Aetna Whole Health SM Brochure

Transcription

1 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Aetna Whole Health SM Brochure For businesses with employees in the greater Roanoke metropolitan area Plans effective August 1, VA B (7/12)

2 For businesses with employees in Virginia, featuring special health plan offerings for the greater Roanoke metropolitan area. Health benefits and health insurance plans are offered and or underwritten by Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). Each insurer has sole financial responsibility for its own products. 2

3 Aetna Whole Health Aetna brings a new model of health care delivery to Roanoke Aetna is offering insurance benefits plans supported by a distinct model of health care delivery to employers in the greater Roanoke metropolitan area. Aetna Whole Health is an offering of Aetna health benefits and insurance plans supported by doctors, hospitals and outpatient specialty centers from Carilion Clinic and LewisGale Regional Health System (LGRHS) and Aetna s network that offers Roanoke-area businesses a unique opportunity to help their employees optimize their health. Aetna s approach to aligning with accountable care organizations (ACOs) and integrated health systems The National Committee for Quality Assurance (NCQA) defines an accountable care organization as follows: ACOs are alliances of physicians, hospitals and other providers that coordinate care for a particular group of patients to help improve quality and reduce costs. ACOs emphasize preventive care to keep people healthy, and coordination among providers to prevent errors and duplication. ACOs take responsibility for patients care and organize medical services to ensure patients get the right care at the right time. 1 Integrated health systems establish quality and performance standards for patient care and include relationships with independent community physicians. In the greater Roanoke metropolitan area, Aetna Whole Health is a portfolio of products that includes an ACO collaboration with Carilion Clinic and a health system relationship with LGRHS. Aetna Whole Health offers: Competitive health care plans for Virginia businesses with eligible employees. Attractively priced plan offerings that reflect the cost and quality benefits of this collaboration. Several plan options that offer your Roanoke-area employees a lower copay differential to encourage them to use certain Designated Network Providers. Access to Aetna s broad network of providers, including Carilion Clinic and LewisGale Regional Health System. What sets patient care apart with an Aetna Whole Health Designated Network Provider Aetna Whole Health Designated Network Providers* are primary care doctors who have been recognized or are in the process of being recognized by the NCQA for meeting stringent efficiency and quality measures. Operating under NCQA guidelines, these doctors received recognition as a Patient-Centered Medical Home (PCMH) provider. PCMH is a team-based approach to medical care, coordinated by a personal physician. It coordinates a patient s health care needs, including preventive services, acute and chronic illness treatment, and end-of-life management. This coveted recognition validates these doctors high performance in these areas: Care coordination Quality Safety Access to care By adhering to these measures, Designated Network Providers reinforce to their patients their commitment to care excellence. They have developed innovative approaches to delivering care that will help improve the overall health of our members: Through personalized care and patient engagement. By working together to share member health information as patients pass through different health care settings. How a PCMH is different from what you ve experienced before In a PCMH each patient has an ongoing relationship with a personal doctor. That doctor: Coordinates the patient s health care needs. Leads a team of health care providers chosen to help meet the patient s particular health care needs. Makes it easy for patients to get care by offering same-day appointments, expanded office hours and communications via . Has secure, electronic access to all information needed to care for each patient. No more filling out forms or answering the same questions over and over. Stays apprised of patients health status through a variety of health care management tools. 1 Accountable Care Organizations (ACO). Available at: Accessed September 12, * This includes those providers who have the designation, those who meet the standard of care guidelines, those whose applications are in the NCQA approval process and those who adhere to NCQA s standards. 3

4 A new model of health care delivery designed with Roanoke-area businesses in mind Same quality local care for your employees Aetna Whole Health plans help Virginia businesses like yours access health services that fit their needs and their budgets. Our Aetna Whole Health portfolio of plans in Virginia includes: Three Aetna Open Access Managed Choice (OAMC) medical plans that provide a financial incentive for choosing Designated Network Providers who are recognized for delivering quality care. Here s how the OAMC copay differential works: When members use a primary care physician, they will pay: A $5 copay per office visit ( ) when using a Designated Network Provider. A $30 per office visit ( ) when using a Non-Designated Network Provider. We also offer a number of traditional PPO, HSA-compatible and consumer-directed plans that allow members to access any network provider for covered services at a lower out-of-pocket cost, or non-network providers at higher out-of-pocket costs. See our Virginia plan guide for more details. Aetna makes it easier to manage your health plan Aetna Whole Health plans include access to a robust suite of resources and online tools that saves you time and money while helping your employees make better health decisions. Easy-to-navigate plans Aetna s group health benefits and insurance plans are easy to set up, administer and use. Once enrolled, you will have access not only to your health insurance benefits, but also to online resources and information to help you and your employees make more informed decisions about your health. Aetna e-business for plan sponsors Aetna will help you save time and manage your benefits through a suite of innovative, easy-to-use online tools, supporting enrollment transactions. The benefits enrollment process is easier than ever, replacing paper-based enrollment with a secure electronic solution. More benefits for Virginia businesses Aetna Whole Health clients can tap into corporate buying power through Aetna s Resource Connection, which features discounted goods and services. While not insurance, these discounts* can help you save on office supplies, HR support, payroll, technology assistance and more. For more information, visit: *Programs provide access to discounted prices and are not insured benefits. The member is responsible for the full cost of the discounted prices. Please refer to pages 5-11 for more information about Aetna Whole Health plans in Virginia. 4

5 Traditional - PPO Plan Options Plan Options VA PPO 1.5 (20/250A) +, * VA PPO 2.5 (20/500A) +, * Member Benefits In-Network Out-of-Network 1 In-Network Out-of-Network 1 Member Coinsurance 0% 20% after 0% Plan Year Deductible 2 N/A $500 per member $1,000 family N/A $500 per member $1,000 family Plan Year Out-of-Pocket Maximum 3 $1,500 per member $3,000 family $3,000 per member $6,000 family $2,000 per member $4,000 family $3,500 per member $7,000 family Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Preventive Care Well-baby/Child/Adult Exams (Age and frequency schedules apply. In-network and out-of-network combined.) $0 copay Well-baby/Child: 0%, 20% after $0 copay Well-baby/Child: 0%, Routine Gyn Exams (Routine exam, pap smear and other routine tests, once every plan year. In-network and out-of-network combined.) $0 copay 20%, $0 copay 30%, Routine Mammograms $0 copay 20% after $0 copay Routine Eye Exam (One exam per 24 months. $0 copay 20% after $0 copay Aetna Vision SM Discount Program Included Not covered Included Not covered Primary Physician Office Visit $20 copay 20% after $20 copay Specialist Office Visit $30 copay 20% after $40 copay Outpatient Services Lab $30 copay 20% after $40 copay Outpatient Services X-ray $30 copay 20% after $40 copay Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) Chiropractic Services (20 visits per plan year. Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per plan year. Outpatient Speech Therapy (30 visits per plan year. Durable Medical Equipment ($5,000 plan-year maximum. $100 copay 20% after $200 copay $10 copay 20% after $10 copay 25% after $30 copay 20% after $40 copay $30 copay 20% after $40 copay 50% 50% after 50% 50% after Inpatient Hospital $250 copay per admission 20% after $500 copay per admission Outpatient Surgery $50 copay 20% after $300 copay Emergency Room (Copay if admitted.) $150 copay $150 copay, $200 copay $200 copay, Urgent Care $50 copay 20% after $75 copay Prescription Drugs (Includes 90-day transition of coverage (TOC) for prior authorization 5 ) Prescription Drugs: 30-day supply 6 Option 1: $10/$25/$50 Option 2: $10/$35/$60 Option 1: $10/$25/$50 plus 30% Option 2: $10/$35/$60 plus 30% Option 1: $10/$25/$50 Option 2: $10/$35/$60 Option 1: $10/$25/$50 plus 30% Option 2: $10/$35/$60 plus 30% Prescription Drugs: 31- to 90-day supply 6 Option 1: $20/$50/$100 Option 2: $20/$70/$120 Not covered Option 1: $20/$50/$100 Option 2: $20/$70/$120 Not covered Aetna Specialty CareRx SM Drugs: 30-day supply Option 1: $100 copay Option 2: $200 copay Not covered Option 1: $100 copay Option 2: $200 copay Not covered *Optional Features: Morbid Obesity Morbid Obesity See pages for important plan provisions. 5

6 Traditional - PPO Plan Options Plan Options VA PPO 3.5 (25/10%) +, * VA PPO 4.5 (25/20%) +, * Member Benefits In-Network Out-of-Network 1 In-Network Out-of-Network 1 Member Coinsurance 10% 20% 50% after Plan Year Deductible 2 N/A $1,000 per member $2,000 family N/A $2,000 per member $4,000 family Plan Year Out-of-Pocket Maximum 3 $2,500 per member $5,000 family $4,000 per member $8,000 family $3,000 per member $6,000 family $5,000 per member $10,000 family Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Preventive Care Well-baby/Child/Adult Exams (Age and frequency schedules apply. In-network and out-of-network combined.) $0 copay Well-baby/Child: 0%, $0 copay Well-baby/Child: 0%, 50% after Routine Gyn Exams (Routine exam, pap smear and other routine tests, once every plan year. In-network and out-of-network combined.) $0 copay 30%, $0 copay 50%, Routine Mammograms $0 copay $0 copay 50% after Routine Eye Exam (One exam per 24 months. $0 copay $0 copay 50% after Aetna Vision SM Discount Program Included Not covered Included Not covered Primary Physician Office Visit $25 copay $25 copay 50% after Specialist Office Visit $50 copay $50 copay 50% after Outpatient Services Lab $50 copay $50 copay 50% after Outpatient Services X-ray $50 copay $50 copay 50% after Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) Chiropractic Services (20 visits per plan year. Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per plan year. Outpatient Speech Therapy (30 visits per plan year. Durable Medical Equipment ($5,000 plan-year maximum. $200 copay $200 copay 50% after $10 copay 25% after $10 copay 25% after $50 copay $50 copay 50% after $50 copay $50 copay 50% after 50% 50% after 50% 50% after Inpatient Hospital 10% 20% 50% after Outpatient Surgery 10% 20% 50% after Emergency Room (Copay if admitted.) $200 copay $200 copay, $200 copay $200 copay, Urgent Care $75 copay $75 copay 50% after Prescription Drugs (Includes 90-day transition of coverage (TOC) for prior authorization 5 ) Prescription Drugs: 30-day supply 6 $10/$35/$60 $10/$35/$60 plus 30% $10/$35/$60 $10/$35/$60 plus 30% Prescription Drugs: 31- to 90-day supply 6 $20/$70/$120 Not covered $20/$70/$120 Not covered Aetna Specialty CareRx SM Drugs: 30-day supply $200 copay Not covered $200 copay Not covered *Optional Features: Morbid Obesity Morbid Obesity See pages for important plan provisions. 6

7 Consumer Directed - OA MC Consumer Directed Plan Options Plan Options VA OAMC Consumer Directed Plan 1.5 (1000 Ded) +, * VA OAMC Consumer Directed Plan 2.5 (2000 Ded) +, * Member Benefits In-Network Out-of-Network 1 In-Network Out-of-Network 1 Member Coinsurance 20% after 50% after 20% after 50% after Plan Year Deductible 2 $1,000 per member $2,000 family $2,000 per member $4,000 family $2,000 per member $4,000 family $4,000 per member $8,000 family Plan Year Out-of-Pocket Maximum 3 $3,000 per member $6,000 family $5,000 per member $10,000 family $4,000 per member $8,000 family $8,000 per member $16,000 family Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Preventive Care Well-baby/Child/Adult Exams (Age and frequency schedules apply. In-network and out-of-network combined.) $0 copay, Well-baby/Child: 0%, 50% after $0 copay; Well-baby/Child: 0%, 50% after Routine Gyn Exams (Routine exam, pap smear and other routine tests, once every plan year. In-network and out-of-network combined.) $0 copay, 50%, $0 copay; 50%, Routine Mammograms $0 copay, 50% after $0 copay; 50% after Routine Eye Exam (One exam per 24 months. $0 copay, 50% after $0 copay; 50% after Aetna Vision SM Discount Program Included Not covered Included Not covered Primary Physician Office Visit 6 Designated Provider: $5 copay, Non-Designated Provider: $30 copay, 50% after Designated Provider: $5 copay, Non-Designated Provider: $30 copay, 50% after Specialist Office Visit $50 copay, 50% after $50 copay, 50% after Outpatient Services Lab 20% after 50% after 20% after 50% after Outpatient Services X-ray 20% after 50% after 20% after 50% after Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) Chiropractic Services (20 visits per plan year. Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per plan year. Outpatient Speech Therapy (30 visits per plan year. Durable Medical Equipment ($5,000 plan-year maximum. 20% after 50% after 20% after 50% after 20% after 25% after 20% after 25% after 20% after 50% after 20% after 50% after 20% after 50% after 20% after 50% after 50% after 50% after 50% after 50% after Inpatient Hospital 20% after 50% after 20% after 50% after Outpatient Surgery 20% after 50% after 20% after 50% after Emergency Room 20% after 20% after 20% after 20% after Urgent Care 20% after 50% after 20% after 50% after Prescription Drugs (Includes 90-day transition of coverage (TOC) for prior authorization 5 ) Prescription Drugs: 30-day supply 6 $10/$35/$60 $10/$35/$60 plus 30% $10/$35/$60 $10/$35/$60 plus 30% Prescription Drugs: 31- to 90-day supply 6 $20/$70/$120 Not covered $20/$70/$120 Not covered Aetna Specialty CareRx SM Drugs: 30-day supply $200 copay Not covered $200 copay Not covered *Optional Features: Morbid Obesity Morbid Obesity See pages for important plan provisions. 7

8 Consumer Directed - OA MC Consumer Directed Plan Option Plan Options VA OAMC Consumer Directed Plan 3.5 (3000 Ded) +, * Member Benefits In-Network Out-of-Network 1 Member Coinsurance 20% after 50% after Plan Year Deductible 2 Plan Year Out-of-Pocket Maximum 3 $3,000 per member $6,000 family $5,000 per member $10,000 family $5,000 per member $10,000 family $10,000 per member $20,000 family Lifetime Maximum Benefit Unlimited Unlimited Preventive Care Well-baby/Child/Adult Exams (Age and frequency schedules apply. In-network and out-of-network combined.) Routine Gyn Exams (Routine exam, pap smear and other routine tests, once every plan year. In-network and out-of-network combined.) $0 copay, 0%, $0 copay, 50%, Routine Mammograms $0 copay, 50% after Routine Eye Exam (One exam per 24 months. $0 copay, 50% after Aetna Vision SM Discount Program Included Not covered Primary Physician Office Visit 6 Designated Provider: $5 copay, Non-Designated Provider: $30 copay, 50% after Specialist Office Visit $50 copay, 50% after Outpatient Services Lab 20% after 50% after Outpatient Services X-ray 20% after 50% after Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) Chiropractic Services (20 visits per plan year. Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per plan year. Outpatient Speech Therapy (30 visits per plan year. Durable Medical Equipment ($5,000 plan-year maximum. 20% after 50% after 20% after 25% after 20% after 50% after 20% after 50% after 50% after 50% after Inpatient Hospital 20% after 50% after Outpatient Surgery 20% after 50% after Emergency Room 20% after 20% after Urgent Care 20% after 50% after Prescription Drugs (Includes 90-day transition of coverage (TOC) for prior authorization 5 ) Prescription Drugs: 30-day supply 6 $10/$35/$60 $10/$35/$60 plus 30% Prescription Drugs: 31- to 90-day supply 6 $20/$70/$120 Not covered Aetna Specialty CareRx SM Drugs: 30-day supply $200 copay Not covered *Optional Features: Morbid Obesity See pages for important plan provisions. 8

9 Consumer Directed - PPO HSA Compatible Plan Options Plan Options VA PPO HSA Compatible 1.5 (1500 Ded) +, * VA PPO HSA Compatible 2.5 (2500 Ded) +, * Member Benefits In-Network Out-of-Network 1 In-Network Out-of-Network 1 Member Coinsurance 0% after 0% after Plan Year Deductible 2 $1,500 individual $3,000 family $3,000 individual $6,000 family $2,500 individual $5,000 family $5,000 individual $10,000 family Plan Year Out-of-Pocket Maximum 3 $3,000 individual $6,000 family $6,000 individual $12,000 family $5,000 individual $10,000 family $10,000 individual $20,000 family Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Preventive Care Well-baby/Child/Adult Exams (Age and frequency schedules apply. In-network and out-of-network combined.) $0 copay, Well-baby/Child: 0%, $0 copay, Well-baby/Child: 0%, Routine Gyn Exams (Routine exam, pap smear and other routine tests, once every plan year. In-network and out-of-network combined.) $0 copay, 30%, $0 copay, 30%, Routine Mammograms $0 copay, $0 copay, Routine Eye Exam (One exam per 24 months. $0 copay, $0 copay, Aetna Vision SM Discount Program Included Not covered Included Not covered Primary Physician Office Visit $20 copay after $30 copay after Specialist Office Visit $40 copay after $50 copay after Outpatient Services Lab $40 copay after $50 copay after Outpatient Services X-ray $40 copay after $50 copay after Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) $200 copay after $200 copay after Chiropractic Services (20 visits per plan year. Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per plan year. $10 copay after 25% after $10 copay after $40 copay after $50 copay after 25% after Outpatient Speech Therapy (30 visits per plan year. Durable Medical Equipment ($5,000 plan-year maximum. $40 copay after $50 copay after 50% after 50% after 50% after 50% after Inpatient Hospital $500 copay per admission after $300 copay per day, 5 day copay maximum per admission, after Outpatient Surgery $300 copay after $200 copay after Emergency Room (Copay if admitted.) $200 copay after $200 copay after $200 copay after $200 copay after Urgent Care $75 copay after $75 copay after Prescription Drugs (Includes 90-day transition of coverage (TOC) for prior authorization 4 ) Prescription Drugs: 30-day supply 5 $10/$35/$60 after integrated $10/$35/$60 plus 30% after integrated $10/$35/$60 after integrated $10/$35/$60 plus 30% after integrated Prescription Drugs: 31- to 90-day supply 5 $20/$70/$120 after integrated Not covered $20/$70/$120 after integrated Not covered *Optional Features: Morbid Obesity Morbid Obesity Aetna See pages is the brand for important plan provisions. 9

10 Consumer Directed - PPO HSA Compatible Plan Option Plan Options VA PPO HSA Compatible 3.5 (5000 Ded) +, * Member Benefits In-Network Out-of-Network 1 Member Coinsurance 10% after 50% after Plan Year Deductible 2 Plan Year Out-of-Pocket Maximum 3 $5,000 individual $10,000 family $6,000 individual $12,000 family $5,000 individual $10,000 family $10,000 individual $20,000 family Lifetime Maximum Benefit Unlimited Unlimited Preventive Care Well-baby/Child/Adult Exams (Age and frequency schedules apply. In-network and out-of-network combined.) Routine Gyn Exams (Routine exam, pap smear and other routine tests, once every plan year. In-network and out-of-network combined.) 0%, Well-baby/Child: 0%, 50% after 0%, 50%, Routine Mammograms 0%, 50% after Routine Eye Exam (One exam per 24 months. 0%, 50% after Aetna Vision SM Discount Program Included Not covered Primary Physician Office Visit 10% after 50% after Specialist Office Visit 10% after 50% after Outpatient Services Lab 10% after 50% after Outpatient Services X-ray 10% after 50% after Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) Chiropractic Services (20 visits per plan year. Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per plan year. Outpatient Speech Therapy (30 visits per plan year. Durable Medical Equipment ($5,000 plan-year maximum. 10% after 50% after 10% after 25% after 10% after 50% after 10% after 50% after 50% after 50% after Inpatient Hospital 10% after 50% after Outpatient Surgery 10% after 50% after Emergency Room 10% after 10% after Urgent Care 10% after 50% after Prescription Drugs (Includes 90-day transition of coverage (TOC) for prior authorization 4 ) Prescription Drugs: 30-day supply 5 $10/$35/$60 after integrated $10/$35/$60 plus 30% after integrated Prescription Drugs: 31- to 90-day supply 5 $20/$70/$120 after integrated Not covered Aetna Specialty CareRx SM Drugs: 30-day supply $200 copay after integrated Not covered *Optional Features: Morbid Obesity Morbid Obesity Aetna See pages is the brand for important plan provisions. 10

11 Traditional - Indemnity Plan Option Plan Options VA Indemnity 1.5 (500 Ded) +, * Member Benefits Out-of-Network 1 Member Coinsurance Plan Year Deductible 2 Plan Year Out-of-Pocket Maximum 3 Lifetime Maximum Benefit $500 per member $1,000 family $3,000 per member $6,000 family Unlimited Preventive Care Well-baby/Child/Adult Exams (Age and frequency schedules apply.) Routine Gyn Exams (Routine exam, pap smear and other routine tests, once every plan year.) Routine Mammograms Routine Eye Exam (One exam per 24 months.) Aetna Vision SM Discount Program Primary Physician Office Visit Specialist Office Visit Outpatient Services - Lab Outpatient Services - X-ray Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) Chiropractic Services (20 visits per plan year) Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per plan year.) Outpatient Speech Therapy (30 visits per plan year) Durable Medical Equipment ($5,000 plan-year maximum) Inpatient Hospital Outpatient Surgery Emergency Room Urgent Care 0%, 0%, 0%, 0%, Included 25% after 50% after Prescription Drugs (Includes 90-day transition of coverage (TOC) for prior authorization 5 ) Prescription Drugs: 30-day supply 6 $10/$35/$60 Prescription Drugs: 31- to 90-day supply 6 $20/$70/$120 Aetna Specialty CareRx SM Drugs: 30-day supply *Optional Features: $200 copay Morbid Obesity See pages for important plan provisions. 11

12 Important Plan Provisions All Plan Options (Pages 5 11) + This is a partial description of benefits available; for more information, refer to the specific plan design summary. Generic formulary contraceptives are covered without member cost-share (for example, no copayment). Certain religious organizations or religious employers may be exempt from offering contraceptive services. 1 Open Access Managed Choice POS (OA MC) and PPO Plans: 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 s under your plan. No dollar amount above the recognized charge counts toward your 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 care in network. You pay cost sharing and s 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 s. Indemnity Plan: Payment for care is determined based upon the lowest of: the provider s usual charge for furnishing it; or the charge Aetna determines to be appropriate, based on factors such as the cost of providing the same or a similar service or supply and the manner in which charges for the service or supply are made. These charges are referred to in your plan as reasonable or recognized charges. Some benefits are subject to limitations or visit maximums. Members or providers may be required to pre-certify or obtain prior approval for certain services. Note: For a summary list of Limitations and Exclusions, refer to page 14. Please refer to Aetna s Producer World web site at for more detailed benefit descriptions. Or for more information, please contact your licensed agent or Aetna Sales Representative. 12

13 Traditional - PPO and Indemnity Plan Options (Pages 5 6 and 11) and Consumer Directed - OA MC Consumer Directed Plan Options (Pages 7 8) 2 Once the family is met, all family members will be considered as having met their for the remainder of the plan year. No one family member may contribute more than the individual amount to the family. Deductible credit and carryover do not apply. OA MC Consumer Directed Plans: All covered expenses accumulate separately toward the in-network and out-of-network. 3 Once the family out-of-pocket maximum is met, all family members will be considered as having met their out-of-pocket maximum for the remainder of the plan year. No one family member may contribute more than the individual out-of-pocket maximum amount to the family out-of-pocket maximum. Prescription drugs do not apply toward the out-of-pocket maximum. PPO and OA MC Consumer Directed Plans: All covered expenses accumulate separately toward the in-network and out-of-network out-of-pocket maximum. PPO, OA MC Consumer Directed and Indemnity Plans: Deductible applies to the out-of-pocket maximum. 4 OA MC Plans: Easily locate provider information online. Go to 5 Transition of Coverage for Prior Authorizations helps members of new groups to transition to Aetna by providing a 90-calendar-day opportunity, beginning on the group s initial effective date, during which time prior authorization requirements will not apply to certain drugs. Once the 90 calendar days have expired, prior authorization edits will apply to all drugs requiring prior authorization as listed in the formulary guide. Members who have claims paid for a drug requiring prior authorization during the transition of coverage period, may continue to receive this drug after the 90 calendar days and will not be required to obtain a prior authorization for this drug. 6 Contraceptives and diabetic supplies included. Consumer Directed - PPO HSA Compatible Plan Options (Pages 9 10) 2 All covered prescription drug and medical expenses, except in-network preventive care services, apply to the. All covered expenses accumulate separately toward the in-network and out-of-network. The individual can only be met when a member is enrolled for self-only coverage with no dependent coverage. The family can be met by a combination of family members or by any single individual within the family. Once the family is met, all family members will be considered as having met their for the remainder of the plan year. Deductible credit and carryover do not apply. 3 All amounts paid as, copayments or coinsurance for covered services and supplies apply toward the out-of-pocket maximum. All covered expenses accumulate separately toward the in-network and out-of-network out-of-pocket maximum. The individual out-of-pocket maximum can only be met when a member is enrolled for self-only coverage with no dependent coverage. The family out-of-pocket maximum can be met by a combination of family members or by any single individual within the family. Once the family out-of-pocket maximum is met, all family members will be considered as having met their out-of-pocket maximum for the remainder of the plan year. 4 Transition of Coverage for Prior Authorizations helps members of new groups to transition to Aetna by providing a 90-calendar-day opportunity, beginning on the group s initial effective date, during which time prior authorization requirements will not apply to certain drugs. Once the 90 calendar days have expired, prior authorization edits will apply to all drugs requiring prior authorization as listed in the formulary guide. Members who have claims paid for a drug requiring prior authorization during the transition of coverage period, may continue to receive this drug after the 90 calendar days and will not be required to obtain a prior authorization for this drug. 5 Contraceptives and diabetic supplies included. 13

14 Limitations and Exclusions These plans do not cover all health care expenses and include exclusions and limitations. Members should refer to their plan documents to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, plan documents may contain exceptions to this list based on state mandates. All medical or hospital services not specifically covered in, or which are limited or excluded in the plan documents Charges related to any eye surgery mainly to correct refractive errors Cosmetic surgery, including breast reduction Custodial care Dental care and X-rays Donor egg retrieval Experimental and investigational procedures Hearing aids Immunizations for travel or work Infertility services, including, but not limited to, artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services unless specifically listed as covered in plan documents Non-medically necessary services or supplies Orthotics Over-the-counter medications and supplies Reversal of sterilization Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies or counseling Special duty nursing Pre-existing conditions exclusion provision These plans impose a pre-existing conditions exclusion, which may be in some circumstances (that is, creditable coverage) and may not be applicable. A pre-existing conditions exclusion means that if the member has a medical condition before coming to the plan, the member might have to wait a certain period of time before the plan will provide coverage for that condition. This exclusion applies only to conditions for which medical advice, diagnosis or treatment was recommended or received or for which the individual took prescribed drugs within 180 days. Generally, this period ends the day before coverage becomes effective. However, if the member was in a waiting period for coverage, the 180-day period ends on the day before the waiting period begins. The exclusion period, if applicable, may last up to 365 days from the first day of coverage, or if the member was in a waiting period, from the first day of the waiting period. If the member had prior creditable coverage within 90 days immediately before the date enrolled under the plan, then the pre-existing conditions exclusion in the plan, if any, will be. If the member had no prior creditable coverage within the 90 days prior to the enrollment date (either because the member had no prior coverage or because there was more than a 90-day gap from the date the prior coverage terminated to the enrollment date), we will apply the plan s pre-existing conditions exclusion. In order to reduce or possibly eliminate the exclusion period based on creditable coverage, the member should provide us a copy of any Certificates of Creditable Coverage. Groups with 2 to 50 eligible employees: Please contact Aetna Member Services at AETNA ( ) for assistance in obtaining a Certificate of Creditable Coverage from the prior carrier or with any questions on the information provided. Groups with 51 to 100 eligible employees: Please contact Aetna Member Services at for assistance in obtaining a Certificate of Creditable Coverage from the prior carrier or with any questions on the information provided. The pre-existing condition exclusion does not apply to pregnancy nor to a child under the age of 19. Note: For late enrollees, coverage will be delayed until the plan s next open enrollment; the pre-existing exclusion will be applied from the individual s effective date of coverage. Aetna is the brand 14

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16 Contact us For more information regarding the Aetna Whole Health plans for Virginia, please contact your broker or Aetna sales/account executive. This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Rates and benefits may vary by location. Health benefits/health insurance plans contain exclusions and limitations. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Plan features and availability may vary by location and group size. Aetna HealthFund HRAs are subject to employer- defined use and forfeiture rules, and are unfunded liabilities of your employer. Fund balances are not vested benefits. Investment services are independently offered through HealthEquity, Inc. Aetna Specialty Pharmacy refers to Aetna Specialty Pharmacy, LLC, a subsidiary of Aetna Inc., which is a licensed pharmacy that operates through specialty pharmacy prescription fulfillment. This pharmacy is a for-profit entity. Providers are independent contractors and not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna s Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to Aetna Inc VA B (7/12)