BENEFIT PLAN. What Your Plan Covers and How Benefits are Paid. Appendix A. Prepared Exclusively for The Dow Chemical Company

Transcription

1 Appendix A BENEFIT PLAN Prepared Exclusively for The Dow Chemical Company What Your Plan Covers and How Benefits are Paid Choice POS II (Home Host/IDS - MAP Plus and MAP Plus Aexcel Plus with Prescription Drug - Option 1)

2 Table of Contents Schedule of Benefits... Issued with Your Booklet SOB-8A-CPOS II (Home Host/IDS MAP Plus & MAP Plus Aexcel Plus with Prescription Drug Plan- Option 1)...1 SOB-8B-CPOS II (Home Host/IDS MAP Plus & MAP Plus Aexcel Plus with Prescription Drug Plan- Option 1-Out-of-Area)...32 Preface...63 Coverage for You and Your Dependents...64 Health Expense Coverage...64 Treatment Outcomes of Covered Services How Your Medical Plan Works...65 Common Terms...65 About Your Aetna Choice POS II Medical Plan 65 Availability of Providers How Your Aetna Choice POS II Medical Plan Works...66 Understanding Precertification Services and Supplies Which Require Precertification Emergency and Urgent Care...73 In Case of a Medical Emergency Coverage for Emergency Medical Conditions In Case of an Urgent Condition Coverage for an Urgent Condition Non-Urgent Care Follow-Up Care After Treatment of an Emergency or Urgent Medical Condition Requirements For Coverage...75 What The Plan Covers...76 Aetna Choice POS II Medical Plan...76 Preventive Care...76 Routine Physical Exams Preventive Care Immunizations Well Woman Preventive Visits Routine Cancer Screenings Screening and Counseling Services Prenatal Care Comprehensive Lactation Support and Counseling Services Family Planning Services - Female Contraceptives Family Planning - Other Vision Care Services Limitations Physician Services...82 Physician Visits Surgery Anesthetics Alternatives to Physician Office Visits Hospital Expenses...83 Room and Board Other Hospital Services and Supplies Outpatient Hospital Expenses Coverage for Emergency Medical Conditions Coverage for Urgent Conditions Alternatives to Hospital Stays Outpatient Surgery and Physician Surgical Services Birthing Center Home Health Care Skilled Nursing Care Skilled Nursing Facility Hospice Care Other Covered Health Care Expenses Acupuncture Ambulance Service Ground Ambulance Air or Water Ambulance Diagnostic and Preoperative Testing Diagnostic Complex Imaging Expenses Outpatient Diagnostic Lab Work Outpatient Diagnostic Radiological Services Outpatient Preoperative Testing Durable Medical and Surgical Equipment (DME) Experimental or Investigational Treatment Pregnancy Related Expenses Prosthetic Devices Treatment of Autism Expense Short-Term Rehabilitation Therapy Services Cardiac Rehabilitation Benefits Pulmonary Rehabilitation Benefits Outpatient Cognitive Therapy, Physical Therapy, Occupational Therapy and Speech Therapy Rehabilitation Benefits. Reconstructive or Cosmetic Surgery and Supplies Reconstructive Breast Surgery Transgender Reassignment (Sex Change) Surgery Specialized Care Chemotherapy Radiation Therapy Benefits Outpatient Infusion Therapy Benefits Specialty Care Prescription Drugs Kidney Disease Treatment Diabetic Education Treatment of Infertility Basic Infertility Expenses Comprehensive Infertility and Advanced Reproductive Technology (ART) Expenses Comprehensive Infertility Services Benefits Advanced Reproductive Technology (ART) Benefits Eligibility for ART Benefits

3 Covered ART Benefits Exclusions and Limitations Fertility Preservation Benefits for Cancer Patients Only Spinal Manipulation Treatment Jaw Joint Disorder Treatment Transplant Services Network of Transplant Specialist Facilities Obesity Treatment Treatment of Mental Disorders and Substance Abuse Oral and Maxillofacial Treatment (Mouth, Jaws and Teeth) Medical Plan Exclusions Your Pharmacy Benefit How the Pharmacy Plan Works Getting Started: Common Terms Accessing Pharmacies and Benefits Accessing Network Pharmacies and Benefits Emergency Prescriptions Availability of Providers Cost Sharing for Network Benefits When You Use an Out-of-Network pharmacy Cost Sharing for Out-of-Network Benefits Pharmacy Benefit Retail Pharmacy Benefits Mail Order Pharmacy Benefits Network Benefits for Specialty Care Drugs Other Covered Expenses *Defines the Terms Shown in Bold Type in the Text of This Document. Over-the-counter drugs Precertification Pharmacy Benefit Limitations Pharmacy Benefit Exclusions Coordination of Benefits Coordination of Benefits General Provisions Type of Coverage Physical Examinations Legal Action Additional Provisions Assignments Misstatements Rescission of Coverage Reporting of Claims Payment of Benefits Records of Expenses Contacting Aetna Effect of Benefits Under Other Plans Effect of A Health Maintenance Organization Plan (HMO Plan) On Coverage Discount Programs Discount Arrangements Incentives Claims, Appeals and External Review Glossary *

4 Schedule of Benefits Employer: The Dow Chemical Company ASA: Control: Issue Date: February 10, 2016 Effective Date: October 1, 2015 Schedule: 8A Booklet Base: 8 For: Choice POS II (Home Host/ IDS MAP Plus & MAP Plus Aexcel Plus with Prescription Drug Plan Option 1) This is an ERISA plan, and you have certain rights under this plan. Please contact your Employer for additional information. PLAN FEATURES Deductible* Aetna Choice POS II Medical Plan HOME HOST AETNA NETWORK NETWORK OUT-OF-NETWORK Individual Deductible* $125 $125 $500 Family Deductible* Employee + 1 Dependent Plan $250 $250 $1,000 Employee + Family Plan $375 $375 $1,500 Per Admission Copayment $250 per admission* $250 per admission* Not Applicable *Maximum of $500 (2 Per Admission Copayments per family per ) *Unless otherwise indicated, any applicable must be met before benefits are paid. Common Accident Deductible $125 $125 $500 1

5 Plan Maximum Out of Pocket Limit includes plan, per visit s and copayments. Plan Maximum Out of Pocket Limit excludes precertification penalties. Effective October 1, 2015 through December 31, 2015: Individual Maximum Out of Pocket Limit: For Home Host network expenses: 4% of annual salary to $6,350 maximum. For Aetna network expenses: 4% of annual salary to $6,350 maximum For out-of-network expenses: 8% of annual salary. Family Maximum Out of Pocket Limit: For Home Host network expenses: 8% of annual salary to $12,700 maximum. For Aetna network expenses: 8% of annual salary to $12,700 maximum. For out-of-network expenses: 12% of annual salary. Effective January 1, 2016: Individual Maximum Out of Pocket Limit: For Home Host network expenses: 4% of annual salary to $6,850 maximum. For Aetna network expenses: 4% of annual salary to $6,850 maximum For out-of-network expenses: 8% of annual salary. Family Maximum Out of Pocket Limit: For Home Host network expenses: 8% of annual salary to $13,700 maximum. For Aetna network expenses: 8% of annual salary to $13,700 maximum. For out-of-network expenses: 12% of annual salary. Lifetime Maximum Benefit per person Unlimited Unlimited Unlimited Payment Percentage listed in the Schedule below reflects the Plan Payment Percentage. This is the amount the Plan pays. You are responsible to pay any s and the remaining payment percentage. You are responsible for full payment of any non-covered expenses you incur. All Covered Expenses Are Subject To The Deductible Unless Otherwise Noted In The Schedule Below. Maximums for specific covered expenses, including visit, day and dollar maximums are combined maximums between network and out-of-network, unless specifically stated otherwise. 2

6 PLAN FEATURES Preventive Care Benefits Routine Physical Exams Office Visits HOME HOST NETWORK AETNA NETWORK OUT-OF-NETWORK Year apply. Year apply. No applies. Covered Persons through age 21: Maximum Age & Visit Limits Subject to any age and visit limits provided for in the comprehensive guidelines supported by the American Academy of Pediatrics/Bright Futures Guidelines for Children and Adolescents. Subject to any age and visit limits provided for in the comprehensive guidelines supported by the American Academy of Pediatrics/Bright Futures Guidelines for Children and Adolescents. Subject to any age and visit limits provided for in the comprehensive guidelines supported by the American Academy of Pediatrics/Bright Futures Guidelines for Children and Adolescents. For details, contact your physician or Member Services by logging onto the Aetna website or calling the number on the back of your ID card. For details, contact your physician or Member Services by logging onto the Aetna website or calling the number on the back of your ID card. For details, contact your physician or Member Services by logging onto the Aetna website or calling the number on the back of your ID card Covered Persons ages 22 but less than 65: Maximum Visits per Covered Persons age 65 and over: Maximum Visits per 1 visit 1 visit 1 visit 1 visit 1 visit 1 visit 3

7 Preventive Care Immunizations Performed in a facility or physician's office Year apply. Year apply. No applies. Subject to any age and visit limits provided for in the comprehensive guidelines supported by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. Subject to any age and visit limits provided for in the comprehensive guidelines supported by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. Subject to any age and visit limits provided for in the comprehensive guidelines supported by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. For details, contact your physician or Member Services by logging onto the Aetna website or calling the number on the back of your ID card. For details, contact your physician or Member Services by logging onto the Aetna website or calling the number on the back of your ID card. For details, contact your physician or Member Services by logging onto the Aetna website or calling the number on the back of your ID card. Screening & Counseling Services Office Visits Obesity and/or Healthy Diet Year apply. Year apply. No applies. Misuse of Alcohol and/or Drugs & Use of Tobacco Products Sexually Transmitted Infections Genetic Risk for Breast and Ovarian Cancer Obesity and/or Healthy Diet Maximum Visits per (This maximum applies only to Covered Persons ages 22 & older.) 26 visits (however, of these only 10 visits will be allowed under the Plan for healthy diet counseling provided in connection with Hyperlipidemia (high cholesterol) and other known risk factors for cardiovascular and diet-related chronic disease)* 26 visits (however, of these only 10 visits will be allowed under the Plan for healthy diet counseling provided in connection with Hyperlipidemia (high cholesterol) and other known risk factors for cardiovascular and diet-related chronic disease)* 26 visits (however, of these only 10 visits will be allowed under the Plan for healthy diet counseling provided in connection with Hyperlipidemia (high cholesterol) and other known risk factors for cardiovascular and diet-related chronic disease)* *Note: In figuring the Maximum Visits, each session of up to 60 minutes is equal to one visit. 4

8 Misuse of Alcohol and/or Drugs Maximum Visits per 5 visits* 5 visits* 5 visits* *Note: In figuring the Maximum Visits, each session of up to 60 minutes is equal to one visit. Use of Tobacco Products Maximum Visits per Unlimited Unlimited Unlimited Sexually Transmitted Infections Benefit Maximums Maximum Visits per 2 visits* 2 visits* 2 visits* *Note: In figuring the Maximum Visits, each session of up to 30 minutes is equal to one visit. Well Woman Preventive Visits Office Visits Subject to any age limits provided for in the comprehensive guidelines supported by the Health and Human Resources Administrations* Year apply. Year apply. No applies. *No age limits for routine ob/gyn exam and pap smear Well Woman Preventive Visits Maximum Visits per 1 visit 1 visit 1 visit 5

9 Routine Cancer Screening Outpatient Year apply. No copay or apply. No applies. *No Out-of-Network coverage for routine colorectal screenings. Maximums Subject to any age; family history and frequency guidelines as set forth in the most current: evidence-based items that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force; and the comprehensive guidelines supported by the Health Resources and Services Administration.* For details, contact your physician or Member Services by logging onto the Aetna website or calling the number on the back of your ID card. Subject to any age; family history and frequency guidelines as set forth in the most current: evidence-based items that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force; and the comprehensive guidelines supported by the Health Resources and Services Administration.* For details, contact your physician or Member Services by logging onto the Aetna website or calling the number on the back of your ID card. Subject to any age; family history and frequency guidelines as set forth in the most current: evidence-based items that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force; and the comprehensive guidelines supported by the Health Resources and Services Administration.* For details, contact your physician or Member Services by logging onto the Aetna website or calling the number on the back of your ID card. *Note: Routine Mammograms, routine Prostate Specific Antigen (PSA) tests and/or Digital Rectal Exams (DRE) are not subject to age or visit limits. Lung Cancer Screening Year apply. Year apply. 70% per visit after Lung Cancer Screening Maximum One screening every 12 months* One screening every 12 months* One screening every 12 months* *Important Note: Lung cancer screenings in excess of the maximum as shown above are covered under the Outpatient Diagnostic and Preoperative Testing section of your Schedule of Benefits. 6

10 Prenatal Care Office Visits Year apply Year apply. No applies. Important Note: Refer to the Physician Services and Pregnancy Expenses sections of the Schedule of Benefits for more information on coverage levels for pregnancy expenses under this Plan, including other prenatal care, delivery and postnatal care office visits. Comprehensive Lactation Support and Counseling Services Lactation Counseling Services Facility or Office Visits Year apply. Year apply. No applies. Lactation Counseling Services Maximum Visits either in a group or individual setting 6 visits per 12 months 6* visits per 12 months 6 visits per 12 months *Important Note: Visits in excess of the Lactation Counseling Services Maximum as shown above, are covered under the Physician Services office visit section of the Schedule of Benefits. Breast Pumps & Supplies 100% per item 100% per item 100% per item Year apply. Year apply. No applies. Important Note: Refer to the Comprehensive Lactation Support and Counseling Services section of the Booklet for limitations on breast pumps and supplies. Family Planning Services Female Contraceptive Counseling Services -Office Visits. Year apply.. Year apply. No applies. Contraceptive Counseling Services - Maximum Visits either in a group or individual setting 2* visits per 12 months 2* visits per 12 months 2* visits per 12 months *Important Note: Visits in excess of the Contraceptive Counseling Services Maximum as shown above, are covered under the Physician Services office visit section of the Schedule of Benefits. 7

11 Family Planning Services - Female Contraceptives Female Contraceptive Generic Prescription Drugs and Devices provided, administered, or removed, by a Physician during an Office Visits. 100% per item. Year apply. 100% per item. Year apply. 100% per item No applies. Family Planning - Other Voluntary Termination of Pregnancy Outpatient Voluntary Sterilization for Males Outpatient Family Planning - Female Voluntary Sterilization Inpatient Year apply. Year apply. 70% per visit after 70% per visit after No applies. Outpatient Year apply. Year apply. No applies. PLAN FEATURES Vision Care Eye Examinations including refraction HOME HOST NETWORK 100% per exam Year apply. AETNA NETWORK 100% per exam Year apply. OUT-OF-NETWORK 100% per exam No applies. Maximum Benefit per 1 exam 1 exam 1 exam 8

12 PLAN FEATURES HOME HOST NETWORK AETNA NETWORK OUT-OF-NETWORK Physician Services Office Visits to Primary Care Physician Office visits (non-surgical) to non-specialist $10 visit copay then the plan pays 100% No applies. $20 visit copay then the plan pays 100% No applies. 70% per visit after Applies to Aetna Choice POS II: Specialist Office Visits $10 visit copay then the plan pays 100% No applies. $50 visit copay then the plan pays 100% No applies. 70% per visit after Applies to Aetna Choice POS II with Aexcel Plus: Specialist Office Visits $10 visit copay then the plan pays 100% No applies. $50 visit copay then the plan pays 100% No applies. 70% per visit after Aexcel Designated Network Specialist $50 visit copay then the plan pays 100% $50 visit copay then the plan pays 100% Not applicable No applies. No applies. Non-Designated Network Specialist $50 visit copay then the plan pays 100% $50 visit copay then the plan pays 100% Not applicable No applies. No applies. Out of Network Provider Specialist Not applicable Not applicable 70% per visit after 9

13 Applies to Aetna Choice POS II: Physician Office Visits- Surgery Applies to Aetna Choice POS II with Aexcel Plus: Physician Office Visits- Surgery 70% per visit after 70% per visit after Aexcel Designated Network Specialist Not applicable Non-Designated Network Specialist Not applicable Out of Network Provider Specialist Not applicable Not applicable 70% per visit after Confirmatory Consultations (Second Opinions) Year apply. Year apply. No applies. Walk-In Clinic Visit (Non-Emergency) Preventive Care Services* Immunizations Year apply. For details, contact your physician, log onto the Aetna website or call the number on the back of your ID card. Year apply. For details, contact your physician, log onto the Aetna website or call the number on the back of your ID card. No applies. Individual Screening and Counseling Services for Tobacco Use Year apply. Year apply. No applies. Maximum Benefit per visit - Individual Screening and Counseling Services for Tobacco Use Refer to the Preventive Care Benefit section earlier in this Schedule of Benefits for maximums that may apply to these types of services Refer to the Preventive Care Benefit section earlier in this Schedule of Benefits for maximums that may apply to these types of services Refer to the Preventive Care Benefit section earlier in this Schedule of Benefits for maximums that may apply to these types of services 10

14 Walk-In Clinic Visit (Non-Emergency) Continued Individual Screening and Counseling Services for Obesity Year apply. Year apply. No applies. Maximum Benefit per visit - Individual Screening and Counseling Services for Obesity Refer to the Preventive Care Benefit section earlier in this Schedule of Benefits for maximums that may apply to these types of services Refer to the Preventive Care Benefit section earlier in this Schedule of Benefits for maximums that may apply to these types of services Refer to the Preventive Care Benefit section earlier in this Schedule of Benefits for maximums that may apply to these types of services *Important Note: Not all preventive care services are available at all Walk-In Clinics. The types of services offered will vary by the provider and location of the clinic. These services may also be obtained from your physician. All Other Services $20 visit copay then the plan pays 100% $20 visit copay then the plan pays 100% 70% per visit after No applies. No applies. Applies to Aetna Choice POS II: Physician Services for Inpatient Facility and Hospital Visits 70% per visit after Applies to Aetna Choice POS II with Aexcel Plus: Physician Services for Inpatient Facility and Hospital Visits 70% per visit after Aexcel Designated Network Specialist Not applicable Non-Designated Network Specialist Not applicable Out of Network Provider Specialist Not applicable Not applicable 70% per visit after Administration of Anesthesia 85% per procedure after 70% per procedure after 11

15 Allergy Testing and Treatment $10 visit copay then the plan pays 100%* No applies. *. 70% per visit after. *100% no copay or for lab expenses. Allergy Injections Year apply.. 70% per visit after. PLAN FEATURES HOME HOST NETWORK Emergency Medical Services Hospital Emergency $100 copay per visit Facility and Physician after the then the plan pays 85% AETNA NETWORK $100 copay per visit after the then the plan pays 85% OUT-OF-NETWORK Paid the same as the Network level of benefits. See Important Note Below Important Note: Please note that as these providers are not network providers and do not have a contract with Aetna, the provider may not accept payment of your cost share (your and payment percentage), as payment in full. You may receive a bill for the difference between the amount billed by the provider and the amount paid by this Plan. If the Emergency Room Facility or physician bills you for an amount above your cost share, you are not responsible for paying that amount. Please send us the bill at the address listed on the back of your member ID card and we will resolve any payment dispute with the provider over that amount. Make sure your member ID number is on the bill. Non-Emergency Care in a Hospital Emergency Room $100 copay per visit after the then the plan pays 85% $100 copay per visit after the then the plan pays 85% $100 per visit after the then the plan pays 70% Important Notice: A separate hospital emergency room or copay applies for each visit to an emergency room for emergency care. If you are admitted to a hospital as an inpatient immediately following a visit to an emergency room, your or copay is waived. Covered expenses that are applied to the emergency room or copay cannot be applied to any other or copay under your plan. Likewise, covered expenses that are applied to any of your plan s other s or copays cannot be applied to the emergency room or copay. 12

16 Urgent Care Services Urgent Medical Care (at a non-hospital free standing facility) $20 copay per visit after the then the plan pays 100% $20 copay per visit after the then the plan pays 100% 70% per visit after Urgent Medical Care (from other than a non-hospital free standing facility) Refer to Emergency Medical Services and Physician Services above. Refer to Emergency Medical Services and Physician Services above. Refer to Emergency Medical Services and Physician Services above. Important Notice: A separate urgent care copay applies for each visit to a network urgent care provider for urgent care. Covered expenses that are applied to the urgent care copay cannot be applied to any other copay under your plan. Likewise, covered expenses that are applied to your plan s other copays cannot be applied to the urgent care copay. PLAN FEATURES HOME HOST NETWORK AETNA NETWORK OUT-OF-NETWORK Outpatient Diagnostic and Preoperative Testing Complex Imaging Services Complex Imaging 85% per test after 85% per test after 70% per test after Diagnostic Laboratory Testing Diagnostic Laboratory 100% per procedure Testing Year apply. 100% per procedure Year apply. 70% per procedure after Diagnostic X-Rays (except Complex Imaging Services) Diagnostic X-Rays 85% per procedure after 85% per procedure after 70% per procedure after 13

17 PLAN FEATURES Outpatient Surgery Outpatient Surgery HOME HOST NETWORK 85% per visit/surgical procedure after Calendar Year AETNA NETWORK 85% per visit/surgical procedure after Calendar Year OUT-OF-NETWORK 70% per visit/surgical procedure after Calendar Year PLAN FEATURES HOME HOST NETWORK Inpatient Facility Expenses Birthing Center Payable in accordance with the type of expense incurred and the place where service is provided. AETNA NETWORK Payable in accordance with the type of expense incurred and the place where service is provided. OUT-OF-NETWORK Payable in accordance with the type of expense incurred and the place where service is provided. Hospital Facility Expenses Room and Board (including maternity) $250 per admission copay after then the plan pays 85% $250 per admission copay after Calendar Year then the plan pays 85% 70% per admission after Other than Room and Board 85% per admission after 85% per admission after 70% per admission after Skilled Nursing Inpatient Facility $250 per admission copay after then the plan pays 85% $250 per admission copay after Calendar Year then the plan pays 85% 70% per admission after Maximum Days per Unlimited Unlimited 180 days* *Additional days of confinement subject to review for medical necessity. PLAN FEATURES Specialty Benefits Home Health Care (Outpatient) HOME HOST NETWORK the AETNA NETWORK the OUT-OF-NETWORK 70% per visit after the Maximum Visits per 50 visits 50 visits 50 visits 14

18 Skilled Nursing Care (Outpatient) the the 70% per visit after the Private Duty Nursing (Outpatient) the the 70% per visit after the Maximum per $15,000 $15,000 $15,000 Hospice Benefits Hospice Care - Facility Expenses (Room & Board) 100% per admission Year apply 100% per admission Year apply 100% per admission No applies. Hospice Care - Other Expenses during a stay 100% per admission Year apply 100% per admission Year apply 100% per admission No applies. Maximum Benefit per lifetime Unlimited days Unlimited days Unlimited days Hospice Outpatient Visits Year apply Year apply No applies. PLAN FEATURES Infertility Treatment HOME HOST NETWORK AETNA NETWORK OUT-OF-NETWORK Basic Infertility Expenses Coverage is for the diagnosis and treatment of the underlying medical condition causing the infertility only. Payable in accordance with the type of expense incurred and the place where service is provided Payable in accordance with the type of expense incurred and the place where service is provided. Payable in accordance with the type of expense incurred and the place where service is provided. Comprehensive Infertility Expenses 85% per procedure after 85% per procedure after 70% per procedure after 15

19 Artificial Insemination Lifetime Maximum Benefit Ovulation Induction Lifetime Maximum Benefit 6 cycles of treatment* 6 cycles of treatment* 6 cycles of treatment* 6 cycles of treatment* 6 cycles of treatment* 6 cycles of treatment* *The maximum of 6 attempts per lifetime is a combined maximum that includes Artificial Insemination and Ovulation Induction. Advanced Reproductive Technology (ART) Expenses 85% per procedure after 85% per procedure after 70% per procedure after Maximum per lifetime 3 cycles of treatment 3 cycles of treatment 3 cycles of treatment PLAN FEATURES HOME HOST NETWORK Inpatient Treatment of Mental Disorders MENTAL DISORDERS AETNA NETWORK OUT-OF-NETWORK Hospital Facility Expenses Room and Board $250 per admission copay after then the plan pays 85% $250 per admission copay after Calendar Year then the plan pays 85% 70% per admission after Other than Room and Board 85% per admission after 85% per admission after 70% per admission after Physician Services 70% per visit after Inpatient Residential Treatment Facility Expenses $250 per admission copay after then the plan pays 85% $250 per admission copay after Calendar Year then the plan pays 85% 70% per admission after Inpatient Residential Treatment Facility Expenses Physician Services 70% per visit after 16

20 Outpatient Treatment Of Mental Disorders Outpatient Services Office Visits $50 per visit copay then the plan pays 100% $50 per visit copay then the plan pays 100% 70% per visit after the No applies. No applies. Other Than Office Visits 85% after 85% after 70% after the Calendar Year PLAN FEATURES HOME HOST NETWORK Inpatient Treatment of Substance Abuse AETNA NETWORK OUT-OF-NETWORK Hospital Facility Expenses Room and Board $250 per admission copay after then the plan pays 85% $250 per admission copay after Calendar Year then the plan pays 85% 70% per admission after the Other than Room and Board 85% per admission after 85% per admission after 70% per admission after Physician Services 70% per visit after Inpatient Residential Treatment Facility Expenses $250 per admission copay after then the plan pays 85% $250 per admission copay after Calendar Year then the plan pays 85% 70% per admission after Inpatient Residential Treatment Facility Expenses Physician Services 70% per visit after 17

21 Outpatient Treatment of Substance Abuse Outpatient Treatment Office Visits $50 per visit copay then the plan pays 100% $50 per visit copay then the plan pays 100% 70% per visit after No applies. No applies. Other Than Office Visits 85% after 85% after 70% after PLAN FEATURES HOME HOST NETWORK Obesity Treatment Non Surgical AETNA NETWORK OUT-OF-NETWORK Outpatient Obesity Treatment (non surgical) the the 70% per visit after the PLAN FEATURES HOME HOST NETWORK Obesity Treatment Surgical Inpatient Morbid Obesity $250 per admission copay Surgery (includes after Surgical procedure and then the plan Acute Hospital Services) pays 85% AETNA NETWORK $250 per admission copay after Calendar Year then the plan pays 85% OUT-OF-NETWORK 70% per admission after the Outpatient Morbid Obesity Surgery 85% per service after 85% per service after 70% per service after Maximum Benefit Morbid Obesity Surgery (Inpatient and Outpatient) Unlimited Unlimited Unlimited 18

22 PLAN FEATURES HOME HOST NETWORK NETWORK (IOE Facility) NETWORK (Non-IOE Facility) OUT-OF- NETWORK Transplant Services Facility and Non-Facility Expenses Transplant Facility Expenses 70% per admission after $250 per admission copay after Calendar Year, then the plan pays 85% 70% per admission after 70% per admission after Transplant Physician Services (including office visits) Payable in accordance with the type of expense incurred and the place where service is provided Payable in accordance with the type of expense incurred and the place where service is provided Payable in accordance with the type of expense incurred and the place where service is provided Payable in accordance with the type of expense incurred and the place where service is provided PLAN FEATURES HOME HOST NETWORK Other Covered Health Expenses AETNA NETWORK OUT-OF-NETWORK Acupuncture in lieu of anesthesia 85% per procedure after 85% per procedure after 70% per procedure after Ground, Air or Water Ambulance 85% after 85% after 70% after Kidney Disease Treatment 70% per visit after Maximum per visit Not applicable Not applicable $1,720 Diabetic Education Year applies. Year applies. No applies. Maximum Benefit per $500 $500 $500 19

23 Durable Medical and Surgical Equipment Includes Orthotics & foot orthotics $10 per item copay then the plan pays 100% No applies. 85% per item after the 70% per item after the Clinical Trial Therapies (Experimental or Investigational Treatment) Payable in accordance with the type of expense incurred and the place where service is provided. Payable in accordance with the type of expense incurred and the place where service is provided. Payable in accordance with the type of expense incurred and the place where service is provided. Routine Patient Costs Payable in accordance with the type of expense incurred and the place where service is provided. Payable in accordance with the type of expense incurred and the place where service is provided. Payable in accordance with the type of expense incurred and the place where service is provided. Jaw Joint Disorder Treatment For non-surgical treatment of TMJ and for TMJ Intraoral devices 70% per visit after Calendar Year Maximum Benefit per Lifetime $500 $500 $500 Oral and Maxillofacial Treatment (Mouth, Jaws and Teeth) Payable in accordance with the type of expense incurred and the place where service is provided. Payable in accordance with the type of expense incurred and the place where service is provided. Payable in accordance with the type of expense incurred and the place where service is provided. Prosthetic Devices 85% per item after 85% per item after 70% per item after PLAN FEATURES For Transgender Surgery Expenses HOME HOST NETWORK 85% after the Calendar Year AETNA NETWORK 85% after the Calendar Year OUT-OF-NETWORK 70% after the Calendar Year 20

24 PLAN FEATURES Outpatient Therapies HOME HOST NETWORK AETNA NETWORK OUT-OF-NETWORK Chemotherapy Payable in accordance with the type of expense incurred and the place where service is provided. Payable in accordance with the type of expense incurred and the place where service is provided. Payable in accordance with the type of expense incurred and the place where service is provided. Infusion Therapy (Performed in a Physician s Office or Home Care) $10 visit copay then the plan pays 100% No applies. 85% after 70% per visit after the Performed in a Hospital Outpatient Department or Non-Hospital Outpatient Facility $10 visit copay then the plan pays 100% No applies. 85% after 70% per visit after the Radiation Therapy Payable in accordance with the type of expense incurred and the place where service is provided. Payable in accordance with the type of expense incurred and the place where service is provided. Payable in accordance with the type of expense incurred and the place where service is provided. PLAN FEATURES Autism Spectrum Disorder For child to age 18 Autism Physical therapy HOME HOST NETWORK $10 visit copay then the plan pays 100% No applies. AETNA NETWORK OUT-OF-NETWORK 70% per visit after Autism Occupational Therapy, Speech Therapy 70% per visit after Autism Applied Behavior Analysis Office Visits $50 per visit copay then the plan pays 100% No applies $50 per visit copay then the plan pays 100% No applies. 70% per visit after Autism Applied Behavior Analysis Other Than Office Visits 70% per visit after 21

25 PLAN FEATURES HOME HOST NETWORK Short Term Outpatient Rehabilitation Therapies 5 AETNA NETWORK OUT-OF-NETWORK Outpatient Physical Therapy $10 per visit copay then the plan pays 100% No applies. 70% per visit after Outpatient Occupational Therapy 70% per visit after PLAN FEATURES Spinal Manipulation HOME HOST NETWORK $10 per visit copay then the plan pays 100% AETNA NETWORK 85% after OUT-OF-NETWORK 70% per visit after No applies. Spinal Manipulation Maximum visits per 30 visits 30 visits 30 visits Pharmacy Benefit PLAN FEATURES NETWORK OUT-OF-NETWORK Prescription Drug Deductible Individual Deductible* $100 $100 Family Deductible* Employee + 1 Dependent Plan Employee + Family Plan $200 $300 $200 $300 Prescription Drug Deductible The individual prescription drug applies separately to you and each of your covered dependents. The family prescription drug applies to you and your covered dependents combined. After prescription drug covered expenses reach the prescription drug, the plan will begin to pay benefits for prescription drug covered expenses for the rest of the. The prescription drug applies to network and out-of-network prescription drug covered expenses combined. The prescription drug applies to all prescription drug covered expenses except, drugs dispensed by a mail-order pharmacy. 22

26 Copays/Deductibles PER PRESCRIPTION COPAY/DEDUCTIBLE NETWORK OUT-OF-NETWORK The following Generic Prescription Drugs information applies Effective October 1, 2015 through December 31, 2015: Generic Prescription Drugs For each initial 30 day supply filled at a retail pharmacy 20% 20% This applies to all refills after the second refill of a 30 day supply filled at a retail pharmacy For all fills of a 90 day supply filled at a mail order pharmacy or a CVS/pharmacy 50% 50% 20% Not Applicable The following Generic Prescription Drugs information applies Effective January 1, 2016: Generic Prescription Drugs For each initial 30 day supply filled at a retail pharmacy Formulary Prescription Drugs 20% 20% Non Formulary Prescription Drugs This applies to all refills after the second refill of a 30 day supply filled at a retail pharmacy Formulary Prescription Drugs Non Formulary Prescription Drugs For all fills of a 90 day supply filled at a mail order pharmacy or a CVS/pharmacy Formulary Prescription Drugs Non Formulary Prescription Drugs 30% 50% 50% 20% 30% 30% 50% 50% Not Applicable Not Applicable 23

27 Preferred Brand-Name Prescription Drugs For each initial 30 day supply filled at a retail pharmacy 20% 20% This applies to all refills after the second refill of a 30 day supply filled at a retail pharmacy For all fills of a 90 day supply filled at a mail order pharmacy or a CVS/pharmacy 50% 50% 20% Not Applicable Non-Preferred Brand-Name Prescription Drugs For each initial 30 day supply filled at a retail pharmacy 30% 30% This applies to all refills after the second refill of a 30 day supply filled at a retail pharmacy For all fills of at least a 31 day supply and up to a 90 day supply filled at a mail order pharmacy or a CVS/pharmacy 50% 50% 30% Not Applicable Preferred Specialty Care Prescription Drug For each 30 day supply 20% of the negotiated charge not to exceed $200 Non-preferred Specialty Care Prescription Drugs For each 30 day supply 20% of the negotiated charge not to exceed $200 20% of the recognized charge not to exceed $200 20% of the recognized charge not to exceed $200 If you or your prescriber request a covered brand-name prescription drug when a covered generic prescription drug equivalent is available, you will be responsible for the cost difference between the generic prescription drug and the brand-name prescription drug, plus the applicable cost sharing. Copay and Deductible Waiver Waiver for Risk-Reducing Breast Cancer Prescription Drugs The per prescription copay/ and any prescription drug will not apply to risk-reducing breast cancer generic prescription drugs when obtained at a network pharmacy. This means that such risk-reducing breast cancer generic prescription drugs will be paid at 100%. Deductible and copayment/coinsurance waiver for tobacco cessation prescription and over-thecounter drugs 24

28 The prescription drug and the per prescription copayment/coinsurance will not apply to the first two 90-day treatment regimens for tobacco cessation prescription drugs and OTC drugs when obtained at a network pharmacy. This means that such prescription drugs and OTC drugs will be paid at 100%. Your prescription drug and any prescription copayment/coinsurance will apply after those two regimens have been exhausted. Waiver for Prescription Drug Contraceptives The per prescription copay/ and any prescription drug will not apply to contraceptive methods that are: generic prescription drugs; contraceptive devices; or FDA-approved female generic emergency contraceptives, when obtained at a network pharmacy. This means that such contraceptive methods will be paid at 100%. Refer to the Pharmacy Plan Features for information on coverage for FDA-Approved female over-the-counter contraceptives (Non-Emergency). The per prescription copay/ and any prescription drug continue to apply: When the contraceptive methods listed above are obtained at an out-of-network pharmacy For contraceptive methods that are: - brand-name prescription drugs and devices and - FDA-approved female brand-name emergency contraceptives, that have a generic equivalent, or generic alternative available within the same therapeutic drug class obtained at an out-of-network pharmacy or network pharmacy unless you are granted a medical exception. PLAN FEATURES NETWORK OUT-OF-NETWORK FDA-Approved Female Generic Over-the-Counter Contraceptives 100% per supply No copay or applies. Not covered. For each 30 day supply filled at a retail pharmacy FDA-Approved Female Generic Emergency Over-the-Counter Contraceptives 100% per supply No copay or applies. Not covered. Important Note: This Plan does not cover all over-the-counter (OTC) contraceptives. For a current listing, contact Member Services by logging on the Aetna website at or calling the toll-free number on the back of the ID card. 25

29 Preventive Care Drugs and Supplements Preventive care drugs and supplements filled at a pharmacy with a prescription: Coverage will be subject to any sex, age, medical condition, family history, and frequency guidelines in the recommendations of the United States Preventive Services Task Force. For details on the guidelines and the current list of covered preventive care drugs and supplements, contact your physician or Member Services by logging onto the Aetna website or calling the number on the back of your ID card. 100% per item. No copay or applies. Not Covered. Important Note: Refer to the Booklet and the Preventive Care section for a complete description of the preventive care drugs and supplements covered under this Plan and for any limitations that apply to these benefits. Tobacco Cessation Prescription and Over-the-Counter Drugs Tobacco cessation prescription drugs and OTC drugs filled at a pharmacy for each 90 day supply. Maximums: Coverage is permitted for two 90-day treatment regimens only. Any additional treatment regimens will be subject to the cost sharing in your schedule of benefits below. Coverage will be subject to any sex, age, medical condition, family history, and frequency guidelines in the recommendations of the United States Preventive Services Task Force. For details on the guidelines and the current list of covered tobacco cessation prescription drugs and OTC drugs, contact Member Services by logging onto your Aetna Navigator secure member website at or calling the number on the back of your ID card. 100% per supply No copay or applies. Not covered. 26

30 Coinsurance Prescription Drug Plan Coinsurance NETWORK OUT-OF-NETWORK 100% of the negotiated charge 100% of the recognized charge The prescription drug plan coinsurance is the percentage of prescription drug covered expenses that the plan pays after any applicable s and copays have been met. The following Precertification and step therapy language applies effective January 1, 2016: Precertification and step therapy for certain prescription drugs is required. If precertification is not obtained, the prescription drug will not be covered. Expense Provisions The following provisions apply to your health expense plan. This section describes cost sharing features, benefit maximums and other important provisions that apply to your Plan. The specific cost sharing features and the applicable dollar amounts or benefit percentages are contained in the attached health expense sections of this Schedule of Benefits. This Schedule of Benefits replaces any Schedule of Benefits previously in effect under your plan of health benefits. KEEP THIS SCHEDULE OF BENEFITS WITH YOUR BOOKLET. Deductible Provisions Covered expenses applied to the out-of-network provider s will be applied to satisfy the network provider s. Covered expenses applied to the network provider s will be applied to satisfy the out-of-network provider s. All covered expenses accumulate toward the network provider and out-of-network provider s except for those covered expenses identified later in this Schedule of Benefits. You and each of your covered dependents have separate s. Each of you must meet your separately and they cannot be combined. This Plan has individual and family s. Network Provider Deductible Individual This is the amount of covered expenses that you and each of your covered dependents incur each from a network provider for which no benefits will be paid. This individual applies separately to you and each of your covered dependents. After covered expenses reach this individual, this Plan will begin to pay benefits for covered expenses that you incur from a network provider for the rest of the. Family Deductible Limit When you and each of your covered dependents incur covered expenses that apply towards the individual Calendar Year s, these expenses will also count toward a family limit. 27

31 To satisfy this family limit for the rest of the, the following must happen: The combined covered expenses that you and each of your covered dependents incur towards the individual s must reach this family limit in a. When this occurs in a, the individual s for you and your covered dependents will be considered to be met for the rest of the. Out-of-Network Provider Deductible Individual This is the amount of covered expenses that you and each of your covered dependents incur each from an out-of-network provider for which no benefits will be paid. This individual applies separately to you and each of your covered dependents. After covered expenses reach this individual ; this Plan will begin to pay benefits for covered expenses that you incur from an out-ofnetwork provider for the rest of the. Family Deductible Limit When you and each of your covered dependents incur covered expenses that apply towards the individual Calendar Year s, these expenses will also count toward a family limit. To satisfy this family limit for the rest of the, the following must happen: The combined covered expenses that you and each of your covered dependents incur towards the individual s must reach this family limit in a. When this occurs in a, the individual s for you and your covered dependents will be considered to be met for the rest of the. Common Accident Out-of-Network Deductible Limit This limit applies when two or more family members are injured in the same accident. The common accident out-ofnetwork limit places a limit on your expenses when covered expenses are applied toward the separate s for out-of-network providers. When this occurs, and all covered expenses related to the accident in that exceed the common accident out-of-network limit, your plan will then pay the excess amount based on the plan payment percentage. The added benefit will be reduced by any family out-of-network limit benefit amount paid for the same covered expenses. Copayments and Benefit Deductible Provisions Copayment, Copay This is a specified dollar amount or percentage of the negotiated charge required to be paid by you at the time you receive a covered service from a network provider. It represents a portion of the applicable expense. Per Admission Copayment A Per Admission Copayment is an amount you are required to pay when you or a covered dependent have a stay in an inpatient facility. A copayment is a specified dollar amount or percentage of the negotiated charge required to be paid by you at the time you receive a covered service from a network provider. It represents a portion of the applicable expense. 28

32 Separate copayments may apply per facility. These copayments are in addition to any other copayments applicable under this plan. They may apply to each stay or they may apply on a per day basis up to a per admission maximum amount. Not more than two per admission copayments per family will apply for each facility type during a Calendar Year. Covered expenses applied to the per admission copayment cannot be applied to any other copayment required in your plan. Likewise, covered expenses applied to your plan s other copayments cannot be applied to meet the per admission copayment. For the stay of a well newborn baby (starting at birth), the per admission copayment amount will be waived. Payment Provisions Payment Percentage This is the percentage of your covered expenses that the plan pays and the percentage of covered expenses that you pay. The percentage that the plan pays is referred to as the Plan Payment Percentage. Once applicable s have been met, your plan will pay a percentage of the covered expenses, and you will be responsible for the rest of the costs. The payment percentage may vary by the type of expense. Refer to your Schedule of Benefits for payment percentage amounts for each covered benefit. Maximum Out-of-Pocket Limit The Maximum Out-of-Pocket Limit is the maximum amount you are responsible to pay for covered expenses during the. This Plan has an individual Maximum Out-of-Pocket Limit. As to the individual Maximum Out-of-Pocket Limit, each of you must meet your Maximum Out-of-Pocket Limit separately and they cannot be combined and applied towards one limit. Certain covered expenses do not apply toward the Maximum Out-of-Pocket Limit. See list below. Network Provider Maximum Out-of-Pocket Limit Individual Once the amount of eligible network provider expenses you or your covered dependents have paid during the meets the individual Maximum Out-of-Pocket Limit, this Plan will pay 100% of such covered expenses that apply toward the limit for the remainder of the for that person. Family Maximum Out-of-Pocket Limit When you and each of your covered dependents incur covered expenses that apply towards the individual Calendar Year network provider Maximum Out-of-Pocket Limit, these expenses will also count toward a family network provider Maximum Out-of-Pocket Limit. 29

33 To satisfy this family network provider Maximum Out-of-Pocket Limit for the rest of the, the following must happen: The family Maximum Out-of-Pocket Limit is a cumulative Maximum Out-of-Pocket Limit for all family members. The family network provider Maximum Out-of-Pocket Limit can be met by a combination of family members with no single individual within the family contributing more than the individual network provider Maximum Out-of-Pocket Limit amount in a. Out-of Network Provider Maximum Out-of-Pocket Limit Individual Once the amount of eligible out-of-network provider expenses you or your covered dependents have paid during the meets the individual Maximum Out-of-Pocket Limit, this Plan will pay 100% of such covered expenses that apply toward the limit for the remainder of the for that person. Family Maximum Out-of-Pocket Limit When you and each of your covered dependents incur covered expenses that apply towards the individual Calendar Year out-of-network provider Maximum Out-of-Pocket Limit, these expenses will also count toward a family outof-network provider Maximum Out-of-Pocket Limit. To satisfy this family out-of-network provider Maximum Out-of-Pocket Limit for the rest of the, the following must happen: The family Maximum Out-of-Pocket Limit is a cumulative Maximum Out-of-Pocket Limit for all family members. The family out-of-network provider Maximum Out-of-Pocket Limit can be met by a combination of family members with no single individual within the family contributing more than the individual out-ofnetwork provider Maximum Out-of-Pocket Limit amount in a. The Maximum Out-of-Pocket Limit applies to both network and out -of-network benefits. Covered expenses applied to the out-of-network Maximum Out-of-Pocket Limit will be applied to satisfy the in-network Maximum Out-of-Pocket Limit and covered expenses applied to the in-network Maximum Out-of-Pocket Limit will be applied to satisfy the out-of-network Maximum Out-of-Pocket Limit. Covered expenses that are subject to the Maximum Out-of-Pocket Limit include prescription drug expenses provided under the Medical or Prescription drug Plans, as applicable. Expenses That Do Not Apply to Your Out-of-Pocket Limit Certain covered expenses do not apply toward your plan out-of-pocket limit. These include: Charges over the recognized charge; Non-covered expenses; Any covered expenses which are payable by Aetna at 50%; and Expenses that are not paid, or precertification benefit reductions because a required precertification for the service(s) or supply was not obtained from Aetna. 30