California Plan guide

Transcription

1 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions California Plan guide The health of business, well planned. Effective April 1, 2013 For businesses with eligible employees CA B (1/13)

2 Team with Aetna for the health of your business Introducing a new suite of products and services designed specifically for companies with 51 to 100 eligible employees. Health/Dental benefits, health/dental insurance and Life insurance plans/policies are offered and/or underwritten by Aetna Health of California Inc., Aetna Dental of California 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. 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 Business commitment 5 Benefits for every stage of life 8 Medical overview 11 Medical plan options 38 Dental overview 40 Dental plan options 45 Life and disability overview 49 Underwriting guidelines 54 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 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 Health Maintenance Organization (HMO) Aetna Value Network HMO (AVN) Health Savings Account (HSA)* and Health Reimbursement Accounts (HRA) Open Access Managed Choice (OAMC) Dental plans Dental Dental Maintenance Organization (DMO ) Dental Preferred Provider Organization (PPO) Dental Freedom-of-Choice (FOC) 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 personal health records and printable temporary member ID cards. Get real cost and health information to help make the right care decisions with an online Cost of Care Estimator. Manage health records online with the Personal Health Record. Use of the Aetna Health Connections SM disease management program, which provides personal support to members to help them manage their conditions. 24/7 access to a nurse helps members 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. Aetna Resource Connection SM features goods and services such as office supplies, HR support, payroll, technology assistance, and more. *HSAs are currently not available to HMO members in CA. 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 51 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. 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 Consumer-directed health plans HSA-compatible plans* HMO plans AVN 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 Consumer-directed health plans Traditional plans HMO plans AVN 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 Traditional plans Consumer-directed health plans HMO plans AVN 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 Consumer-directed health plans HSA-compatible plans* HMO plans AVN plans *HSAs are currently not available to HMO members in CA. 5

6 California Provider Network County OAMC** HMO/HMO Deductible/ HMO HRA Aetna Value Network SM HMO Alameda Alpine Amador Butte Calaveras Colusa Contra Costa*** Del Norte El Dorado Fresno Glenn Large doctor network* -- More than 65,000 doctors and 400 hospitals. -- Aetna Value SM Network = 38,673* doctors and 470 hospitals -- HMO Network = 68,529* doctors and 489 hospitals -- Aetna Open Access Managed Choice Network = 75,429* doctors and 507 hospitals Humboldt Imperial Inyo Kern Kings Lake Lassen Los Angeles*** Madera Marin Mariposa Mendocino Merced Modoc Mono Monterey Napa Nevada Vitalidad is available in San Diego county. The Basic HMO (formerly Vitalidad Plus) network is available in select areas of Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco, Santa Barbara and Santa Clara counties. *According to the Aetna Enterprise Provider Database as of April 30, Network subject to change. **PPO/OOA plans are available to members who reside outside the OAMC Network. *** The Aetna Value Network HMO plans are available in select areas of Contra Costa, Los Angeles, Riverside, San Bernardino, San Diego, San Joaquin, San Mateo and Sonoma counties. Contact Aetna for more information. The HMO network is available in select areas of Fresno, Placer, Riverside, Sacramento, San Bernardino, San Joaquin, Solano, Sonoma and Yolo Counties. Contact Aetna for more information. 6

7 County OAMC** HMO/HMO Deductible/ HMO HRA Aetna Value Network SM HMO Orange Placer Plumas Riverside*** Sacramento San Benito San Bernardino*** San Diego** San Francisco San Joaquin*** San Luis Obispo San Mateo*** Santa Barbara Santa Clara Santa Cruz Shasta Sierra The following independent practice associations (IPA) are not available to HMO/HMO Deductible HMO/HRA members: Kern Independence Medical Group Los Angeles All Care Medical Group Cedars-Sinai Health Associates Cedars-Sinai Medical Care Foundation Family Care Specialists IPA, A Medical Group Prudent Medical Care Group Torrance Hospital IPA Medical Group Orange AMVI Medical Group Mission Hospital Affiliated Physicians Mission Heritage Medical Group St. Joseph Heritage Medical Group St. Joseph Hospital Affiliated Physicians St. Jude Affiliated Physicians St. Jude Heritage Medical Group San Diego Scripps Clinic Medical Group Scripps Coastal Medical Center Siskiyou Solano Sonoma*** Stanislaus Sutter Tehama Trinity Tulare Tuolumne Ventura Yolo Yuba Vitalidad is available in San Diego county. The Basic HMO (formerly Vitalidad Plus) network is available in select areas of Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco, Santa Barbara and Santa Clara counties. *According to the Aetna Enterprise Provider Database as of April 30, Network subject to change. **PPO/OOA plans are available to members who reside outside the OAMC Network. *** The Aetna Value Network HMO plans are available in select areas of Contra Costa, Los Angeles, Riverside, San Bernardino, San Diego, San Joaquin, San Mateo and Sonoma counties. Contact Aetna for more information. The HMO network is available in select areas of Fresno, Placer, Riverside, Sacramento, San Bernardino, San Joaquin, Solano, Sonoma and Yolo Counties. Contact Aetna for more information. 7

8 Aetna Medical Plans 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. 8

9 Medical Overview Aetna will offer the in-state portfolio (OAMC only) 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 in-state indemnity plan. Product Name Product Description PCP Required Referrals Required Network Health Maintenance Organization (HMO) Aetna HMO Deductible Plan Aetna HealthFund HMO HRA Aetna Value Network HMO Vitalidad Mexico con Aetna SM * (Available for California employers) Basic HMO*, ** (Available for California employers) Aetna Open Access Managed Choice (OAMC) Indemnity Each family member selects a primary care physician (PCP) participating in our network. The PCP provides routine and preventive care and helps coordinate the member s total health care. The PCP refers members to participating specialists and facilities for medically necessary specialty care. Only services provided or referred by the PCP are covered except for emergency, urgently needed care or direct access benefits, unless approved by the HMO in advance of receiving services. Utilizes all the services of the HMO with a subset of the HMO Network with additional savings by applying a deductible and coinsurance for certain medical services. Combines the features of a conventional HMO with those of consumer-directed health plans including a fund to help members pay for medical expenses. All the services of the HMO provided by a subset of the full HMO network. Aetna Value Network plans offers benefits similar to Aetna s HMO plan, with premium savings by accessing only a select network of providers. HMO plans that feature the Sistemas Medicos Nacionales, S.A. de C.V. (SIMNSA) provider network in Northern Mexico service area. San Diego county employees access health care services from participating providers in the Mexican cities of Tijuana, Tecate and Mexicali. Members choose a Mexico-based primary care physician (PCP). Only services provided or referred by their PCP, except for emergency or urgent care, are covered unless approved by the HMO in advance. Coverage for employees in select zip codes in California and in the Mexican cities of Tijuana, Tecate, or Mexicali through a specially developed provider network. Plans are available to California employers who provide employees and their dependents access to care from a California-based primary care physician (PCP) or a Mexican-based PCP. Covered benefits differ based on PCP country location. Members can visit any participating provider for covered services without a referral. Members have the freedom to choose network providers at lower out-of-pocket costs, or non-network providers at higher out-of-pocket costs at any time. Members can 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 participating provider for covered services without a referral. Yes Yes HMO Yes Yes HMO Deductible Yes Yes HMO Deductible Yes Yes Aetna Value Network SM HMO Yes Yes Vitalidad HMO* Yes Yes Basic HMO* (formerly Vitalidad Plus HMO) No No Aetna Open Access Managed Choice POS No No N/A * Provider network through Sistemas Medicos Nacionales, S.A. de C.V. (SIMNSA). This health plan may be limited in benefits, rights and remedies under U.S. federal and state law. Este Plan de Salud puede tener limitaciones en sus beneficios, derechos y resoluciones bajo las leyes federales estatales de Los Estados Unidos. **Formerly Vitalidad PlusSM California con Aetna. 9

10 An explanation of out-of-pocket limits OAMC These limits include coinsurance. These limits do not include amounts over allowable charges, copays, deductibles, failure-toprecertify penalty and Rx (including Specialty CareRx). HSA HDHP* These limits include coinsurance, copays and Rx (including Specialty Care Rx). These limits do not include amounts over allowable charges, deductibles, and failure-to-precertify penalty. HMO/AVN HMO/HMO Deductible/ HMO HRA/Vitalidad HMO/Basic HMO** These limits include coinsurance and copays and deductibles. These limits do not include member cost-sharing for prescription drugs. Ways to meet the family deductible and out-of-pocket limit OAMC HSA HDHP* HMO/AVN HMO/HMO Deductible/ HMO HRA/Vitalidad HMO/Basic HMO** Embedded aggregate True Integrated Family (TIF) Embedded aggregate Each covered family member needs to satisfy only his or her individual deductible and/or out-of-pocket limit. The family deductible and/or out-of-pocket limit can be met by a combination of family members or by a single member. There is no individual deductible and/or out-of-pocket limit to satisfy. Each covered family member only needs to satisfy his or her individual deductible and/or out-of-pocket limit. *HSAs are currently not available to HMO members in CA. **Formerly Vitalidad Plus HMO. 10

11 HMO/AVN Plans Plan names HMO/AVN 1.7 HMO/AVN 4.7 HMO/AVN 9.7 HMO/AVN 10.7 Network HMO or AVN HMO HMO or AVN HMO HMO or AVN HMO HMO or AVN HMO PCP/Referrals Required Yes Yes Yes Yes Member benefits Calendar-Year Plan Deductible None None None None Out-of-Pocket Limit $1,500 Individual $3,000 Family $1,500 Individual $3,000 Family $2,000 Individual $4,000 Family $2,500 Individual $5,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 3 Embedded aggregate 3 Embedded aggregate 3 Embedded aggregate 3 Not Included in Out-of-Pocket Limit Prescription drug copays Prescription drug copays Prescription drug copays Prescription drug copays Primary Care Physician Office Visit1 $10 copay $10 copay $15 copay $15 copay Specialist Office Visit1 $10 copay $10 copay $15 copay $15 copay Preventive Care/Screenings/Immunizations No charge No charge No charge No charge Diagnostic Testing (X-ray, blood work) Lab: No charge X-ray: $10 copay Lab: No charge X-ray: $10 copay Lab: No charge X-ray: $15 copay Lab: No charge X-ray: $15 copay Imaging (CT/PET scans, MRIs) $100 copay $100 copay $100 copay $100 copay Prescription Drug Deductible (applies to brand and non-formulary brand-name drugs) Prescription Drugs 1 Generic Formulary/Brand Formulary/ Generic & Brand Non-Formulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply None None None None $10/$20/$35 $15/$25/$40 $15/$25/$40 $10/$20/$35 Pharmacy Plan Type Three Tier Open Formulary Three Tier Open Formulary Three Tier Open Formulary Three Tier Open Formulary Aetna Specialty CareRx SM self-injectables Covered under medical Covered under medical Covered under medical Covered under medical Outpatient Surgery, Hospital OP Department $100 copay $100 copay $200 copay $200 copay Outpatient Surgery, Freestanding Facility No charge No charge No charge No charge Inpatient Hospital Facility $100 copay per admission $100 copay per admission $250 copay per admission $250 copay per admission Rehabilitation Services 2 (PT/OT/ST) (60 visits per incident) $10 copay $10 copay $15 copay $15 copay Emergency Room $100 copay $100 copay $100 copay $100 copay Emergency Medical Transport $100 copay $100 copay $100 copay $100 copay Urgent Care $35 copay $35 copay $35 copay $35 copay Primary & Specialist Physician E-Visit Not covered Not covered Not covered Not covered Walk-In Clinics Not covered Not covered Not covered Not covered Chiropractic (20 visits per calendar year) $15 copay $15 copay $15 copay $15 copay Routine Vision (one exam per member every 24 months) No charge No charge No charge No charge See page 37 for footnotes. 11

12 HMO/AVN Plans Plan names HMO/AVN 11.7 HMO/AVN 12.7 HMO/AVN 15.7* HMO/AVN 16.7 Network HMO or AVN HMO HMO or AVN HMO HMO or AVN HMO HMO or AVN HMO PCP/Referrals Required Yes Yes Yes Yes Member benefits Calendar-Year Plan Deductible None None None None Out-of-Pocket Limit $2,500 Individual $5,000 Family $2,500 Individual $5,000 Family $2,500 Individual $5,000 Family $2,500 Individual $5,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 3 Embedded aggregate 3 Embedded aggregate 3 Embedded aggregate 3 Not Included in Out-of-Pocket Limit Prescription drug copays Prescription drug copays Prescription drug copays Prescription drug copays Primary Care Physician Office Visit1 $15 copay $15 copay $20 copay $20 copay Specialist Office Visit1 $20 copay $20 copay $20 copay $25 copay Preventive Care/Screenings/Immunizations No charge No charge No charge No charge Diagnostic Testing (X-ray, blood work) Lab: No charge X-ray: $20 copay Lab: No charge X-ray: $20 copay Lab: No charge X-ray: $20 copay Lab: No charge X-ray: $25 copay Imaging (CT/PET scans, MRIs) $100 copay $100 copay $100 copay $100 copay Prescription Drug Deductible (applies to brand and non-formulary brand-name drugs) Prescription Drugs 1 Generic Formulary/Brand Formulary/ Generic & Brand Non-Formulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply None None None None $15/$25/$40 $15/$25/$40 $15/$25/$40 $20/$35/$50 Pharmacy Plan Type Three Tier Open Formulary Three Tier Open Formulary Three Tier Open Formulary Three Tier Open Formulary Aetna Specialty CareRx SM self-injectables Covered under medical Covered under medical Covered under medical Covered under medical Outpatient Surgery, Hospital OP Department $200 copay $300 copay $300 copay $300 copay Outpatient Surgery, Freestanding Facility No charge $100 copay $100 copay $100 copay Inpatient Hospital Facility $250 copay per admission $300 copay per admission $500 copay per admission $500 copay per admission Rehabilitation Services 2 (PT/OT/ST) (60 visits per incident) $20 copay $20 copay $20 copay $25 copay Emergency Room $100 copay $100 copay $100 copay $100 copay Emergency Medical Transport $100 copay $100 copay $100 copay $100 copay Urgent Care $35 copay $35 copay $35 copay $35 copay Primary & Specialist Physician E-Visit Not covered Not covered Not covered Not covered Walk-In Clinics Not covered Not covered Not covered Not covered Chiropractic (20 visits per calendar year) $15 copay $15 copay $15 copay $15 copay Routine Vision (one exam per member every 24 months) No charge No charge No charge No charge See page 37 for footnotes. 12

13 HMO/AVN Plans Plan names HMO/AVN 21.7 HMO/AVN 22.7* HMO/AVN 23.7 Network HMO or AVN HMO HMO or AVN HMO HMO or AVN HMO PCP/Referrals Required Yes Yes Yes Member benefits Calendar-Year Plan Deductible None None None Out-of-Pocket Limit $3,000 Individual $6,000 Family $3,500 Individual $7,000 Family $3,500 Individual $7,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 3 Embedded aggregate 3 Embedded aggregate 3 Not Included in Out-of-Pocket Limit Prescription drug copays Prescription drug copays Prescription drug copays Primary Care Physician Office Visit1 $30 copay $30 copay $40 copay Specialist Office Visit1 $40 copay $40 copay $50 copay Preventive Care/Screenings/Immunizations No charge No charge No charge Diagnostic Testing (X-ray, blood work) Lab: No charge X-ray: $40 copay Lab: No charge X-ray: $40 copay Lab: No charge X-ray: $50 copay Imaging (CT/PET scans, MRIs) $100 copay $100 copay $100 copay Prescription Drug Deductible (applies to brand and non-formulary brand-name drugs) Prescription Drugs 1 Generic Formulary/Brand Formulary/ Generic & Brand Non-Formulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply None None None $15/$25/$40 $15/$35/$50 $15/$35/$50 Pharmacy Plan Type Three Tier Open Formulary Three Tier Open Formulary Three Tier Open Formulary Aetna Specialty CareRx SM self-injectables Covered under medical Covered under medical Covered under medical Outpatient Surgery, Hospital OP Department $200 copay $500 copay $500 copay Outpatient Surgery, Freestanding Facility No charge $200 copay $200 copay Inpatient Hospital Facility $750 copay per day up to 3 days per admission $1,000 copay per day up to 3 days per admission $1,000 copay per day up to 3 days per admission Rehabilitation Services 2 (PT/OT/ST) (60 visits per incident) $40 copay $40 copay $50 copay Emergency Room $100 copay $100 copay $100 copay Emergency Medical Transport $100 copay $100 copay $100 copay Urgent Care $35 copay $35 copay $35 copay Primary & Specialist Physician E-Visit Not covered Not covered Not covered Walk-In Clinics Not covered Not covered Not covered Chiropractic (20 visits per calendar year) $15 copay $15 copay $15 copay Routine Vision (one exam per member every 24 months) No charge No charge No charge See page 37 for footnotes. 13

14 HMO Deductible Plans Plan names HMO DED 1.7 HMO DED 2.7 HMO DED 3.7 Network HMO Deductible HMO Deductible HMO Deductible PCP/Referrals Required Yes Yes Yes Member benefits Calendar-Year Plan Deductible $250 Individual $500 Family $500 Individual $1,000 Family $1,500 Individual $3,000 Family Out-of-Pocket Limit $2,000 Individual $4,000 Family $2,000 Individual $4,000 Family $2,500 Individual $5,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 3 Embedded aggregate 3 Embedded aggregate 3 Not Included in Out-of-Pocket Limit Prescription drug copays Prescription drug copays Prescription drug copays Primary Care Physician Office Visit1 $15 copay; deductible waived $10 copay; deductible waived $10 copay; deductible waived Specialist Office Visit1 $25 copay; deductible waived $15 copay; deductible waived $20 copay; deductible waived Preventive Care/Screenings/Immunizations No charge No charge No charge Diagnostic Testing (X-ray, blood work) Lab: $25 copay; deductible waived X-ray: $25 copay; deductible waived Lab: $15 copay; deductible waived X-ray: $15 copay; deductible waived Lab: $20 copay; deductible waived X-ray: $20 copay; deductible waived Imaging (CT/PET scans, MRIs) $150 copay; deductible waived $150 copay; deductible waived $150 copay; deductible waived Prescription Drug Deductible (applies to brand and non-formulary brand-name drugs) Prescription Drugs 1 Generic Formulary/Brand Formulary/ Generic & Brand Non-Formulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply None None None $10/$20/$35 $10/$20/$35 $10/$20/$35 Pharmacy Plan Type Three Tier Open Formulary Three Tier Open Formulary Three Tier Open Formulary Aetna Specialty CareRx SM self-injectables Covered under medical Covered under medical Covered under medical Outpatient Surgery, Hospital OP Department $150 copay after deductible $150 copay after deductible $150 copay after deductible Outpatient Surgery, Freestanding Facility 0% after deductible 0% after deductible 0% after deductible Inpatient Hospital Facility $250 copay after deductible $250 copay after deductible $250 copay after deductible Rehabilitation Services 2 (PT/OT/ST) (60 visits per incident) $25 copay; deductible waived $15 copay; deductible waived $20 copay; deductible waived Emergency Room $100 copay after deductible $100 copay after deductible $100 copay after deductible Emergency Medical Transport $100 copay after deductible $100 copay after deductible $100 copay after deductible Urgent Care $35 copay; deductible waived $35 copay; deductible waived $35 copay; deductible waived Primary & Specialist Physician E-Visit Not covered Not covered Not covered Walk-In Clinics Not covered Not covered Not covered Chiropractic (20 visits per calendar year) $15 copay; deductible waived $15 copay; deductible waived $15 copay; deductible waived Routine Vision (one exam per member every 24 months) No charge No charge No charge See page 37 for footnotes. 14

15 HMO Deductible Plans Plan names HMO DED 4.7 HMO DED 5.7 HMO DED 6.7 Network HMO Deductible HMO Deductible HMO Deductible PCP/Referrals Required Yes Yes Yes Member benefits Calendar-Year Plan Deductible $250 Individual $500 Family $1,000 Individual $2,000 Family $500 Individual $1,000 Family Out-of-Pocket Limit $3,000 Individual $6,000 Family $3,000 Individual $6,000 Family $3,500 Individual $7,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 3 Embedded aggregate 3 Embedded aggregate 3 Not Included in Out-of-Pocket Limit Prescription drug copays Prescription drug copays Prescription drug copays Primary Care Physician Office Visit1 $10 copay; deductible waived $20 copay; deductible waived $40 copay; deductible waived Specialist Office Visit1 $25 copay; deductible waived $40 copay; deductible waived $50 copay; deductible waived Preventive Care/Screenings/Immunizations No charge No charge No charge Diagnostic Testing (X-ray, blood work) Lab: $25 copay; deductible waived X-ray: $25 copay; deductible waived Lab: $40 copay; deductible waived X-ray: $40 copay; deductible waived Lab: $50 copay; deductible waived X-ray: $50 copay; deductible waived Imaging (CT/PET scans, MRIs) $150 copay; deductible waived $150 copay; deductible waived $150 copay; deductible waived Prescription Drug Deductible (applies to brand and non-formulary brand-name drugs) Prescription Drugs 1 Generic Formulary/Brand Formulary/ Generic & Brand Non-Formulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply None None None $10/$30/$50 $15/$25/$40 $20/$35/$50 Pharmacy Plan Type Three Tier Open Formulary Three Tier Open Formulary Three Tier Open Formulary Aetna Specialty CareRx SM self-injectables Covered under medical Covered under medical Covered under medical Outpatient Surgery, Hospital OP Department 10% after deductible 10% after deductible 20% after deductible Outpatient Surgery, Freestanding Facility 0% after deductible 0% after deductible 0% after deductible Inpatient Hospital Facility 10% after deductible 10% after deductible 20% after deductible Rehabilitation Services 2 (PT/OT/ST) (60 visits per incident) $25 copay; deductible waived $40 copay; deductible waived $50 copay; deductible waived Emergency Room $100 copay after deductible $100 copay after deductible $100 copay after deductible Emergency Medical Transport $100 copay after deductible $100 copay after deductible $100 copay after deductible Urgent Care $35 copay; deductible waived $35 copay; deductible waived $35 copay; deductible waived Primary & Specialist Physician E-Visit Not covered Not covered Not covered Walk-In Clinics Not covered Not covered Not covered Chiropractic (20 visits per calendar year) $15 copay; deductible waived $15 copay; deductible waived $15 copay; deductible waived Routine Vision (one exam per member every 24 months) No charge No charge No charge See page 37 for footnotes. 15

16 HMO Deductible Plans Plan names HMO DED 7.7 HMO DED 8.7 HMO DED 9.7 Network HMO Deductible HMO Deductible HMO Deductible PCP/Referrals Required Yes Yes Yes Member benefits Calendar-Year Plan Deductible $1,000 Individual $2,000 Family $1,000 Individual $2,000 Family $1,000 Individual $2,000 Family Out-of-Pocket Limit $3,500 Individual $7,000 Family $3,500 Individual $7,000 Family $3,500 Individual $7,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 3 Embedded aggregate 3 Embedded aggregate 3 Not Included in Out-of-Pocket Limit Prescription drug copays Prescription drug copays Prescription drug copays Primary Care Physician Office Visit1 $30 copay; deductible waived $15 copay; deductible waived $10 copay; deductible waived Specialist Office Visit1 $50 copay; deductible waived $25 copay; deductible waived $20 copay; deductible waived Preventive Care/Screenings/Immunizations No charge No charge No charge Diagnostic Testing (X-ray, blood work) Lab: $50 copay; deductible waived X-ray: $50 copay; deductible waived Lab: $25 copay; deductible waived X-ray: $25 copay; deductible waived Lab: $20 copay; deductible waived X-ray: $20 copay; deductible waived Imaging (CT/PET scans, MRIs) $150 copay; deductible waived $150 copay; deductible waived $150 copay; deductible waived Prescription Drug Deductible (applies to brand and non-formulary brand-name drugs) Prescription Drugs 1 Generic Formulary/Brand Formulary/ Generic & Brand Non-Formulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply None None None $15/$25/$40 $15/$25/$40 $15/$25/$40 Pharmacy Plan Type Three Tier Open Formulary Three Tier Open Formulary Three Tier Open Formulary Aetna Specialty CareRx SM self-injectables Covered under medical Covered under medical Covered under medical Outpatient Surgery, Hospital OP Department 20% after deductible 20% after deductible 20% after deductible Outpatient Surgery, Freestanding Facility 0% after deductible 0% after deductible 0% after deductible Inpatient Hospital Facility 20% after deductible 20% after deductible 20% after deductible Rehabilitation Services 2 (PT/OT/ST) (60 visits per incident) $50 copay; deductible waived $25 copay; deductible waived $20 copay; deductible waived Emergency Room $100 copay after deductible $100 copay after deductible $100 copay after deductible Emergency Medical Transport $100 copay after deductible $100 copay after deductible $100 copay after deductible Urgent Care $35 copay; deductible waived $35 copay; deductible waived $35 copay; deductible waived Primary & Specialist Physician E-Visit Not covered Not covered Not covered Walk-In Clinics Not covered Not covered Not covered Chiropractic (20 visits per calendar year) $15 copay; deductible waived $15 copay; deductible waived $15 copay; deductible waived Routine Vision (one exam per member every 24 months) No charge No charge No charge See page 37 for footnotes. 16

17 HMO Deductible Plans Plan names HMO DED 10.7 Network PCP/Referrals Required HMO Deductible Yes Member benefits Calendar-Year Plan Deductible Out-of-Pocket Limit Deductible & Out-of-Pocket Limit Accumulation Not Included in Out-of-Pocket Limit Primary Care Physician Office Visit 1 Specialist Office Visit 1 Preventive Care/Screenings/Immunizations Diagnostic Testing (X-ray, blood work) Imaging (CT/PET scans, MRIs) Prescription Drug Deductible (applies to brand and non-formulary brand-name drugs) Prescription Drugs 1 Generic Formulary/Brand Formulary/ Generic & Brand Non-Formulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply Pharmacy Plan Type Aetna Specialty CareRx SM self-injectables Outpatient Surgery, Hospital OP Department Outpatient Surgery, Freestanding Facility Inpatient Hospital Facility Rehabilitation Services 2 (PT/OT/ST) (60 visits per incident) Emergency Room Emergency Medical Transport Urgent Care Primary & Specialist Physician E-Visit Walk-In Clinics Chiropractic (20 visits per calendar year) Routine Vision (one exam per member every 24 months) $500 Individual $1,000 Family $3,500 Individual $7,000 Family Embedded aggregate 3 Prescription drug copays $10 copay; deductible waived $20 copay; deductible waived No charge Lab: $20 copay; deductible waived X-ray: $20 copay; deductible waived $150 copay; deductible waived None $10/$20/$35 Three Tier Open Formulary Covered under medical 20% after deductible 0% after deductible 20% after deductible $20 copay; deductible waived $100 copay after deductible $100 copay after deductible $35 copay; deductible waived Not covered Not covered $15 copay; deductible waived No charge See page 37 for footnotes. 17

18 HMO HRA Plans Plan names HMO HRA 1.7 HMO HRA 2.7 HMO HRA 3.7 Network HMO Deductible HMO Deductible HMO Deductible PCP/Referrals Required Yes Yes Yes Member benefits HRA Fund Amount 4 $250 Individual $500 Family $250 Individual $500 Family $250 Individual $500 Family Calendar-Year Plan Deductible $750 Individual $1,500 Family $1,000 Individual $2,000 Family $500 Individual $1,000 Family Out-of-Pocket Limit $2,000 Individual $4,000 Family $3,000 Individual $6,000 Family $3,000 Individual $6,000 Family Deductible & Out-of-Pocket Limit Accumulation True Integrated Family 5 True Integrated Family 5 True Integrated Family 5 Not Included in Out-of-Pocket Limit Prescription drug copays Prescription drug copays Prescription drug copays Primary Care Physician Office Visit1 $15 copay; deductible waived $25 copay; deductible waived $10 copay; deductible waived Specialist Office Visit1 $25 copay; deductible waived $40 copay; deductible waived $25 copay; deductible waived Preventive Care/Screenings/Immunizations No charge No charge No charge Diagnostic Testing (X-ray, blood work) Lab: $25 copay; deductible waived X-ray: $25 copay; deductible waived Lab: $40 copay; deductible waived X-ray: $40 copay; deductible waived Lab: $25 copay; deductible waived X-ray: $25 copay; deductible waived Imaging (CT/PET scans, MRIs) $150 copay; deductible waived $150 copay; deductible waived $150 copay; deductible waived Prescription Drug Deductible (applies to brand and non-formulary brand-name drugs) Prescription Drugs 1 Generic Formulary/Brand Formulary/ Generic & Brand Non-Formulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply None None None $10/$20/$35 $15/$25/$40 $10/$30/$50 Pharmacy Plan Type Three Tier Open Formulary Three Tier Open Formulary Three Tier Open Formulary Aetna Specialty CareRx SM self-injectables Covered under medical Covered under medical Covered under medical Outpatient Surgery, Hospital OP Department $250 copay after deductible $500 copay after deductible 10% after deductible Outpatient Surgery, Freestanding Facility $150 copay after deductible $300 copay after deductible $250 copay after deductible Inpatient Hospital Facility $250 copay after deductible $500 copay after deductible 10% after deductible Rehabilitation Services 2 (PT/OT/ST) (60 visits per incident) $25 copay; deductible waived $40 copay; deductible waived $25 copay; deductible waived Emergency Room $100 copay after deductible $100 copay after deductible $100 copay after deductible Emergency Medical Transport $100 copay after deductible $100 copay after deductible $100 copay after deductible Urgent Care $35 copay; deductible waived $35 copay; deductible waived $35 copay; deductible waived Primary & Specialist Physician E-Visit Not covered Not covered Not covered Walk-In Clinics Not covered Not covered Not covered Chiropractic (20 visits per calendar year) $15 copay; deductible waived $15 copay; deductible waived $15 copay; deductible waived Routine Vision (one exam per member every 24 months) No charge No charge No charge See page 37 for footnotes. 18

19 HMO HRA Plans Plan names HMO HRA 5.7 HMO HRA 7.7 Network HMO Deductible HMO Deductible PCP/Referrals Required Yes Yes Member benefits HRA Fund Amount 4 Calendar-Year Plan Deductible Out-of-Pocket Limit $500 Individual $1,000 Family $1,500 Individual $3,000 Family $3,500 Individual $7,000 Family $500 Individual $1,000 Family $1,500 Individual $3,000 Family $3,500 Individual $7,000 Family Deductible & Out-of-Pocket Limit Accumulation True Integrated Family 5 True Integrated Family 5 Not Included in Out-of-Pocket Limit Prescription drug copays Prescription drug copays Primary Care Physician Office Visit1 $10 copay; deductible waived $30 copay; deductible waived Specialist Office Visit1 $20 copay; deductible waived $50 copay; deductible waived Preventive Care/Screenings/Immunizations No charge No charge Diagnostic Testing (X-ray, blood work) Lab: $20 copay; deductible waived X-ray: $20 copay; deductible waived Lab: $50 copay; deductible waived X-ray: $50 copay; deductible waived Imaging (CT/PET scans, MRIs) $150 copay; deductible waived $150 copay; deductible waived Prescription Drug Deductible (applies to brand and non-formulary brand-name drugs) None None Prescription Drugs 1 Generic Formulary/Brand Formulary/ Generic & Brand Non-Formulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply $15/$25/$40 $15/$25/$40 Pharmacy Plan Type Three Tier Open Formulary Three Tier Open Formulary Aetna Specialty CareRx SM self-injectables Covered under medical Covered under medical Outpatient Surgery, Hospital OP Department 20% after deductible 20% after deductible Outpatient Surgery, Freestanding Facility $100 copay after deductible $100 copay after deductible Inpatient Hospital Facility 20% after deductible 20% after deductible Rehabilitation Services 2 (PT/OT/ST) (60 visits per incident) $20 copay; deductible waived $50 copay; deductible waived Emergency Room $100 copay after deductible $100 copay after deductible Emergency Medical Transport $100 copay after deductible $100 copay after deductible Urgent Care $35 copay; deductible waived $35 copay; deductible waived Primary & Specialist Physician E-Visit Not covered Not covered Walk-In Clinics Not covered Not covered Chiropractic (20 visits per calendar year) $15 copay; deductible waived $15 copay; deductible waived Routine Vision (one exam per member every 24 months) No charge No charge See page 37 for footnotes. 19

20 OAMC Plans OAMC 1.8 Participating Providers Non-Participating Providers 6 Network Managed Choice POS (Open Access) NA PCP/Referrals Required No NA Calendar-Year Plan Deductible Out-of-Pocket Limit $250 Individual $500 Family $2,000 Individual $4,000 Family $500 Individual $1,000 Family $4,000 Individual $8,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 3 Embedded aggregate 3 Not Included in Out-of-Pocket Limit Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Primary Care Physician Office Visit1 $10 copay; deductible waived 30% after deductible Specialist Office Visit1 $10 copay; deductible waived 30% after deductible Preventive Care/Screenings/Immunizations No charge 30% after deductible Diagnostic Testing (X-ray, blood work) 10% after deductible 30% after deductible Imaging (CT/PET scans, MRIs) 20% after deductible 40% after deductible Prescription Drug Deductible None NA Prescription Drugs 1 Generic Formulary/Brand Formulary/Brand Non-Formulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply $10/$20/$35 30% after $10/$20/$35 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx Includes self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward Out-of-pocket payment limit) 20% up to $150 per prescription Not covered Outpatient Surgery, Hospital OP Department $100 copay plus 10% after deductible 30% after deductible; Aetna pays up to Outpatient Surgery, Freestanding Facility 10% after deductible 30% after deductible; Aetna pays up to Inpatient Hospital Facility $100 copay plus 10% after deductible $250 copay plus 30% after deductible Rehabilitation Services 2 (PT/OT/Chiropractic) (25 visits per calendar year, participating and non-participating providers combined) $10 copay; deductible waived 30% after deductible Emergency Room $100 copay plus 10%; deductible waived $100 copay plus 10%; deductible waived Emergency Medical Transport 10% after deductible 10% after deductible Urgent Care $35 copay; deductible waived 30% after deductible Primary & Specialist Physician E-Visit (register at $10 copay; deductible waived Not covered Walk-In Clinics $10 copay; deductible waived Not covered Chiropractic Covered under Rehabilitation Services Covered under Rehabilitation Services Routine Vision (one exam per member every 24 months) No charge Not covered See page 37 for footnotes. 20

21 OAMC Plans OAMC 3.8 Participating Providers Non-Participating Providers 6 Network Managed Choice POS (Open Access) NA PCP/Referrals Required No NA Calendar-Year Plan Deductible Out-of-Pocket Limit $250 Individual $500 Family $2,000 Individual $4,000 Family $500 Individual $1,000 Family $4,000 Individual $8,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 3 Embedded aggregate 3 Not Included in Out-of-Pocket Limit Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Primary Care Physician Office Visit1 $15 copay; deductible waived 30% after deductible Specialist Office Visit1 $15 copay; deductible waived 30% after deductible Preventive Care/Screenings/Immunizations No charge 30% after deductible Diagnostic Testing (X-ray, blood work) 10% after deductible 30% after deductible Imaging (CT/PET scans, MRIs) 20% after deductible 40% after deductible Prescription Drug Deductible None NA Prescription Drugs 1 Generic Formulary/Brand Formulary/Brand Non-Formulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply $15/$25/$40 30% after $15/$25/$40 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx Includes self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward Out-of-pocket payment limit) 20% up to $150 per prescription Not covered Outpatient Surgery, Hospital OP Department $100 copay plus 10% after deductible 30% after deductible; Aetna pays up to Outpatient Surgery, Freestanding Facility 10% after deductible 30% after deductible; Aetna pays up to Inpatient Hospital Facility $100 copay plus 10% after deductible $250 copay plus 30% after deductible Rehabilitation Services 2 (PT/OT/Chiropractic) (25 visits per calendar year, participating and non-participating providers combined) $15 copay; deductible waived 30% after deductible Emergency Room $100 copay plus 10%; deductible waived $100 copay plus 10%; deductible waived Emergency Medical Transport 10% after deductible 10% after deductible Urgent Care $35 copay; deductible waived 30% after deductible Primary & Specialist Physician E-Visit (register at $10 copay; deductible waived Not covered Walk-In Clinics $15 copay; deductible waived Not covered Chiropractic Covered under Rehabilitation Services Covered under Rehabilitation Services Routine Vision (one exam per member every 24 months) No charge Not covered See page 37 for footnotes. 21

22 OAMC Plans OAMC 4.8 Participating Providers Non-Participating Providers 6 Network Managed Choice POS (Open Access) NA PCP/Referrals Required No NA Calendar-Year Plan Deductible Out-of-Pocket Limit $250 Individual $500 Family $2,000 Individual $4,000 Family $500 Individual $1,000 Family $4,000 Individual $8,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 3 Embedded aggregate 3 Not Included in Out-of-Pocket Limit Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Primary Care Physician Office Visit1 $15 copay; deductible waived 30% after deductible Specialist Office Visit1 $15 copay; deductible waived 30% after deductible Preventive Care/Screenings/Immunizations No charge 30% after deductible Diagnostic Testing (X-ray, blood work) 10% after deductible 30% after deductible Imaging (CT/PET scans, MRIs) 20% after deductible 40% after deductible Prescription Drug Deductible None NA Prescription Drugs 1 Generic Formulary/Brand Formulary/Brand Non-Formulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply $10/$20/$35 30% after $10/$20/$35 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx Includes self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward Out-of-pocket payment limit) 20% up to $150 per prescription Not covered Outpatient Surgery, Hospital OP Department $100 copay plus 10% after deductible 30% after deductible; Aetna pays up to Outpatient Surgery, Freestanding Facility 10% after deductible 30% after deductible; Aetna pays up to Inpatient Hospital Facility $100 copay plus 10% after deductible $250 copay plus 30% after deductible Rehabilitation Services 2 (PT/OT/Chiropractic) (25 visits per calendar year, participating and non-participating providers combined) $15 copay; deductible waived 30% after deductible Emergency Room $100 copay plus 10%; deductible waived $100 copay plus 10%; deductible waived Emergency Medical Transport 10% after deductible 10% after deductible Urgent Care $35 copay; deductible waived 30% after deductible Primary & Specialist Physician E-Visit (register at $10 copay; deductible waived Not covered Walk-In Clinics $15 copay; deductible waived Not covered Chiropractic Covered under Rehabilitation Services Covered under Rehabilitation Services Routine Vision (one exam per member every 24 months) No charge Not covered See page 37 for footnotes. 22

23 OAMC Plans OAMC 5.8 Participating Providers Non-Participating Providers 6 Network Managed Choice POS (Open Access) NA PCP/Referrals Required No NA Calendar-Year Plan Deductible Out-of-Pocket Limit $250 Individual $500 Family $2,000 Individual $4,000 Family $500 Individual $1,000 Family $4,000 Individual $8,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 3 Embedded aggregate 3 Not Included in Out-of-Pocket Limit Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Primary Care Physician Office Visit1 $20 copay; deductible waived 30% after deductible Specialist Office Visit1 $20 copay; deductible waived 30% after deductible Preventive Care/Screenings/Immunizations No charge 30% after deductible Diagnostic Testing (X-ray, blood work) 10% after deductible 30% after deductible Imaging (CT/PET scans, MRIs) 20% after deductible 40% after deductible Prescription Drug Deductible None NA Prescription Drugs 1 Generic Formulary/Brand Formulary/Brand Non-Formulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply $15/$25/$40 30% after $15/$25/$40 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx Includes self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward Out-of-pocket payment limit) 20% up to $150 per prescription Not covered Outpatient Surgery, Hospital OP Department $100 copay plus 10% after deductible 30% after deductible; Aetna pays up to Outpatient Surgery, Freestanding Facility 10% after deductible 30% after deductible; Aetna pays up to Inpatient Hospital Facility $100 copay plus 10% after deductible $250 copay plus 30% after deductible Rehabilitation Services 2 (PT/OT/Chiropractic) (25 visits per calendar year, participating and non-participating providers combined) $20 copay; deductible waived 30% after deductible Emergency Room $100 copay plus 10%; deductible waived $100 copay plus 10%; deductible waived Emergency Medical Transport 10% after deductible 10% after deductible Urgent Care $35 copay; deductible waived 30% after deductible Primary & Specialist Physician E-Visit (register at $10 copay; deductible waived Not covered Walk-In Clinics $20 copay; deductible waived Not covered Chiropractic Covered under Rehabilitation Services Covered under Rehabilitation Services Routine Vision (one exam per member every 24 months) No charge Not covered See page 37 for footnotes. 23

24 OAMC Plans OAMC 6.8 Participating Providers Non-Participating Providers 6 Network Managed Choice POS (Open Access) NA PCP/Referrals Required No NA Calendar-Year Plan Deductible Out-of-Pocket Limit $250 Individual $500 Family $2,000 Individual $4,000 Family $500 Individual $1,000 Family $4,000 Individual $8,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 3 Embedded aggregate 3 Not Included in Out-of-Pocket Limit Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Primary Care Physician Office Visit1 $15 copay; deductible waived 30% after deductible Specialist Office Visit1 $15 copay; deductible waived 30% after deductible Preventive Care/Screenings/Immunizations No charge 30% after deductible Diagnostic Testing (X-ray, blood work) 10% after deductible 30% after deductible Imaging (CT/PET scans, MRIs) 20% after deductible 40% after deductible Prescription Drug Deductible None NA Prescription Drugs 1 Generic Formulary/Brand Formulary/Brand Non-Formulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply $15/$25/$40 30% after $15/$25/$40 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx Includes self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward Out-of-pocket payment limit) 20% up to $150 per prescription Not covered Outpatient Surgery, Hospital OP Department $200 copay plus 10% after deductible 30% after deductible; Aetna pays up to Outpatient Surgery, Freestanding Facility 10% after deductible 30% after deductible; Aetna pays up to Inpatient Hospital Facility $250 copay plus 10% after deductible $500 copay plus 30% after deductible Rehabilitation Services 2 (PT/OT/Chiropractic) (25 visits per calendar year, participating and non-participating providers combined) $15 copay; deductible waived 30% after deductible Emergency Room $100 copay plus 10%; deductible waived $100 copay plus 10%; deductible waived Emergency Medical Transport 10% after deductible 10% after deductible Urgent Care $35 copay; deductible waived 30% after deductible Primary & Specialist Physician E-Visit (register at $10 copay; deductible waived Not covered Walk-In Clinics $15 copay; deductible waived Not covered Chiropractic Covered under Rehabilitation Services Covered under Rehabilitation Services Routine Vision (one exam per member every 24 months) No charge Not covered See page 37 for footnotes. 24

25 OAMC Plans OAMC 7.8 Participating Providers Non-Participating Providers 6 Network Managed Choice POS (Open Access) NA PCP/Referrals Required No NA Calendar-Year Plan Deductible Out-of-Pocket Limit $250 Individual $500 Family $2,500 Individual $5,000 Family $500 Individual $1,000 Family $5,000 Individual $10,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 3 Embedded aggregate 3 Not Included in Out-of-Pocket Limit Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Primary Care Physician Office Visit1 $20 copay; deductible waived 40% after deductible Specialist Office Visit1 $20 copay; deductible waived 40% after deductible Preventive Care/Screenings/Immunizations No charge 40% after deductible Diagnostic Testing (X-ray, blood work) 10% after deductible 40% after deductible Imaging (CT/PET scans, MRIs) 20% after deductible 50% after deductible Prescription Drug Deductible None NA Prescription Drugs 1 Generic Formulary/Brand Formulary/Brand Non-Formulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply $15/$25/$40 30% after $15/$25/$40 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx Includes self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward Out-of-pocket payment limit) 20% up to $150 per prescription Not covered Outpatient Surgery, Hospital OP Department $200 copay plus 10% after deductible 40% after deductible; Aetna pays up to Outpatient Surgery, Freestanding Facility 10% after deductible 40% after deductible; Aetna pays up to Inpatient Hospital Facility $350 copay plus 10% after deductible $750 copay plus 40% after deductible Rehabilitation Services 2 (PT/OT/Chiropractic) (25 visits per calendar year, participating and non-participating providers combined) $20 copay; deductible waived 40% after deductible Emergency Room $100 copay plus 10%; deductible waived $100 copay plus 10%; deductible waived Emergency Medical Transport 10% after deductible 10% after deductible Urgent Care $35 copay; deductible waived 40% after deductible Primary & Specialist Physician E-Visit (register at $10 copay; deductible waived Not covered Walk-In Clinics $20 copay; deductible waived Not covered Chiropractic Covered under Rehabilitation Services Covered under Rehabilitation Services Routine Vision (one exam per member every 24 months) No charge Not covered See page 37 for footnotes. 25

26 OAMC Plans OAMC 8.8 Participating Providers Non-Participating Providers 6 Network Managed Choice POS (Open Access) NA PCP/Referrals Required No NA Calendar-Year Plan Deductible Out-of-Pocket Limit $250 Individual $500 Family $2,500 Individual $5,000 Family $500 Individual $1,000 Family $5,000 Individual $10,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 3 Embedded aggregate 3 Not Included in Out-of-Pocket Limit Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Primary Care Physician Office Visit1 $20 copay; deductible waived 40% after deductible Specialist Office Visit1 $20 copay; deductible waived 40% after deductible Preventive Care/Screenings/Immunizations No charge 40% after deductible Diagnostic Testing (X-ray, blood work) 10% after deductible 40% after deductible Imaging (CT/PET scans, MRIs) 20% after deductible 50% after deductible Prescription Drug Deductible None NA Prescription Drugs 1 Generic Formulary/Brand Formulary/Brand Non-Formulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply $20/$35/$50 30% after $20/$35/$50 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx Includes self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward Out-of-pocket payment limit) 20% up to $150 per prescription Not covered Outpatient Surgery, Hospital OP Department $200 copay plus 10% after deductible 40% after deductible; Aetna pays up to Outpatient Surgery, Freestanding Facility 10% after deductible 40% after deductible; Aetna pays up to Inpatient Hospital Facility $350 copay plus 10% after deductible $750 copay plus 40% after deductible Rehabilitation Services 2 (PT/OT/Chiropractic) (25 visits per calendar year, participating and non-participating providers combined) $20 copay; deductible waived 40% after deductible Emergency Room $100 copay plus 10%; deductible waived $100 copay plus 10%; deductible waived Emergency Medical Transport 10% after deductible 10% after deductible Urgent Care $35 copay; deductible waived 40% after deductible Primary & Specialist Physician E-Visit (register at $10 copay; deductible waived Not covered Walk-In Clinics $20 copay; deductible waived Not covered Chiropractic Covered under Rehabilitation Services Covered under Rehabilitation Services Routine Vision (one exam per member every 24 months) No charge Not covered See page 37 for footnotes. 26

27 OAMC Plans OAMC 9.8 Participating Providers Non-Participating Providers 6 Network Managed Choice POS (Open Access) NA PCP/Referrals Required No NA Calendar-Year Plan Deductible Out-of-Pocket Limit $300 Individual $600 Family $2,500 Individual $5,000 Family $600 Individual $1,200 Family $5,000 Individual $10,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 3 Embedded aggregate 3 Not Included in Out-of-Pocket Limit Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Primary Care Physician Office Visit1 $15 copay; deductible waived 40% after deductible Specialist Office Visit1 $15 copay; deductible waived 40% after deductible Preventive Care/Screenings/Immunizations No charge 40% after deductible Diagnostic Testing (X-ray, blood work) 20% after deductible 40% after deductible Imaging (CT/PET scans, MRIs) 30% after deductible 50% after deductible Prescription Drug Deductible None NA Prescription Drugs 1 Generic Formulary/Brand Formulary/Brand Non-Formulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply $10/$20/$35 30% after $10/$20/$35 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx Includes self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward Out-of-pocket payment limit) 20% up to $150 per prescription Not covered Outpatient Surgery, Hospital OP Department $100 copay plus 20% after deductible 40% after deductible; Aetna pays up to Outpatient Surgery, Freestanding Facility 20% after deductible 40% after deductible; Aetna pays up to Inpatient Hospital Facility $150 copay plus 20% after deductible $300 copay plus 40% after deductible Rehabilitation Services 2 (PT/OT/Chiropractic) (25 visits per calendar year, participating and non-participating providers combined) $15 copay; deductible waived 40% after deductible Emergency Room $100 copay plus 20%; deductible waived $100 copay plus 20%; deductible waived Emergency Medical Transport 20% after deductible 20% after deductible Urgent Care $35 copay; deductible waived 40% after deductible Primary & Specialist Physician E-Visit (register at $10 copay; deductible waived Not covered Walk-In Clinics $15 copay; deductible waived Not covered Chiropractic Covered under Rehabilitation Services Covered under Rehabilitation Services Routine Vision (one exam per member every 24 months) No charge Not covered See page 37 for footnotes. 27

28 OAMC Plans OAMC 10.8 Participating Providers Non-Participating Providers 6 Network Managed Choice POS (Open Access) NA PCP/Referrals Required No NA Calendar-Year Plan Deductible Out-of-Pocket Limit $300 Individual $600 Family $2,500 Individual $5,000 Family $600 Individual $1,200 Family $5,000 Individual $10,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 3 Embedded aggregate 3 Not Included in Out-of-Pocket Limit Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Primary Care Physician Office Visit1 $15 copay; deductible waived 40% after deductible Specialist Office Visit1 $15 copay; deductible waived 40% after deductible Preventive Care/Screenings/Immunizations No charge 40% after deductible Diagnostic Testing (X-ray, blood work) 20% after deductible 40% after deductible Imaging (CT/PET scans, MRIs) 30% after deductible 50% after deductible Prescription Drug Deductible None NA Prescription Drugs 1 Generic Formulary/Brand Formulary/Brand Non-Formulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply $15/$25/$40 30% after $15/$25/$40 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx Includes self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward Out-of-pocket payment limit) 20% up to $150 per prescription Not covered Outpatient Surgery, Hospital OP Department $100 copay plus 20% after deductible 40% after deductible; Aetna pays up to Outpatient Surgery, Freestanding Facility 20% after deductible 40% after deductible; Aetna pays up to Inpatient Hospital Facility $150 copay plus 20% after deductible $300 copay plus 40% after deductible Rehabilitation Services 2 (PT/OT/Chiropractic) (25 visits per calendar year, participating and non-participating providers combined) $15 copay; deductible waived 40% after deductible Emergency Room $100 copay plus 20%; deductible waived $100 copay plus 20%; deductible waived Emergency Medical Transport 20% after deductible 20% after deductible Urgent Care $35 copay; deductible waived 40% after deductible Primary & Specialist Physician E-Visit (register at $10 copay; deductible waived Not covered Walk-In Clinics $15 copay; deductible waived Not covered Chiropractic Covered under Rehabilitation Services Covered under Rehabilitation Services Routine Vision (one exam per member every 24 months) No charge Not covered See page 37 for footnotes. 28

29 OAMC Plans OAMC 11.8 Participating Providers Non-Participating Providers 6 Network Managed Choice POS (Open Access) NA PCP/Referrals Required No NA Calendar-Year Plan Deductible Out-of-Pocket Limit $300 Individual $600 Family $2,500 Individual $5,000 Family $600 Individual $1,200 Family $5,000 Individual $10,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 3 Embedded aggregate 3 Not Included in Out-of-Pocket Limit Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Primary Care Physician Office Visit1 $15 copay; deductible waived 40% after deductible Specialist Office Visit1 $15 copay; deductible waived 40% after deductible Preventive Care/Screenings/Immunizations No charge 40% after deductible Diagnostic Testing (X-ray, blood work) 20% after deductible 40% after deductible Imaging (CT/PET scans, MRIs) 30% after deductible 50% after deductible Prescription Drug Deductible None NA Prescription Drugs 1 Generic Formulary/Brand Formulary/Brand Non-Formulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply $20/$35/$50 30% after $20/$35/$50 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx Includes self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward Out-of-pocket payment limit) 20% up to $150 per prescription Not covered Outpatient Surgery, Hospital OP Department $100 copay plus 20% after deductible 40% after deductible; Aetna pays up to Outpatient Surgery, Freestanding Facility 20% after deductible 40% after deductible; Aetna pays up to Inpatient Hospital Facility $150 copay plus 20% after deductible $300 copay plus 40% after deductible Rehabilitation Services 2 (PT/OT/Chiropractic) (25 visits per calendar year, participating and non-participating providers combined) $15 copay; deductible waived 40% after deductible Emergency Room $100 copay plus 20%; deductible waived $100 copay plus 20%; deductible waived Emergency Medical Transport 20% after deductible 20% after deductible Urgent Care $35 copay; deductible waived 40% after deductible Primary & Specialist Physician E-Visit (register at $10 copay; deductible waived Not covered Walk-In Clinics $15 copay; deductible waived Not covered Chiropractic Covered under Rehabilitation Services Covered under Rehabilitation Services Routine Vision (one exam per member every 24 months) No charge Not covered See page 37 for footnotes. 29

30 OAMC Plans OAMC 13.8 Participating Providers Non-Participating Providers 6 Network Managed Choice POS (Open Access) NA PCP/Referrals Required No NA Calendar-Year Plan Deductible Out-of-Pocket Limit $500 Individual $1,000 Family $3,000 Individual $6,000 Family $1,000 Individual $2,000 Family $6,000 Individual $12,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 3 Embedded aggregate 3 Not Included in Out-of-Pocket Limit Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Primary Care Physician Office Visit1 $20 copay; deductible waived 40% after deductible Specialist Office Visit1 $20 copay; deductible waived 40% after deductible Preventive Care/Screenings/Immunizations No charge 40% after deductible Diagnostic Testing (X-ray, blood work) 20% after deductible 40% after deductible Imaging (CT/PET scans, MRIs) 30% after deductible 50% after deductible Prescription Drug Deductible None NA Prescription Drugs 1 Generic Formulary/Brand Formulary/Brand Non-Formulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply $15/$25/$40 30% after $15/$25/$40 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx Includes self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward Out-of-pocket payment limit) 20% up to $150 per prescription Not covered Outpatient Surgery, Hospital OP Department $200 copay plus 20% after deductible 40% after deductible; Aetna pays up to Outpatient Surgery, Freestanding Facility 20% after deductible 40% after deductible; Aetna pays up to Inpatient Hospital Facility $250 copay plus 20% after deductible $500 copay plus 40% after deductible Rehabilitation Services 2 (PT/OT/Chiropractic) (25 visits per calendar year, participating and non-participating providers combined) $20 copay; deductible waived 40% after deductible Emergency Room $100 copay plus 20%; deductible waived $100 copay plus 20%; deductible waived Emergency Medical Transport 20% after deductible 20% after deductible Urgent Care $35 copay; deductible waived 40% after deductible Primary & Specialist Physician E-Visit (register at $10 copay; deductible waived Not covered Walk-In Clinics $20 copay; deductible waived Not covered Chiropractic Covered under Rehabilitation Services Covered under Rehabilitation Services Routine Vision (one exam per member every 24 months) No charge Not covered See page 37 for footnotes. 30

31 OAMC Plans OAMC 15.8 Participating Providers Non-Participating Providers 6 Network Managed Choice POS (Open Access) NA PCP/Referrals Required No NA Calendar-Year Plan Deductible Out-of-Pocket Limit $500 Individual $1,000 Family $3,000 Individual $6,000 Family $1,000 Individual $2,000 Family $6,000 Individual $12,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 3 Embedded aggregate 3 Not Included in Out-of-Pocket Limit Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Primary Care Physician Office Visit1 $20 copay; deductible waived 40% after deductible Specialist Office Visit1 $20 copay; deductible waived 40% after deductible Preventive Care/Screenings/Immunizations No charge 40% after deductible Diagnostic Testing (X-ray, blood work) 20% after deductible 40% after deductible Imaging (CT/PET scans, MRIs) 30% after deductible 50% after deductible Prescription Drug Deductible None NA Prescription Drugs 1 Generic Formulary/Brand Formulary/Brand Non-Formulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply $20/$35/$50 30% after $20/$35/$50 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx Includes self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward Out-of-pocket payment limit) 20% up to $150 per prescription Not covered Outpatient Surgery, Hospital OP Department $400 copay plus 20% after deductible 40% after deductible; Aetna pays up to Outpatient Surgery, Freestanding Facility $100 copay plus 20% after deductible 40% after deductible; Aetna pays up to Inpatient Hospital Facility $500 copay plus 20% after deductible $1,000 copay plus 40% after deductible Rehabilitation Services 2 (PT/OT/Chiropractic) (25 visits per calendar year, participating and non-participating providers combined) $20 copay; deductible waived 40% after deductible Emergency Room $100 copay plus 20%; deductible waived $100 copay plus 20%; deductible waived Emergency Medical Transport 20% after deductible 20% after deductible Urgent Care $35 copay; deductible waived 40% after deductible Primary & Specialist Physician E-Visit (register at $10 copay; deductible waived Not covered Walk-In Clinics $20 copay; deductible waived Not covered Chiropractic Covered under Rehabilitation Services Covered under Rehabilitation Services Routine Vision (one exam per member every 24 months) No charge Not covered See page 37 for footnotes. 31

32 OAMC Plans OAMC 16.8* Participating Providers Non-Participating Providers 6 Network Managed Choice POS (Open Access) NA PCP/Referrals Required No NA Calendar-Year Plan Deductible Out-of-Pocket Limit $500 Individual $1,000 Family $3,000 Individual $6,000 Family $1,000 Individual $2,000 Family $6,000 Individual $12,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 3 Embedded aggregate 3 Not Included in Out-of-Pocket Limit Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Primary Care Physician Office Visit1 $20 copay; deductible waived 40% after deductible Specialist Office Visit1 $20 copay; deductible waived 40% after deductible Preventive Care/Screenings/Immunizations No charge 40% after deductible Diagnostic Testing (X-ray, blood work) 20% after deductible 40% after deductible Imaging (CT/PET scans, MRIs) 30% after deductible 50% after deductible Prescription Drug Deductible None NA Prescription Drugs 1 Generic Formulary/Brand Formulary/Brand Non-Formulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply $15/$25/$40 30% after $15/$25/$40 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx Includes self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward Out-of-pocket payment limit) 20% up to $150 per prescription Not covered Outpatient Surgery, Hospital OP Department $400 copay plus 20% after deductible 40% after deductible; Aetna pays up to Outpatient Surgery, Freestanding Facility $100 copay plus 20% after deductible 40% after deductible; Aetna pays up to Inpatient Hospital Facility $500 copay plus 20% after deductible $1,000 copay plus 40% after deductible Rehabilitation Services 2 (PT/OT/Chiropractic) (25 visits per calendar year, participating and non-participating providers combined) $20 copay; deductible waived 40% after deductible Emergency Room $100 copay plus 20%; deductible waived $100 copay plus 20%; deductible waived Emergency Medical Transport 20% after deductible 20% after deductible Urgent Care $35 copay; deductible waived 40% after deductible Primary & Specialist Physician E-Visit (register at $10 copay; deductible waived Not covered Walk-In Clinics $20 copay; deductible waived Not covered Chiropractic Covered under Rehabilitation Services Covered under Rehabilitation Services Routine Vision (one exam per member every 24 months) No charge Not covered See page 37 for footnotes. 32

33 OAMC Plans OAMC 20.8 Participating Providers Non-Participating Providers 6 Network Managed Choice POS (Open Access) NA PCP/Referrals Required No NA Calendar-Year Plan Deductible Out-of-Pocket Limit $250 Individual $500 Family $2,500 Individual $5,000 Family $750 Individual $1,500 Family $7,500 Individual $15,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 3 Embedded aggregate 3 Not Included in Out-of-Pocket Limit Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Primary Care Physician Office Visit1 $30 copay; deductible waived 50% after deductible Specialist Office Visit1 $30 copay; deductible waived 50% after deductible Preventive Care/Screenings/Immunizations No charge 50% after deductible Diagnostic Testing (X-ray, blood work) 30% after deductible 50% after deductible Imaging (CT/PET scans, MRIs) 30% after deductible 50% after deductible Prescription Drug Deductible None NA Prescription Drugs 1 Generic Formulary/Brand Formulary/Brand Non-Formulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply $15/$30/$50 30% after $15/$30/$50 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx Includes self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward Out-of-pocket payment limit) 20% up to $150 per prescription Not covered Outpatient Surgery, Hospital OP Department $200 copay plus 30% after deductible 50% after deductible; Aetna pays up to Outpatient Surgery, Freestanding Facility 30% after deductible 50% after deductible; Aetna pays up to Inpatient Hospital Facility $250 copay plus 30% after deductible $500 copay plus 50% after deductible Rehabilitation Services 2 (PT/OT/Chiropractic) (25 visits per calendar year, participating and non-participating providers combined) $30 copay; deductible waived 50% after deductible Emergency Room $100 copay plus 30%; deductible waived $100 copay plus 30%; deductible waived Emergency Medical Transport 30% after deductible 30% after deductible Urgent Care $35 copay; deductible waived 50% after deductible Primary & Specialist Physician E-Visit (register at $10 copay; deductible waived Not covered Walk-In Clinics $30 copay; deductible waived Not covered Chiropractic Covered under Rehabilitation Services Covered under Rehabilitation Services Routine Vision (one exam per member every 24 months) No charge Not covered See page 37 for footnotes. 33

34 OAMC Plans OAMC 22.8 Participating Providers Non-Participating Providers 6 Network Managed Choice POS (Open Access) NA PCP/Referrals Required No NA Calendar-Year Plan Deductible Out-of-Pocket Limit $5,000 Individual $10,000 Family None Individual None Family $10,000 Individual $20,000 Family None Individual None Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 3 Embedded aggregate 3 Not Included in Out-of-Pocket Limit Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including SpecialtyCareRx) Primary Care Physician Office Visit1 $15 copay; deductible waived 50% after deductible Specialist Office Visit1 $15 copay; deductible waived 50% after deductible Preventive Care/Screenings/Immunizations No charge 50% after deductible Diagnostic Testing (X-ray, blood work) 0% after deductible 50% after deductible Imaging (CT/PET scans, MRIs) 0% after deductible 50% after deductible Prescription Drug Deductible None NA Prescription Drugs 1 Generic Formulary/Brand Formulary/Brand Non-Formulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply $20/$40/$70 30% after $20/$40/$70 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx Includes self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward Out-of-pocket payment limit) 20% up to $150 per prescription Not covered Outpatient Surgery, Hospital OP Department 0% after deductible 50% after deductible; Aetna pays up to Outpatient Surgery, Freestanding Facility 0% after deductible 50% after deductible; Aetna pays up to Inpatient Hospital Facility 0% after deductible 50% after deductible Rehabilitation Services 2 (PT/OT/Chiropractic) (25 visits per calendar year, participating and non-participating providers combined) $15 copay; deductible waived 50% after deductible Emergency Room $100 copay; deductible waived per visit $100 copay; deductible waived per visit Emergency Medical Transport 0% after deductible 0% after deductible Urgent Care $35 copay; deductible waived 50% after deductible Primary & Specialist Physician E-Visit (register at $10 copay; deductible waived Not covered Walk-In Clinics $15 copay; deductible waived Not covered Chiropractic Covered under Rehabilitation Services Covered under Rehabilitation Services Routine Vision (one exam per member every 24 months) No charge Not covered See page 37 for footnotes. 34

35 OAMC HSA Plans OAMC HSA 2.7 Participating Providers Non-Participating Providers 6 Network Managed Choice POS (Open Access) NA PCP/Referrals Required No NA Calendar-Year Plan Deductible Out-of-Pocket Limit $2,500 Individual $5,000 Family $1,000 Individual $2,000 Family $3,000 Individual $6,000 Family $1,250 Individual $2,500 Family Deductible & Out-of-Pocket Limit Accumulation True Integrated Family (TIF) 5 True Integrated Family (TIF) 5 Not Included in Out-of-Pocket Limit Amounts over allowable charges, deductible and failure to precertify penalty Amounts over allowable charges, deductible and failure to precertify penalty Primary Care Physician Office Visit1 10% after deductible 30% after deductible Specialist Office Visit1 10% after deductible 30% after deductible Preventive Care/Screenings/Immunizations No charge 30% after deductible Diagnostic Testing (X-ray, blood work) 10% after deductible 30% after deductible Imaging (CT/PET scans, MRIs) 10% after deductible 30% after deductible Prescription Drug Deductible Integrated Medical/Rx deductible Integrated Medical/Rx deductible Prescription Drugs 1 Generic Formulary/Brand Formulary/Brand Non-Formulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply $15/$20/$35 30% after $15/$20/$35 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx Includes self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin, does accumulate toward Out-of-pocket payment limit) 20% Not covered Outpatient Surgery, Hospital OP Department 10% after deductible 30% after deductible; Aetna pays up to Outpatient Surgery, Freestanding Facility 10% after deductible 30% after deductible; Aetna pays up to Inpatient Hospital Facility 10% after deductible 30% after deductible Rehabilitation Services 2 (PT/OT/Chiropractic) (25 visits per calendar year, participating and non-participating providers combined) 10% after deductible 30% after deductible Emergency Room 10% after deductible per visit 10% after deductible per visit Emergency Medical Transport 10% after deductible 10% after deductible Urgent Care 10% after deductible 30% after deductible Primary & Specialist Physician E-Visit (register at 10% after deductible Not covered Walk-In Clinics 10% after deductible Not covered Chiropractic Covered under Rehabilitation Services Covered under Rehabilitation Services Routine Vision (one exam per member every 24 months) No charge Not covered See page 37 for footnotes. 35

36 OAMC HSA Plans OAMC HSA 3.7* Participating Providers Non-Participating Providers 6 Network Managed Choice POS (Open Access) NA PCP/Referrals Required No NA Calendar-Year Plan Deductible Out-of-Pocket Limit $2,500 Individual $5,000 Family $1,000 Individual $2,000 Family $3,000 Individual $6,000 Family $1,500 Individual $3,000 Family Deductible & Out-of-Pocket Limit Accumulation True Integrated Family (TIF) 5 True Integrated Family (TIF) 5 Not Included in Out-of-Pocket Limit Amounts over allowable charges, deductible and failure to precertify penalty Amounts over allowable charges, deductible and failure to precertify penalty Primary Care Physician Office Visit1 20% after deductible 40% after deductible Specialist Office Visit1 20% after deductible 40% after deductible Preventive Care/Screenings/Immunizations No charge 40% after deductible Diagnostic Testing (X-ray, blood work) 20% after deductible 40% after deductible Imaging (CT/PET scans, MRIs) 20% after deductible 40% after deductible Prescription Drug Deductible Integrated Medical/Rx deductible Integrated Medical/Rx deductible Prescription Drugs 1 Generic Formulary/Brand Formulary/Brand Non-Formulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply $15/$20/$35 30% after $15/$20/$35 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx Includes self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin, does accumulate toward Out-of-pocket payment limit) 20% Not covered Outpatient Surgery, Hospital OP Department 20% after deductible 40% after deductible; Aetna pays up to Outpatient Surgery, Freestanding Facility 20% after deductible 40% after deductible; Aetna pays up to Inpatient Hospital Facility 20% after deductible 40% after deductible Rehabilitation Services 2 (PT/OT/Chiropractic) (25 visits per calendar year, participating and non-participating providers combined) 20% after deductible 40% after deductible Emergency Room 20% after deductible per visit 20% after deductible per visit Emergency Medical Transport 20% after deductible 20% after deductible Urgent Care 20% after deductible 40% after deductible Primary & Specialist Physician E-Visit (register at 20% after deductible Not covered Walk-In Clinics 20% after deductible Not covered Chiropractic Covered under Rehabilitation Services Covered under Rehabilitation Services Routine Vision (one exam per member every 24 months) No charge Not covered 36

37 Medical plans for eligible enrolling Footnotes All services are subject to the deductible unless otherwise noted. 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 such as non-emergency hospital care and complex imaging services. Generic formulary contraceptives are covered without member cost share. Certain religious organizations or religious employers may be exempt from offering contraceptive services. * This plan is available for religious exemption. Contact your Aetna representative for more information. 1 Copays related to preventive care services will be waived. Coverage for formulary, generic, FDA-approved women s contraceptives are covered 100% in network. 2 PT, OT, Cognitive Therapy and Speech Therapy for Pervasive Developmental Disorders (including Autism) may be extended beyond the visit maximum when medical and/or behavioral health documentation supports the member s ability to progress toward the treatment goals. 3 Each covered family member only needs to satisfy his or her individual deductible/out-of-pocket limit, not the entire family deductible/out-of-pocket limit. 4 The Fund will be used to pay for member responsibility for services that are subject to the deductible. 5 There is no individual deductible/out-of-pocket limit to satisfy within the family deductible/out-of-pocket limit. Once the family deductible/out-of-pocket limit is met, all family members will be considered as having met their deductible/ out-of-pocket limit for the remainder of the calendar year. 6 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 deductibles under your plan. No dollar amount above the recognized charge counts toward your deductible 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 in-network care. You pay cost sharing and deductibles 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 deductibles. 37

38 Aetna Dental Plans Business decision makers can choose from a variety of dental plan design options that help employees. 38

39 Dental Overview The Mouth Matters SM Research suggests that serious gum disease, known as periodontitis, may be associated with many health problems. This is especially true if serious gum disease continues without treatment. 1 Now, here s the good news. Researchers are discovering that a healthy mouth may be important to your overall health. 1 Aetna Dental/Medical Integration SM (DMI) program,* available at no additional charge to plan sponsors that have both medical and dental coverages with Aetna, focuses on those who are pregnant or have diabetes, coronary artery disease (heart disease) or cerebrovascular disease (stroke) and have not had a recent dental visit. We proactively educate those at-risk members about the impact oral health care can have on their condition. Our member outreach has been proven to successfully motivate those at-risk members who do not normally seek dental care to visit the dentist. Once at the dentist, these at-risk members will receive enhanced dental benefits including an extra cleaning and full coverage for certain periodontal services. The Dental Maintenance Organization (DMO ) Members select a primary care dentist to coordinate their care from the available managed dental network. Each family member may choose a different primary care dentist and may switch dentists at any time via Aetna Navigator or with a call to Member Services. If specialty care is needed, a member s primary care dentist can refer the member to a participating specialist. However, members may visit orthodontists without a referral. There are virtually no claim forms to file, and benefits are not subject to deductibles or annual maximums. Preferred Provider Organization (PPO) plan Members can choose a dentist who participates in the network or choose a licensed dentist who does not. Participating dentists have agreed to offer our members covered services at a negotiated rate and will not balance-bill members. PPO Max plan While the PPO Max dental insurance plan uses the PPO network, when members use out-of-network dentists the service will be covered based on the PPO fee schedule, rather than the reasonable and customary charge. The member will share in more of the costs and may be balance-billed. This plan offers members a quality dental insurance plan with a significantly lower premium that encourages in-network usage. Dual Option plan In the Dual Option plan design, the DMO may be packaged with any one of the PPO plans. Employees may choose between the DMO and PPO offerings at annual enrollment. Voluntary Dental option The Voluntary Dental option is entirely member paid and provides a solution to meet the individual needs of members in the face of rising health care costs. Administration is easy, and members benefit from low group rates and the convenience of payroll deductions. Freedom-of-Choice plan design option Get maximum flexibility with our two-in-one dental plan design. The Freedom-of-Choice plan design option provides the administrative ease of one plan, yet members get to choose between the DMO and PPO plans on a monthly basis. One blended rate is paid. Members may switch between the plans each month by calling Member Services. Plan changes must be made by the 15 th of the month to be effective the following month. 1 MayoClinic.com. Oral health: A window to your overall health. [article online]. February 5, Accessed November *DMI may not be available in all states. 39

40 Aetna Group Dental Plans Option 1A DMO Copay 58 Option 2A DMO Coinsurance Option 3A DMO Copay 66 Option 4A Freedom-of-Choice Monthly selection between DMO and PPO See page 44 for footnotes. 40 Fixed Copay DMO Plan 58 DMO Plan 100/100/60 Fixed Copay DMO Plan 66 DMO Plan 100/100/60 Office Visit Copay $5 $5 $0 $5 N/A Annual Deductible per Member (Does not apply to Diagnostic & Preventive Services) PPO Plan 100/80/50 None None None None $50; 3X Family Maximum Annual Maximum Benefit Unlimited Unlimited Unlimited Unlimited $1,500 Diagnostic Services Oral Exams Periodic oral exam No charge 100% No charge 100% 100% Comprehensive oral exam No charge 100% No charge 100% 100% Problem-focused oral exam No charge 100% No charge 100% 100% X-rays Bitewing single film No charge 100% No charge 100% 100% Complete series No charge 100% No charge 100% 100% Preventive Services Adult Cleaning No charge 100% No charge 100% 100% Child Cleaning No charge 100% No charge 100% 100% Sealants per tooth $5 100% No charge 100% 100% Fluoride application child No charge 100% No charge 100% 100% Space maintainers fixed $60 100% No charge 100% 100% Basic Services Amalgam filling 2 surfaces No charge 100% No charge 100% 80% Resin filling 2 surfaces, anterior No charge 100% No charge 100% 80% Endodontic Services Bicuspid root canal therapy $85 100% No charge 100% 80% Periodontic Services Scaling & root planing per quadrant $55 100% $35 100% 80% Oral Surgery Extraction exposed root or erupted tooth No charge 100% No charge 100% 80% Extraction of impacted tooth soft tissue $46 100% No charge 100% 80% Major Services* Complete upper denture $275 60% $200 60% 50% Partial upper denture (resin base) $275 60% $200 60% 50% Crown Porcelain with noble metal1 $210 60% $180 60% 50% Pontic Porcelain with noble metal1 $210 60% $180 60% 50% Inlay Metallic (3 or more surfaces) $180 60% $180 60% 50% Oral Surgery Removal of impacted tooth partially bony $58 60% $45 60% 80% Endodontic Services Molar root canal therapy $240 60% $146 60% 80% Periodontic Services Osseous surgery per quadrant $300 60% $140 60% 80% Orthodontic Services* (optional) $2,300 copay $2,000 copay $2,300 copay $2,000 copay 50% Orthodontic Lifetime Maximum Does not apply Does not apply Does not apply Does not apply $1,000

41 Aetna Group Dental Plans Option 5A Freedom-of-Choice Active Monthly selection between DMO and PPO Option 6A Active PPO Low DMO Plan 100/100/60 PPO Plan 100/90/60 PPO Plan 100/80/50 Preferred Plan 80/80/50 Office Visit Copay $5 N/A N/A N/A N/A Annual Deductible per Member (Does not apply to Diagnostic & Preventive Services) None $50; 3X Family Maximum $50; 3X Family Maximum $50; 3X Family Maximum Non-Preferred Plan 70/50/50 $50; 3X Family Maximum Annual Maximum Benefit Unlimited $1,500 $1,000 $1,500 $1,500 Diagnostic Services Oral Exams Periodic oral exam 100% 100% 100% 80% 70% Comprehensive oral exam 100% 100% 100% 80% 70% Problem-focused oral exam 100% 100% 100% 80% 70% X-rays Bitewing single film 100% 100% 100% 80% 70% Complete series 100% 100% 100% 80% 70% Preventive Services Adult Cleaning 100% 100% 100% 80% 70% Child Cleaning 100% 100% 100% 80% 70% Sealants per tooth 100% 100% 100% 80% 70% Fluoride application child 100% 100% 100% 80% 70% Space maintainers fixed 100% 100% 100% 80% 70% Basic Services Amalgam filling 2 surfaces 100% 90% 80% 80% 50% Resin filling 2 surfaces, anterior 100% 90% 80% 80% 50% Endodontic Services Bicuspid root canal therapy 100% 90% 80% 80% 50% Periodontic Services Scaling & root planing per quadrant 100% 90% 80% 80% 50% Oral Surgery Extraction exposed root or erupted tooth 100% 90% 80% 80% 50% Extraction of impacted tooth soft tissue 100% 90% 80% 80% 50% Major Services* Complete upper denture 60% 60% 50% 50% 50% Partial upper denture (resin base) 60% 60% 50% 50% 50% Crown Porcelain with noble metal1 60% 60% 50% 50% 50% Pontic Porcelain with noble metal1 60% 60% 50% 50% 50% Inlay Metallic (3 or more surfaces) 60% 60% 50% 50% 50% Oral Surgery Removal of impacted tooth partially bony 60% 90% 80% 80% 50% Endodontic Services Molar root canal therapy 60% 90% 80% 80% 50% Periodontic Services Osseous surgery per quadrant 60% 90% 80% 80% 50% Orthodontic Services* (optional) $2,000 copay 50% 50% 50% 50% Orthodontic Lifetime Maximum Does not apply $1,000 $1,000 $1,000 $1,000 See page 44 for footnotes. 41

42 Aetna Group Dental Plans Option 7A Active PPO Option 8A Active PPO Plus, 90th Preferred Plan 100/90/60 Non-Preferred Plan 100/80/50 Preferred Plan 100/90/60 Non-Preferred Plan 100/80/50 Office Visit Copay N/A N/A N/A N/A Annual Deductible per Member (Does not apply to Diagnostic & Preventive Services) $50; 3X Family Maximum $50; 3X Family Maximum $50; 3X Family Maximum $50; 3X Family Maximum Annual Maximum Benefit $1,500 $1,000 $2,000 $1,500 Diagnostic Services Oral Exams Periodic oral exam 100% 100% 100% 100% Comprehensive oral exam 100% 100% 100% 100% Problem-focused oral exam 100% 100% 100% 100% X-rays Bitewing single film 100% 100% 100% 100% Complete series 100% 100% 100% 100% Preventive Services Adult Cleaning 100% 100% 100% 100% Child Cleaning 100% 100% 100% 100% Sealants per tooth 100% 100% 100% 100% Fluoride application child 100% 100% 100% 100% Space maintainers fixed 100% 100% 100% 100% Basic Services Amalgam filling 2 surfaces 90% 80% 90% 80% Resin filling 2 surfaces, anterior 90% 80% 90% 80% Endodontic Services Bicuspid root canal therapy 90% 80% 90% 80% Periodontic Services Scaling & root planing per quadrant 90% 80% 90% 80% Oral Surgery Extraction exposed root or erupted tooth 90% 80% 90% 80% Extraction of impacted tooth soft tissue 90% 80% 90% 80% Major Services* Complete upper denture 60% 50% 60% 50% Partial upper denture (resin base) 60% 50% 60% 50% Crown Porcelain with noble metal1 60% 50% 60% 50% Pontic Porcelain with noble metal1 60% 50% 60% 50% Inlay Metallic (3 or more surfaces) 60% 50% 60% 50% Oral Surgery Removal of impacted tooth partially bony 90% 80% 90% 80% Endodontic Services Molar root canal therapy 90% 80% 90% 80% Periodontic Services Osseous surgery per quadrant 90% 80% 90% 80% Orthodontic Services* (optional) 50% 50% 50% 50% Orthodontic Lifetime Maximum $1,000 $1,000 $1,500 $1,500 See page 44 for footnotes. 42

43 Aetna Group Dental Plans Option 9A PPO Max 1000 Option 10A PPO Max 1500 Option 11A PPO 1500 Option 12A PPO 2000 PPO Max 1000 Plan 80/80/50 PPO Max 1500 Plan 100/80/50 PPO 1500 Plan 100/80/50 PPO 2000 Plan 100/80/50 Office Visit Copay N/A N/A N/A N/A Annual Deductible per Member (Does not apply to Diagnostic & Preventive Services) $50; 3X Family Maximum $50; 3X Family Maximum $50; 3X Family Maximum $50; 3X Family Maximum Annual Maximum Benefit $1,000 $1,500 $1,500 $2,000 Diagnostic Services Oral Exams Periodic oral exam 80% 100% 100% 100% Comprehensive oral exam 80% 100% 100% 100% Problem-focused oral exam 80% 100% 100% 100% X-rays Bitewing single film 80% 100% 100% 100% Complete series 80% 100% 100% 100% Preventive Services Adult Cleaning 80% 100% 100% 100% Child Cleaning 80% 100% 100% 100% Sealants per tooth 80% 100% 100% 100% Fluoride application child 80% 100% 100% 100% Space maintainers fixed 80% 100% 100% 100% Basic Services Amalgam filling 2 surfaces 80% 80% 80% 80% Resin filling 2 surfaces, anterior 80% 80% 80% 80% Endodontic Services Bicuspid root canal therapy 50% 80% 80% 80% Periodontic Services Scaling & root planing per quadrant 50% 80% 80% 80% Oral Surgery Extraction exposed root or erupted tooth 50% 80% 80% 80% Extraction of impacted tooth soft tissue 50% 80% 80% 80% Major Services* Complete upper denture 50% 50% 50% 50% Partial upper denture (resin base) 50% 50% 50% 50% Crown Porcelain with noble metal1 50% 50% 50% 50% Pontic Porcelain with noble metal1 50% 50% 50% 50% Inlay Metallic (3 or more surfaces) 50% 50% 50% 50% Oral Surgery Removal of impacted tooth partially bony 50% 80% 80% 80% Endodontic Services Molar root canal therapy 50% 80% 80% 80% Periodontic Services Osseous surgery per quadrant 50% 80% 80% 80% Orthodontic Services* (optional) 50% 50% 50% 50% Orthodontic Lifetime Maximum $1,000 $1,000 $1,000 $1,500 See page 44 for footnotes. 43

44 Dental plans for eligible enrolling Footnotes * Coverage Waiting Period applies to all Voluntary PPO & PPO Max plans : Must be an enrolled member of the plan for 12 months before becoming eligible for coverage of any major service including orthodontic services. Does not apply to the DMO and Standard plans. 1 There will be an additional patient charge for the actual cost for gold/high noble metal for these procedures: DMO Options 1A and 3A. Fixed dollar amounts on the DMO in Plan Options 1A 5A are member responsibility. Most oral surgery, endodontic and periodontic services are covered as basic services on the DMO in Plan Options 1A 5A. All oral surgery, endodontic and periodontic services are covered as basic services on the PPO in Plan Options 4A 8A, and 10A 12A. All oral surgery, endodontic and periodontic services are covered as major services on the PPO in Plan Option 9A. Plan Options 9A & 10A; PPO Max non-preferred (out-of-network) coverage is limited to a maximum of the plan s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area. Out-of-network plan payments are limited by geographic area on the PPO in Plan Options 4A 7A, 11A 12A to the prevailing fees at the 80 th percentile and the 90 th percentile in Plan Option 8A. DMO Options 1A 3A can be offered with any one of the PPO plans in Options 6A 12A in a Dual Option package. Orthodontic coverage is available for adults and dependent children. Plan features and availability may vary by location and are subject to change. Information is believed to be accurate as of the production date; however, it is subject to change. Voluntary plans: If there is a lapse in coverage, members may not re-enroll in the plan for a period of two years from the date of termination. If they are eligible for coverage at that time, they may re-enroll, subject to all provisions of the plan, including, but not limited to, the Coverage Waiting Period. Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/ certificate. For a summary list of Limitations and Exclusions, refer to page

45 Aetna Life & Disability Group life and disability is an affordable way to provide life insurance and disability benefits to employees that will help them establish financial protection for themselves and their families. 45

46 Life & disability Overview For groups of 51 and above, Aetna offers a robust portfolio of Life and Disability products with flexible plan features. Please consult your sales representative for a plan designed to meet your groups needs: Basic life Supplemental life AD&D Ultra Supplemental AD&D Ultra Dependent life Short-term disability Long-term disability Life insurance We know that life insurance is an important part of the benefits package you offer your employees. That s why our products and programs are designed to meet your needs for: Flexibility Added value Cost efficiency Experienced support We help you give employees what they re looking for in lifestyle protection through our selected group life insurance options. And we look beyond the benefits payout to include useful enhancements through the Aetna Life Essentials SM program. 46