Unless otherwise indicated, the Deductible must be met prior to benefits being payable.

Transcription

1 PLAN FEATURES PARTICIPATING NON-PARTICIPATING Deductible (per calendar ) $2,000 Employee $5,000 Employee $4,000 Family $10,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Applicable covered expenses, including member cost sharing for prescription drugs, accumulate toward both the participating provider and non-participatinig provider Deductible. Member cost sharing for certain services, as indicated in the plan, are excluded from charges to meet the Deductible. Once Family Deductible is met, all family members will be considered as having met their Deductible for the remainder of the calendar. There is no Individual Deductible to satisfy within the Family Deductible. Out-of-Pocket Maximum (per calendar ) $5,600 Employee $10,000 Employee $11,200 Family $30,000 Family Member cost sharing for certain services may not apply toward the Out-of-Pocket Maximum. Applicable covered expenses accumulate toward both the participating provider and non-participating provider Out-of-Pocket Maximum. Only those participating providers and non-participating providers out of pocket expenses resulting from the application of coinsurance percentage, s and copays (except any penalty amounts) may be used to satisfy the Out-of Pocket Maximum. Once Family Out-of-Pocket Maximumm is met, all family members will be considered as having met their Out-of-Pocket Maximum for the remainder of the calendar. There is no Individual Out-of-Pocket Maximum to satisfy within the Family Out-of-Pocket Maximum. Lifetime Maximum Unlimited unless otherwise indicated. Unlimited unless otherwise indicated. Benefit Limitations -- For any servicee or supply that is subject to a maximum visit, day, or dollar limita- and non-participatinig tion, such services or supplies accumulate toward both the participating provider provider benefit limits under this plan. Payment for Non-Preferred Not Applicable Professional: 105% of Medicare Facility Prevailing Charges Primary Care Physician Selection Not Required Not Applicable Precertification Requirement Certain non-participating providers/participating provider self referred services require precertification or benefits will be reduced. Refer to your plan documents for a complete list of services that require precertification. Referral Requirements None None PREVENTIVE CARE PARTICIPATING NON-PARTICIPATING Routine Adult Physical Exams / Immunizations Covered 100%; waived 1 exam every 24 months age and 1 exam every 12 months age 65 and over. Well Child Exams / Immunizations Covered 100%; waived 50%; after (Age and frequency schedules apply)

2 Childhood immunizations covered 100% waived. No age or frequency schedules apply. Routine Gynecological Care Exams Covered 100%; waived 50%; after Includes Pap smear and related lab fees. One exam per 365 days. One exam per 365 days. Routine Mammograms Covered 100%; waived 50%; after Recommended: one annual mammogram for covered females age 40 and over. Routine Digital Rectal Exams / Prostate Specific Antigen Test Covered 100%; waived Recommended for males 40 and over. Colorectal Cancer Screening For all members 50 and over. Frequency schedule applies Member cost sharing is based on the type of service performed and the place of service where it is rendered; waived Routine Eye Exam Covered 100%; waived Routine Hearing Screening 1 exam per 24 months Subject to Routine Physical Exam benefit. Subject to Routine Physical Exam benefit. PHYSICIAN SERVICES PARTICIPATING NON-PARTICIPATING Primary Care Physician Visits Office Hours: Covered 100% ; after After Office Hours/Home: Covered 100%; after 50%; after Includes services of an internist, general physician, family practitioner or pediatrician. Specialist Office Visits Covered 100%; after 50%; after Prenatal OB Care Covered 100%; after 50%; after E-visit to PCP Covered 100%; after 50%; after An E-visit is an online internet consultation between a physician and an established patient about a non- authorized internet E-visit emergency healthcare matter. This visit must be conducted through an Aetna service vendor. E-visit to Specialist Covered 100%; after 50%; after An E-visit is an online internet consultation between a physician and an established patient about a non- authorized internet E-visit emergency healthcare matter. This visit must be conducted through an Aetna service vendor. Walk-in Clinics Covered 100%; after 50%; after Walk-in Clinics are network, free-standing health care facilities. They are an alternative to a physician's office visit for treatment of unscheduled, non-emergency illnesses and injuries and the administration of certain immunizations. It is not an alternative for emergency room services or the ongoing care provided by a physician. Neither an emergency room, nor the outpatient department of a hospital, shall be considered a Walk-in Clinic. Allergy Treatment Same as applicable participating provider office visit member cost sharing 50%; after

3 Allergy Testing Same as applicable participating provider office visit member cost sharing 50%; after DIAGNOSTIC PROCEDURES PARTICIPATING NON-PARTICIPATING Diagnostic Laboratory Covered 100%; after 50%; after If performed as a part of a physician'ss office visit and billed by the physician, expenses are covered subject to the applicable physician's office visit cost sharing. Diagnostic X-ray Outpatient hospital or other Outpatient facility Covered 100%; after 50%; after (except for Complex Imaging Services) Diagnostic X-ray for Complex Imaging Covered 100%; after Services 50%; after EMERGENCY MEDICAL CARE PARTICIPATING NON-PARTICIPATING Emergency Room Covered 100%; after Refer to participating provider benefit. Non-Emergency Care in an Emergency Room Emergency Use of Ambulance Covered 100%; after Refer to participating provider benefit. Non-Emergency Use of Ambulance HOSPITAL CARE PARTICIPATING NON-PARTICIPATING Inpatient Coverage Covered 100% per admission; after 50% per admission; after Inpatient Maternity Coverage Covered 100% per admission; after 50% per admission; after Outpatient Surgery - Hospital Covered 100% per visit; after 50% per visit; after Outpatient Surgery - Freestanding Facility Covered 100% per visit; after 50% per visit; after MENTAL HEALTH SERVICES PARTICIPATING NON-PARTICIPATING Inpatient Serious Mental Illness Covered 100%; after 50% per admission; after Inpatient Non-Serious Mental Illness Covered 100%; after 50% per admission; after

4 Outpatient Serious Mental Illness Covered 100%; after 50% per visit; after Outpatient Non-Serious Mental Illness Covered 100%; after 50% per visit; after ALCOHOL/DRUG ABUSE SERV- ICES PARTICIPATING NON-PARTICIPATING Inpatient Detoxification Covered 100%; after 50%; after Outpatient Detoxification Covered 100%; after 50% per visit; after Inpatient Rehabilitation Covered 100%; after 50% per admission; after Residential Treatment Facility Covered 100% 50%; after OTHER SERVICES PARTICIPATING NON-PARTICIPATING Skilled Nursing Facility Covered 100% per admission; after Limited to 120 days per calendar 50% per admission; after Limited to 120 days per calendar Home Health Care Covered 100% per visit; after Limited to 60 visits per calendar Limited to 3 intermittent visits per day of 4 hrs or less. Hospice Care - Inpatient Covered 100% per admission; after 50% per visit; after Limited to 60 visits per calendar by a participating home health care agency; 1 visit equals a period 50% per admission; after Hospice Care - Outpatient Covered 100% per visit; after 50% per visit; after Private Duty Nursing Outpatient Rehabilitation Therapy (Includes speech, physical and occupational therapy) Covered 100% per visit; after 50%; after

5 Spinal Manipulation Treatment of Autism Treatment over a 60-day consecutive period per incident of illness or injury beginning with the first day of treatment. Covered 100% per visit; after Limited to 20 visits per calendar Member cost sharing is based on the type of service performed and the place of service where it is rendered Treatment over a 60-day consecutive period per incident of illness or injury beginning with the first day of treatment. 50% per visit; after $1,000 calendar maximum. Member cost sharing is based on the type of service performed and the place of service where it is rendered Covered the same as any other expense. Limited to $36,000 annually for eligible individuals under 21 s of age. Includes coverage for habilitative care and Applied Behavioral Analysis. Once the limit has been met, Applied Behavioral Analysiss will be covered under Mental Health services. Durable Medical Equipment 50%; after 50% (must precertify if over $1,500) Diabetic Supplies Limited to $2,500 per calendar Pharmacy cost sharing applies if Pharmacy coverage is included; otherwise PCP office visit cost sharing applies. Limited to $2,500 per calendar 50%; after Vision Eyewear $100 once per 24 month period Covered same as participating provider benefit Transplants Covered same as any other expense for treatment in an approved IOE transplant facility. Services rendered by a participating Aetna facility, but not an IOE transplant facility, covered at out of network level. Bariatric Surgery Services rendered at an non-ioe transplant facility covered same as any other expense. FAMILY PLANNING PARTICIPATING NON-PARTICIPATING Infertility Treatment Diagnosis and treatment of the underlying medical condition. Comprehensive Infertility Services Member cost sharing is based on the type of service performed and the place of service where it is rendered. Member cost sharing is based on the type of service performed and the place of service where it is rendered. Coverage includes Artificial Insemination (limited to six courses of treatmentt per member's lifetime) and Ovulation Induction (limited to six courses of treatment per member's lifetime). Lifetime maximum ap- was provided, except plies to all procedures covered by any Aetna plan or where no other coverage where prohibited by law. Advanced Reproductive Technology (ART)

6 ART coverage includes In-Vitro Fertilization (IVF), Zygote Intra-Fallopian Transfer (ZIFT), Gamete Intra- Sperm Injection (ICSI) or Fallopian Transfer (GIFT), cryopreserved embryo transfers, Intra-Cytoplasmic ovum microsurgery. Limited to 3 courses of treatment in member's lifetime. Maximum applies to all procedures covered by any Aetna plan except where prohibited by law. Voluntary Sterilization Including tubal ligation and vasectomy. PHARMACY - PRESCRIPTION DRUG BENEFITS Member cost sharing is based on the type of service performed and the place of service where it is rendered. PARTICIPATING Member cost sharing is based on the type of service performed and the place of service where it is rendered; after. NON-PARTICIPATING The full cost of the drug is applied to the before any benefits are considered for payment under the pharmacy plan. Retail $5 copay for formulary generic drugs, $20 copay for formulary brand-name drugs, and $40 copay for non-formulary brand-name and generic drugs up to a 30 day supply at participating pharmacies. Mail Order First prescription fill at any retail drug macy $10 copay for formulary generic drugs, $40 copay for formulary brand-name drugs, and $80 copay for non-formulary brand-name and generic drugs up to a day supply from Aetna Rx Home Delivery. facility. Subsequent fills must be through Aetna Specialty Phar- No Mandatory Generic (NO MG) - Member is responsible to pay the applicable copay only. Plan Includes : Contraceptive drugs and devices obtainable from a pharmacy. Oral fertility drugs included. Precert included with 90 day Transition of Care Step Therapy included with 90 day Transition of Care Dependents Eligibility Spouse, children from birth to age 26. Exclusions and Limitations Plans are provided by: Aetna Health Inc. and Aetna Health Insurance Company. While this material is believed to be accurate as of the production date, it is subject to change. Investment services are independently offered through JPMorgan Institutional Investors, Inc., a subsidi- ary of JPMorgan Chase Bank.

7 This managed care plan may not cover all of your health care expenses. Read your contract carefully to determine which healthh care services are covered. To contact the plan if you are a member, call the number on your ID card; all others, call AETNA ( ). See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. You may be responsible for the health care provider's full charges for any non-covered services, including circum- are independent con- stances where you have exceeded a benefit limit contained in the plan. Providers tractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. The following is a 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 or rider(s) purchased by your employer. All medical and hospital services nott specifically covered in, or which are limited or excluded by your plan documents. Cosmetic surgery, including breast reduction. Custodial care. Dental care and dental x-rays. Donor egg retrieval. Durable medical equipment. Experimental and investigational procedures, except for coverage for medically necessary routine pa- Implantable drugs and certain injectible drugs including injectible infertility drugs. tient care costs for members participating in a cancer clinical trial). Hearing aids. Home births. Immunizations for travel or work except where medically necessary or indicated. Infertility services, including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services, unless specifically listed as covered in your plan docu- by a prescription plan ments. Long-term rehabilitation therapy. Non-medically necessary services or supplies. Orthotics except diabetic orthotics. Outpatient prescription drugs (except for treatment of diabetes), unless covered rider and over-the-counter medications (except as provided in a hospital) and supplies. Radial keratotomy or related procedures. Reversal of sterilization. Services for the treatment of sexual dysfunction or inadequacies including therapy, supplies or counseling or prescription drugs. Special duty nursing. Therapy or rehabilitation other than those listed as covered. Treatment of behavioral disorders. Weight control services including surgical procedures, medical treatments, weight control/loss pro- grams, dietary regimens and supplements, appetite suppressants and other medications; food or food supplements, exercise programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or treat obesity, including Morbid Obesity, or for the purpose of weight reduction, regardless of the existence of comorbid conditions.

8 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. Aetna Rx Home Delivery refers to Aetna Rx Home Delivery, LLC, a licensed pharmacy sub- negotiates with Aetna Rx sidiary of Aetna Inc., that operates through mail order. The charges that Aetna Home Delivery may be higher than the cost they pay for the drugs and the cost of the mail order phar- drugs takes into macy services they provide. For these purposes, the pharmacy's cost of purchasing account discounts, credits and other amounts that they may receive from wholesalers, manufacturers, suppliers and distributors. In case of emergency, call 911 or your local emergency hotline, or go directly to an emergency care facility. Translation of the material into another language may be available. Please call Member Services at AETNA ( ). Puede estar disponible la traduccion de este material en otro idioma. Por favor llame a Servicios al Miembro al AETNA ( ). Plan features and availability may vary by location and group size. For more information about Aetna plans, refer to Aetna Inc.