Imaging (CT/PET scans, MRIs) Inpatient hospital facility Outpatient surgery Emergency room Urgent care Rehabilitation services (PT/OT/ST) 2 Chiropractic 2 Pharmacy 3 Pharmacy Preferred generic drugs $4,000/$8,000 $7,150/$14,300 $7,150/$14,300 $6,500/$13,000 Embedded ¹ Embedded ¹ Embedded ¹ Embedded ¹ $25 copay; $35 copay; $35 copay; $35 copay; $50 copay; 30% after $70 copay; $70 copay; $25 copay; $35 copay; $35 copay; $35 copay; $25 copay; $35 copay; $35 copay; $35 copay; $75 copay; 30% after $100 copay; $100 copay; 20% after 30% after 30% after 20% after 30% after 30% after 20% after 30% after 30% after $350 copay plus 20% 30% after $750 copay plus 30% $750 copay; $100 copay; $125 copay; $125 copay; $125 copay; 20% after 30% after 30% after 20% after 30% after 30% after ; ; $7,100/$14,200 Embedded ¹ $35 copay; $70 copay; $35 copay; $35 copay; $100 copay; 30% after 30% after 30% after $750 copay plus 30% $125 copay; 30% after 30% after Preferred brand drugs Nonpreferred drugs $50 copay 30% after $50 copay $50 copay Generic & Brand: $75 copay Generic & Brand: 50% after Generic & Brand: $100 copay Generic & Brand: $75 copay Specialty drugs 50% up to $500 50% up to $500 after 50% up to $500 50% up to $500 50% up to $500 $50 copay Generic & Brand: $100 copay Health benefits and health insurance plans are offered and/or underwritten by Aetna Health Inc. and/or Aetna Life Insurance Company (Aetna). own products. Each insurer has sole financial responsibility for it's

2 ElectChoiceOpenAccess EPO TX 01/01/2017 Member benefits Plan name TX Silver EPO % The Texas EPO plans are available statewide and also with many local networks. Refer to the network and county availability page for full details. TX Bronze EPO % Value TX Bronze EPO % IRX TX Silver EPO % HSA TX Bronze EPO % HSA (Individual/Family) Out-of-pocket limit (Individual/Family) and out-of-pocket limit accumulation Primary care physician office visit Specialist office visit Walk-in clinics Diagnostic testing: Lab Diagnostic testing: X-ray $5,000/$10,000 $6,350/$12,700 $6,850/$13,700 $3,000/$6,000 $5,750/$11,500 $6,500/$13,000 $6,850/$13,700 $7,150/$14,300 $5,000/$10,000 $6,550/$13,100 Embedded ¹ Embedded ¹ Embedded ¹ Embedded ¹ Embedded ¹ $30 copay; $60 copay; 10% after $35 copay after $60 copay; 10% after 10% after $70 copay after $30 copay; $60 copay; 10% after $35 copay after $30 copay; 10% after 10% after $35 copay after $100 copay; 10% after 10% after $100 copay after Complex Imaging (CT/PET scans, MRIs) 10% after 10% after 10% after Inpatient hospital facility 10% after 10% after 10% after Outpatient surgery 10% after 10% after 10% after Emergency room Urgent care $750 copay; 10% after 10% after $750 copay after $125 copay; $125 copay; 10% after 10% after Rehabilitation services (PT/OT/ST) 2 10% after 10% after $70 copay after Chiropractic 2 10% after 10% after $70 copay after Pharmacy 3 Pharmacy $500 per Member Preferred generic drugs Generic: $20 copay; Generic: 10% after after after Generic: $20 copay after Preferred brand drugs Nonpreferred drugs Specialty drugs $50 copay $75 copay after 10% after $50 copay after 50% after Generic & Brand: $75 copay Generic & Brand: $100 copay after Generic & Brand: 50% after Generic & Brand: $100 copay after Generic & Brand: 50% after 50% up to $500 50% up to $500 after 50% up to $300 after 50% up to $500 after 50% up to $500 after Health benefits and health insurance plans are offered and/or underwritten by Aetna Health Inc. and/or Aetna Life Insurance Company (Aetna). own products. Each insurer has sole financial responsibility for it's

3 EPO TX 01/01/2017 Network and county availability for EPO plans Texas Health (Texas Health) - Collin, Dallas, Denton, Ellis, Johnson, Kaufman, Parker, Rockwall and Tarrant counties Aetna Exclusive Provider Organization (EPO) - all TX counties Aetna Whole Health Baptist Health System & Health Texas Medical Group (Baptist HS & HTMG) - Bexar, Comal, Guadalupe and Kendall counties Aetna Whole Health Memorial Hermann (Memorial Hermann) - Fort Bend, Harris and Montgomery counties Aetna Whole Health Seton Health Alliance (Seton Health) - Hays, Travis and Williamson counties Aetna Savings Plus Amarillo (Amar) - Deaf Smith, Potter and Randall counties Aetna Savings Plus Austin (Aus) - Bastrop, Bell, Burnet, Caldwell, Coryell, Falls, Fayette, Hays, Lampasas, Lee, Limestone, Mclennan, Travis and Williamson counties Aetna Savings Plus Houston (Hou) - Austin, Brazoria, Chambers, Colorado, Fort Bend, Galveston, Grimes, Hardin, Harris, Jasper, Jeffereson, Liberty, Matagorda, Montgomery, Newton, Orange, San Jacinto, Tyler, Walker, Waller and Wharton counties Aetna Savings Plus Longview (Lgvw) - Camp, Franklin, Gregg, Harrison, Marion, Titus and Upshur counties Aetna Savings Plus Lubbock (Lubb) - Lubbock county Aetna Savings Plus Odessa (Ode) - Ector county Aetna Savings Plus San Antonio (San) - Atascosa, Bandera, Bexar, Comal, Guadalupe, Kendall, Medina and Wilson counties HCA Austin (St Davids) - Hays, Travis and Williamson counties HCA San Antonio (Methodist) - Atascosa, Bandera, Bexar, Comal, Guadalupe, Kendall, Medina and Wilson counties Tyler Redbud, East Texas Medical Center Tyler (ETMC) - Smith county Tyler Yellow Rose, Christus Trinity Mother Frances (Mother Frances) - Smith county Note: The plan names for these networks will include the text that is in parenthesis. Health benefits and health insurance plans are offered and/or underwritten by Aetna Health Inc. and/or Aetna Life Insurance Company (Aetna). Each insurer has sole financial responsibility for it's own products.

4 HMO TX 01/01/2017 All HMO plans require PCP election and referrals Member benefits Plan name TX Silver HMO 50%* TX Silver Memorial Hermann HMO 2500 Copay TX Silver Houston HMO 2500 Copay TX Silver Baptist HS & HTMG HMO 2500 Copay TX Silver Seton Health HMO 2500 Copay TX Silver MemorialHermann HMO %ValuIRX TX Silver Houston HMO %ValuIRX TX Silver BaptistHS&HTMG HMO %ValuIRX TX Silver Seton Health HMO %ValuIRX TX Silver KelseyCare HMO 2500 Copay TX Silver KelseyCare HMO % IRX (Individual/Family) Out-of-pocket limit (Individual/Family) and out-of-pocket limit accumulation Primary care physician office visit Specialist office visit Walk-in clinics Diagnostic testing: Lab Diagnostic testing: X-ray Complex Imaging (CT/PET scans, MRIs) Inpatient hospital facility Outpatient surgery Emergency room Urgent care Rehabilitation services (PT/OT/ST) 2 Chiropractic 2 $0/$0 $2,500/$5,000 $5,000/$10,000 $2,500/$5,000 $5,000/$10,000 $7,150/$14,300 $7,150/$14,300 $6,500/$13,000 $7,150/$14,300 $7,150/$14,300 Embedded ¹ Embedded ¹ Embedded ¹ Embedded ¹ Embedded ¹ $60 copay $35 copay; $35 copay; $35 copay; $35 copay; 50% $70 copay; 30% after $70 copay; $70 copay; $60 copay $35 copay; $35 copay; Not Covered Not Covered 50% $35 copay; 30% after $35 copay after 30% after 50% $100 copay; 30% after $100 copay after 30% after 50% $750 copay after 30% after $750 copay after 30% after $1,000/d, days 1-3 after 50% $1,000/d, days 1-3 after 30% after 30% after 50% $750 copay after 30% after $750 copay after 30% after $1,000 copay plus 50% $750 copay after 30% after $750 copay after 30% after 50% $125 copay; $125 copay; $125 copay; $125 copay; 50% $70 copay after 30% after $70 copay; $70 copay; 50% $70 copay after 30% after $70 copay; $70 copay; Pharmacy 3 Pharmacy Preferred generic drugs Preferred brand drugs Nonpreferred drugs Specialty drugs 50% up to $500 50% up to $500 50% up to $500 after 50% up to $500 Generic: $20 copay ; ; Generic & Brand: 50% Generic & Brand: $100 copay Generic & Brand: $100 copay after Generic & Brand: $100 copay ; ; 50% $50 copay $50 copay; $50 copay $50 copay after Generic & Brand: $100 copay after 50% up to $500 after Health benefits and health insurance plans are offered and/or underwritten by Aetna Health Inc. and/or Aetna Life Insurance Company (Aetna). Each insurer has sole financial responsibility for it's own products.

5 HealthNetworkOnlyOpenAccess TX 01/01/2017 Member benefits Plan name TX Silver HNOnly % (Individual/Family) Out-of-pocket limit (Individual/Family) and out-of-pocket limit accumulation Primary care physician office visit Specialist office visit Walk-in clinics Diagnostic testing: Lab Diagnostic testing: X-ray Complex Imaging (CT/PET scans, MRIs) Inpatient hospital facility Outpatient surgery Emergency room Urgent care Rehabilitation services (PT/OT/ST) 2 Chiropractic 2 Pharmacy 3 Pharmacy $3,000/$6,000 $6,500/$13,000 Embedded ¹ $30 copay; $60 copay; $30 copay; $30 copay; $100 copay; 20% after 20% after 20% after $750 copay plus 20% $125 copay; 20% after 20% after Preferred generic drugs Preferred brand drugs Nonpreferred drugs $50 copay Generic & Brand: $100 copay Specialty drugs 50% up to $500 Health benefits and health insurance plans are offered and/or underwritten by Aetna Health Inc. and/or Aetna Life Insurance Company (Aetna). Each insurer has sole financial responsibility for it's own products.

6 Aetna pediatric dental & vision TX 01/01/2017 Pediatric dental plans EPO, HNOnly and HMO Plans Silver HMO 50% Plan EPO HSA Plans Dental Check-Up (aka preventive/diagnostic) Covered in full; Covered in full Dental Basic 30% after 30% 30% after Dental Major 50% after 50% 50% after Dental Ortho 50% after 50% 50% after Pediatric vision plans Vision exam (1 exam per 12 months) Pediatric Vision Hardware EPO, HNOnly and HMO Plans Silver HMO 50% Plan EPO HSA Plans Covered in full; Covered in full; Covered in full Covered in full; Covered in full Notes These plans do not cover all dental and vision expenses and have exclusions and limitations. Members should refer to their plan documents to determine which services are covered and to what extent. *This vision plan will cover the following: One set of eyeglass frames per 12 months. One pair of prescription lenses per 12 months. Prescription contact lenses maximum per 12 months: daily disposables (up to three-month supply), extended wear disposable (up to six-month supply) and nondisposable lenses (one set). Important Notes: This plan will cover either one pair of prescription lenses for eyeglass frames or prescription contact lenses, but not both, per 12 months. Coverage does not include the office visit for the fitting of prescription contact lenses. Pediatric Dental on EPO plans includes Out of Network benefits covered the same as the benefits.

7 Limitations and Exceptions This plan does not cover all health care expenses and includes exclusions and limitations. Members should refer to their plan documents to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, your plan documents may contain exceptions to this list based on state mandates or the plan design purchased. All medical or hospital services not specifically covered in or which are limited or excluded in the plan documents Charges related to any eye surgery mainly to correct refractive errors Cosmetic surgery, including breast reduction Custodial care Adult dental care and x-rays Donor egg retrieval Experimental and investigational procedures Immunizations for travel or work Infertility services, including, but not limited to, artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services, unless specifically listed as covered in your plan documents Non-medically necessary services or supplies Orthotics except as specified in the plan Over-the-counter medications and supplies Reversal of sterilization Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies, counseling and prescription drugs Special duty nursing Weight reduction programs, or dietary supplements This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee results or outcomes. Consult the plan documents (i.e. Group Insurance Certificate and/or Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitation relating to the plan. With the exception of Aetna Rx Home Delivery, all preferred providers and vendors are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change without notice. Certain services require precertification, or prior approval of coverage. Failure to precertify for these services may lead to substantially reduced benefits or denial of coverage. Some of the benefits requiring precertification may include, but are not limited to, inpatient hospital, inpatient mental health, inpatient skilled nursing, outpatient surgery, substance abuse (detoxification, inpatient and outpatient rehabilitation). When the Member s preferred provider is coordinating care, the preferred provider will obtain the precertification. Precertification requirements may vary. For information regarding how medications are reviewed and selected for the formulary, formulary information, and information about other pharmacy programs such as precertification and step therapy, please refer to our website at or the Aetna Medication Formulary Guide. Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna's Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. In addition, in circumstances where your prescription plan uses copayments or coinsurance calculated on a percentage basis or a, use of formulary drugs may not necessarily result in lower costs for the member. Members should consult with their treating physicians regarding questions about specific medications. Refer to your plan documents or contact Member Services for information regarding the terms and limitations of coverage. Aetna Rx Home Delivery refers to Aetna Rx Home Delivery, LLC, a subsidiary of Aetna, Inc., that is a licensed pharmacy providing mail-order pharmacy services. Aetna's negotiated charge with Aetna Rx Home Delivery may be higher than Aetna Rx Home Delivery's cost of purchasing drugs and providing mail-order pharmacy services. Aetna Inc.

8 Footnotes All services are subject to the unless noted otherwise. Some benefits are subject to age and frequency schedules, limitations or visit maximums. Members or Providers may be required to precertify or obtain approval for certain services. Note: Please refer to Aetna s Producer World web site at for specific Summary of Benefits and Coverage documents. Or for more information, please contact your licensed agent or Aetna Sales Representative. s, copays and coinsurance apply to the out-of-pocket maximum (OOP). After the out of pocket maximum is met, members continue to be responsible for any applicable premiums, penalties for failure to precertify (where applicable) and services not covered by Aetna. ¹ Embedded No one family member may contribute more than the individual /out-of-pocket limit amount to the family /out-of-pocket limit. Once the family /out-of-pocket limit is met, all family members will be considered as having met their /out-of-pocket limit for the remainder of the calendar year. 2 Rehabilitation services and Chiropractic - Coverage is limited to 35 visits per calendar year, rehabilitation and habilitation separate. 3 Pharmacy Choose Generics applies - If the physician prescribes or the member requests a covered brand name prescription drug when a generic prescription drug equivalent is available, the member will pay the difference in cost between the brand name prescription drug and the generic prescription drug equivalent plus the applicable costsharing. The cost difference between the generic and brand does not count toward the Out of Pocket Limit. Not all drugs are covered. It is important to look at the Drug List (Aetna Value Plus Formulary) to understand which drugs are covered. * IVF Plans (TX Gold EPO % and TX Silver HMO 50% plans) available with in-vitro fertilization coverage. This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Rates and benefits may vary by location. Health/dental benefits and health/dental insurance and plans contain exclusions and limitations. Plan features and availability may vary by location and group size. Investment services are independently offered through PayFlex. Providers are independent contractors and not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Not all health and dental services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features are subject to change. Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna s Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to Aetna Inc.