Medical plans for Virginia at-a-glance Virginia 1 50 (Plans effective January 1, 2015)

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1 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Medical plans for Virginia at-a-glance Virginia 1 50 (Plans effective January 1, 2015) HMO plans () VA Aetna Gold HMO 500A $0 0% $5,000 $30 $50 $300 $500/admit $15 $50 $300 T1A: $3, VA Aetna Gold HMO 80% $0 20% $5,000 $30 $50 $300 20% $15 $50 $300 T1A: $3, VA Aetna Gold HMO % $1,000 0% $5,000 $30 $50 $300 0% $0 $50 $300 T1A: $3, VA Aetna Silver HMO % $2,000 0% $6,350 $45 $75 $350 0% $20 $75 $350 T1A: $3, VA Aetna Silver HMO % $2,000 40% $6,350 $40 $60 20% 20% 20% 20% 20% T1A: $3, VA Aetna Silver HMO % $2,000 20% $6,350 $40 40% 40% 40% 40% 40% 40% T1A: $3, VA B (11/14)

2 Health Network Only Open Access plans () PCP VA Aetna Gold HNOnly 500A $0 0% $5,000 $30 $50 $300 $500/admit $15 $50 $300 T1A: $3, VA Aetna Gold HNOnly % $1,000 0% $5,000 $30 $50 $300 0% $0 $50 $300 T1A: $3, 100% $2,000 0% $6,350 $45 $75 $350 0% $20 $75 $350 T1A: $3, 90% HSA VA Aetna Bronze HNOnly % HSA VA Aetna Bronze HNOnly % HSA $2,000 10% $6,350 10% 10% 10% 10% after $3,000 0% $6,350 $40 $60 $300 $500/d, days % 10% $15 $60 $4,500 0% $6,350 0% 0% 0% 0% 0% 0% after VA Aetna Gold HNOnly 80% SS $0 20% $5,000 Designated: $15; Non-designated: $30 75% SS 60% SS $2,000 25% $6,350 Designated: $20; Non-designated: $40 $2,000 40% $6,350 Designated: $20; Non-designated: $40 10% T1A: $3, $300 T1A: $3, 0% T1A: $3, $50 $300 20% $15 $50 $300 T1A: $3, $60 25% 25% after 40% 40% 40% after 25% 25% 40% 40% 25% T1A: $3, 40% T1A: $3, VA Aetna Platinum HNOnly 300A $0 0% $6,000 $15 $30 $300 $300/admit $0 $0 $200 T1A: $3, Health benefits and health insurance plans are offered, underwritten and/or administered by Aetna Health Inc. and/or Aetna Life Insurance Company (Aetna). Each insurer has sole financial responsibility for its own products. 2

3 Health Network Only Open Access plans () VA Aetna Platinum HNOnly 80% $0 20% $6,000 $15 $30 $300 20% $0 $0 $200 T1A: $3, VA Aetna Gold HNOnly % $500 20% $6,350 $25 $50 $300 20% 20% 20% 20% T1A: $3, VA Aetna Gold HNOnly % $1,000 20% $6,350 $30 $50 $300 20% 20% 20% 20% T1A: $3, 100% SJ $2,000 0% $6,350 $20 $50 $300 $250/admit $0 $0 after $500 T1A: $3, PPO plans () VA Aetna Bronze PPO 3000 HSA VA Aetna Bronze PPO /50 HSA VA Aetna Gold PPO 100/50 500A VA Aetna Gold PPO /50 VA Aetna Gold PPO /50 VA Aetna Gold PPO /50 $3,000 0% $6,350 $40 $60 $300 $500/d, days 1 5 $15 $60 $4,500 0% $6,350 0% 0% 0% 0% 0% 0% after $ 300 T1A: $3, 0% T1A: $3, $0 0% $5,000 $30 $50 $300 $500/admit $15 $50 $300 T1A: $3, $1,000 0% $5,000 $30 $50 $300 0% $0 $50 $300 T1A: $3, $1,000 20% $6,350 $30 $50 $300 20% 20% 20% 20% T1A: $3, $500 20% $6,350 $25 $50 $300 20% 20% 20% 20% T1A: $3, 3

4 PPO plans () PCP VA Aetna Gold PPO 80/50 SS VA Aetna Platinum PPO 100/50 300A VA Aetna Platinum PPO 80/50 VA Aetna Silver PPO /50 VA Aetna Silver PPO /50 SJ VA Aetna Silver PPO /50 SS VA Aetna Silver PPO /50 SS VA Aetna Silver PPO /50 HSA Indemnity plan $0 20% $5000 Designated: $15; Non-designated: $30 $50 $300 20% $15 $50 $300 T1A: $3, $0 0% $6,000 $15 $30 $300 $300/admit $0 $0 $200 T1A: $3, $0 20% $6,000 $15 $30 $300 20% 20% 20% 20% T1A: $3, $2,000 0% $6,350 $45 $75 $350 0% $20 $75 $350 T1A: $3, $2,000 0% $6,350 $25 $50 $300 $250/admit $2,000 40% $6,350 Designated: $20; Non-designated: $40 $2,000 25% $6,350 Designated: $20; Non-designated: $40 40% 40% 40% after $0 $0 after 40% 40% $60 25% 25% 25% 25% $2,000 10% $6,350 10% 10% 10% 10% 10% 10% $500 T1A: $3, 40% T1A: $3, 25% T1A: $3, 10% T1A: $3, () VA Aetna Silver Indemnity % $2,000 20% $6,000 20% 20% 20% 20% 20% 20% 20% 20%\20%\ 20%\20% 4

5 Footnotes This is a partial description of benefits available. For more information, refer to the specific Summary of Benefits and Coverage (SBC). The dollar amount copayments indicate what the member is required to pay. The coinsurance percentage amounts indicate what Aetna is required to pay. Some benefits are subject to ations or maximums. Members or providers may be required to precertify, or obtain prior approval for certain services, such as non-emergency care. We cover the cost of care differently based on whether health care providers, such as doctors and s, are in network/designated or out of network. To learn how we pay out-of-network benefits 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. Existing members may sign on to your Aetna Navigator member site. The way we pay out-of-network doctors and s applies when members choose to get care out of network. When they have no choice (for example: emergency after a car accident), we will pay the bill as if they received care in network. Members pay the plan s copayments, coinsurance and uctibles for the in-network/designated level of benefits. Contact Aetna if a provider asks for more. Members are not responsible for any outstanding balance billed by providers for emergency services beyond copayments, coinsurance and uctibles. 5

6 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 and health insurance plans contain exclusions and ations. Plan features and availability may vary by location and group size. Investment services are independently offered through HealthEquity, Inc. 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, ations and conditions of coverage. Plan features are subject to change. Aetna receives rebates from drug manufacturers that may be taken into account in determining the Aetna Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. If you are in a plan that requires the selection of a primary care physician and your primary care physician is part of an integrated delivery system or physician group, your primary care physician will generally refer you to specialists and s that are affiliated with the delivery system or physician group. 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 (11/14)