DELAWARE PLAN GUIDE. Aetna Avenue Your Destination for Small Business Solutions. PLANS EFFECTIVE October 1, 2010

Transcription

1 Aetna Avenue Your Destination for Small Business Solutions DELAWARE PLAN GUIDE PLANS EFFECTIVE October 1, 2010 For businesses with 1-50 eligible employees DE A (6/10)

2 D E L AWA R E p l a n G U I D E Health care is a journey Aetna Avenue is the way I n this guide : 2 Small business commitment 3 Benefits for every stage of life 4 Medical overview 9 Medical plan options 18 Dental overview 19 Dental plan options 24 Life & disability overview 26 Life plan options 27 Life & disability plan options 28 Underwriting guidelines 38 Limitations and exclusions As a small business owner, providing value to your customers and growing your business are your top priorities. Yet, today health care is a business issue for every entrepreneur. Small businesses need health insurance benefits plans that fit their workplace. Aetna Avenue provides employers with a choice of insurance benefits solutions. We know that choice, ease and reputation are as valuable to employers as they are to employees. Aetna offers a variety of plans for small business from medical plans, to dental, life and disability plans. Health benefits and health insurance, dental insurance, life insurance and disability insurance or benefits plans/policies are offered, underwritten or administered by Aetna Health Inc., Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna).

3 C HOICE For business owners and employees At Aetna, we provide employers a choice of health insurance benefits plans. Within these benefits programs, employers can choose specific plan designs that fit business and employee needs. Employees have access to a wide network of doctors and other providers ensuring that they have a choice in how they receive their health care. Medical plans supporting members on their health care journey Traditional plans Cost-sharing plans Consumer-directed plans Dental, life and disability plans providing valuable protection PPO PPO Max Preventive Basic term life insurance Packaged life and disability plans E a se Allowing you to focus on your business Employers want to focus on their customers and growing their business not the health insurance benefits program. Aetna makes sure that our plan designs are easy to set-up, administer, use and provide support to ensure your success. Administration making it work for your business Aetna s plan designs automatically process health claim reimbursements, provide a password-protected website to keep track of accounts and are supported by knowledgeable service representatives. Secure and online, Aetna Enroll SM makes managing health benefits easy and eliminates time-consuming, expensive paper-based processes. Ready on day-one making it work for your employees Once employees are members of the Aetna health benefits and health insurance plans, they ll have access to our various tools and resources to help them use the plans effectively from the start. Aetna Navigator our online resource for employers, members and providers Look up rates for providers, facilities and hospitals for common services and treatment Track medical claims online Discount programs for eye, dental and other health care Personal Health Record providing a complete picture of health Temporary ID cards available for members to print as needed Simple Steps To A Healthier Life, an online health and wellness program Reputat i on In business it s everything Your reputation is important to your business. At Aetna, our reputation is just as important. With 150 years of experience, we value our name, products and services and focus on delivering the right solution for your small business our reputation depends upon it. Our account executives, underwriters and customer service representatives are committed to providing your small business the valuable service it deserves. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 1

4 D E L AWA R E p l a n G U I D E Aetna Avenue s commitment to small business employers We know that small business owners health insurance benefits needs are often different than a larger employer. Aetna Avenue focuses on employers with 1-50 employees and our insurance benefits programs are designed to work for this size group. We ll work with you to determine the right plans for your business and assist you through implementation. Aetna s market map Guiding your small business health care journey Aetna s market map is a resource for brokers and employers to help determine the right insurance benefits plan for their business. The market map asks specific questions related to the business and employee need in order to narrow the field of plan design choices. Basic benefits for your employees Limiting the expense to your business Allowing employees to buy-up and share more of the cost You might be a Basic buyer These plans fit DE POS No-Referral 2.2 ($30 w/$15/$45/$75 Rx) DE POS Cost-Sharing No-Referral 1.2 ($1,000 Ded) Employee responsibility These plans fit Do you value Consumerism s ability to make a difference Tools and resources to support consumerism Innovative plan design You might be a Value seeker DE POS Cost-Sharing No-Referral 3.2 ($2,000 Ded) DE POS HSA Compatible No-Referral 1.2 ($1,500 Ded) DE POS HSA Compatible No-Referral 2.2 ($2,500 Ded) Traditional benefits plans These plans fit Limiting the financial impact on employees You might be a Traditionalist DE POS No-Referral 1.2 ($20 w/$10/$35/$60 Rx) 2

5 Y o u n g S i n g l e s Consumer-directed health plans Y o u n g Fa m i l i e s Traditional plans E s ta b l i s h e d FA M I L I E S Cost-sharing plans E m p t y N e s t e r s Cost-sharing plans Health insurance benefits for every stage of life Young singles Includes singles and couples without children Ready to conquer the world? Thinking big thoughts? Well, one of those thoughts should be about health coverage. Since they re probably on a budget, they might want an affordable policy with lower monthly payments and modest out-of-pocket costs that also provides for quality preventive care, prescription drug coverage and financial protection to help safeguard their assets. Young families Includes married couples and single parents with young children and teens Children tend to get sick more than adults which means employees and their pediatricians get to know each other quite well. It also means they re probably looking for health coverage with lower fees for office visits, lower monthly payments and caps on their out-of-pocket expenses. And, of course, they can benefit from quality preventive care for the entire family. Established families Includes married couples and single parents with teens and college-aged children As the children get older, the entire family s needs change. Time management is important for active parents and children. Teenagers still need checkups and care for injuries and illness, while parents need to start thinking about their own needs, like plan designs that cover preventive care and screenings and promote a healthy lifestyle. And college brings financial concerns to the forefront, as well as the need for a national network. Emp t y nesters Includes men and women age 55 and over with no children at home The kids are leaving home. It s a wistful time, but also an exciting one. What are the plans? Travel? Leisure? Reassessing health coverage needs? These employees are probably looking for a policy that combines financial security with quality coverage for prescriptions, hospital inpatient/outpatient services and emergency care. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 3

6 D E L AWA R E p l a n G U I D E Aetna Avenue Medic al Overv iew Delaware provider network* Both PPO and POS plans offered in all three counties : New Castle Kent Sussex Wellness On Us SM Wellness for employees means a healthier business for employers. Our small business plans in Delaware** offer $0 copays for in-network eye exams on top of $0 copay for in-network preventive care! It s one more way for us to help employees get a step closer to better health. See what employees can get for $0:*** Immunizations $0 copay Routine vision exams $0 copay Routine physicals Child wellness visits Routine mammogram Routine OB/GYN visits $0 copay $0 copay $0 copay $0 copay * Network subject to change. ** Basic and Standard HMO and Indemnity plans apply $0 copay for in-network preventive care as required by federal legislation. ***Any benefits limitations for preventive services will still be applied per the plan design. 4

7 Plan Name Description PCP Required Basic and Standard HMO Aetna POS No-Referral Aetna PPO Aetna Indemnity/ Basic and Standard Indemnity A health maintenance organization (HMO) uses a network of participating providers. Each family member selects a primary care physician (PCP) participating in our network. The PCP provides routine and preventive care and helps coordinate the member s total health care. The PCP refers members to participating specialists and facilities for medically necessary specialty care. Only services provided or referred by the PCP are covered except for emergency, urgently needed care or direct access benefits, unless approved by the HMO in advance of receiving services. The Aetna POS No-Referral plan is a two-tiered product that allows members to access care in or out of network. Members have lower out-of-pocket costs when they use the in-network tier of the plan. Member cost sharing increases if members decide to go out of network. Members may go to their PCP or directly to a participating specialist without a referral. It is their choice, each time they seek care. PPO plan members can access any recognized provider for covered services without a referral. Each time members seek health care, they have the freedom to choose either network providers at lower out-of-pocket costs, or non-network providers at higher out-of-pocket costs. The Aetna Indemnity plan option is available for employees who live outside the plan s network service area. Aetna also offers the Basic and Standard Indemnity plans in Delaware. Members coordinate their own health care and may access any recognized provider for covered services without a referral. Referrals Required Yes Yes HMO Network Yes/ Optional No Aetna Choice POS (Open Access) No No Open Choice PPO No No N/A M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 5

8 D E L AWA R E p l a n G U I D E AETNA HIGH - DEDUC T IBLE HSA COMPAT IBLE POS NO - REFERR AL / PPO PL ANS Aetna High-Deductible HSA Compatible POS No-Referral and PPO Health Plans are compatible with a Health Savings Account (HSA). HSA-compatible plans provide integrated medical and pharmacy benefits. Preventive care services are waived from the deductible. HSAs provide employers and their qualified employees with an affordable tax-advantaged solution that allows them to better manage their qualified medical and dental expenses. Employees can build a savings fund to assist in covering their future medical and dental expenses. HSA accounts can be funded by the employer or employee and are portable. Fund contributions may be tax-deductible (limits apply). When funds are used to cover qualified out-of-pocket medical and dental expenses, they are not taxed. Note: Employers and employees should consult with their tax advisor to determine eligibility requirements and tax advantages for participation in the HSA plan. SMALL GROUP SITUS Aetna Small Group benefits and rates are based on the group s headquarter location, subject to applicable small group reform laws. Eligible employees who live or work in CT, DC, DE, MD, NJ, NY, PA and VA (the situs region) will receive the same rates and benefits as the headquarter location. AETNA SMALL GROUP MULT I -STATE SOLUTION As part of Aetna s commitment to make it easier for small businesses to do business with us, and bring more consistency across benefits offerings to employers with employees in multiple locations, Aetna offers a multi-state solution. Delaware-domiciled employers can offer a DE PPO plan to their employees who live and work outside the situs region. The situs region is comprised of the following eight states CT, DC, DE, MD, NJ, NY, PA and VA. The rates and benefits will match those offered in Delaware. If the out-of-situs employee resides in a non-network area, the employee will be enrolled in an indemnity plan. Plan sponsors will need to continue to meet Small Group underwriting guidelines, and the majority of eligible employees must be in Delaware. In all instances, extraterritorial benefits that may apply on any of the out-of-state employees will be implemented to the extent these are more comprehensive than the domiciled state benefits. These benefits will only apply to the out-of-state employees in the states where required. For dental products, an out-of-state dental plan will be offered to employees who live and work outside the situs region defined above. 6

9 Health Reimbursement Arrangement (HRA) The Aetna HealthFund HRA combines the protection of a deductible-based health plan with a health fund that pays for eligible health care services. The member cannot contribute to the HRA, and employers have control over HRA plan designs. The fund is available to an employee for qualified expenses on the plan s effective date. The HRA and the HSA provide members with financial support for higher outof-pocket health care expenses. Aetna s consumer-directed health products and services give members the information and resources they need to help make informed health care decisions for themselves and their families while helping lower employers costs. COBRA administration Aetna COBRA administration offers a full range of notification, documentation and record-keeping processes that can assist employers with managing the complex billing and notification processes that are required for COBRA compliance, while also helping to save them time and money. Section 125 Cafeteria Plans and Section 132 Transit Reimbursement Accounts Employees can reduce their taxable income, and employers can pay less in payroll taxes. There are three ways to save: Premium Only Plans (POP) Employees can pay for their portion of the group health insurance expenses on a pretax basis. Flexible Savings Account (FSA) FSAs give employees a chance to save for health expenses with pretax money. Health Care Spending Accounts allow employees to set aside pretax dollars to pay for outof-pocket expenses as defined by the IRS. Dependent Care Spending Accounts allow participants to use pretax dollars to pay child or elder care expenses. Transit Reimbursement Account (TRA) TRAs allow participants to use pretax dollars to pay transportation and parking expenses for the purpose of commuting to and from work. 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. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Information is subject to change. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 7

10 D E L AWA R E p l a n G U I D E He alth Sav i ngs Account ( HSA) No set-up or administrative fees The Aetna HealthFund HSA, when coupled with a HSA-compatible high-deductible health benefits and health insurance plan, is a tax-advantaged savings account. Once enrolled, account contributions can be made by the employee and/or employer. The HSA can be used to pay for qualified expenses tax free. Member s HSA Plan H S A A c c o u n t You own your HSA Contribute tax free You choose how and when to use your dollars Roll it over each year and let it grow Earns interest, tax free T o d ay Use for qualified expenses with tax-free dollars F u t u r e Plan for future and retiree health-related costs H i g h - d e d u c t i b l e h e a lt h p l a n Eligible in-network preventive care services will not be subject to the deductible You pay 100% until deductible is met, then only pay a share of the cost Meet out-of-pocket maximum, then plan pays 100% 8

11 T R A D I T I O N A L P O S N O - R E F E R R A L P L A N O P T I O N S Plan Options DE POS NO-REFERRAL 1.2 DE POS NO-REFERRAL 2.2 ($20 w/$10/$35/$60 RX) +5 ($30 w/$15/$45/$75 RX) +5 Member Benefits In-Network Out-of-Network 1 In-Network Out-of-Network 1 No Referral Needed No Referral Needed No Referral Needed No Referral Needed Plan Coinsurance N/A 50% after deductible N/A 50% after deductible Plan Year Deductible 2 N/A $5,000 per member $15,000 family Plan Year Out-of-Pocket Maximum 3 (Deductible and prescription drugs do not apply toward the Out-of-Pocket Maximum.) $2,500 per member $5,000 family $10,000 per member $30,000 family N/A $3,000 per member $6,000 family Lifetime Maximum Benefit Unlimited Unlimited Wellness On Us SM Well-Baby/Child and Adult Physical Exams (Age and frequency schedules apply. In-network and out-of-network combined.) Routine GYN Exams (Limited to one exam and Pap smear per 365 days. In-network and out-of-network combined.) Routine Mammograms (One baseline mammogram for females age 35-39; and one mammogram per plan year for females age 40 and over. In-network and out-of-network combined.) Routine Eye Exam (One exam per 24 months. In-network and out-of-network combined.) Glasses and Contact Lens Reimbursement $5,000 per member $15,000 family $10,000 per member $30,000 family $0 copay 50%, deductible waived $0 copay 50%, deductible waived $0 copay 50%, deductible waived $0 copay 50%, deductible waived $0 copay 50% after deductible $0 copay 50% after deductible $0 copay 50% after deductible $0 copay 50% after deductible $100/24 month period. In-network and out-of-network combined. $100/24 month period. In-network and out-of-network combined. Aetna Vision SM Discount Program Included Not Covered Included Not Covered Primary Physician Office Visit $20 copay 50% after deductible $30 copay 50% after deductible Specialist Office Visit $40 copay 50% after deductible $50 copay 50% after deductible Outpatient Services Lab $0 copay 50% after deductible $0 copay 50% after deductible Outpatient Services X-Ray $40 copay 50% after deductible $50 copay 50% after deductible Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services (20 visits per plan year. In-network and out-of-network combined.) Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per plan year. In-network and out-of-network combined.) Outpatient Speech Therapy (30 visits per plan year. In-network and out-of-network combined.) Durable Medical Equipment ($2,500 Plan Year Maximum. In-network and out-of-network combined.) Inpatient Hospital $200 copay 50% after deductible $200 copay 50% after deductible $40 copay 50% after deductible $50 copay 50% after deductible $40 copay 50% after deductible $50 copay 50% after deductible $40 copay 50% after deductible $50 copay 50% after deductible 50% 50% after deductible 50% 50% after deductible $300 copay per day, 5 day copay maximum per admission 50% after deductible $500 copay per day, 5 day copay maximum per admission 50% after deductible Outpatient Surgery $300 copay 50% after deductible $500 copay 50% after deductible Emergency Room (Copay waived if admitted.) $200 copay $200 copay $200 copay $200 copay Urgent Care $75 copay 50% after deductible $75 copay 50% after deductible Mental Health Inpatient (Serious: Unlimited days per plan year. In-network and out-ofnetwork combined. Non-Serious: Limited to 30 days per plan year. In-network and out-of-network combined.) Substance Abuse Inpatient $300 copay per day, 5 day copay maximum per admission $300 copay per day, 5 day copay maximum per admission 50% after deductible $500 copay per day, 5 day copay maximum per admission 50% after deductible $500 copay per day, 5 day copay maximum per admission 50% after deductible 50% after deductible Prescription Drugs Prescription Drug Deductible N/A N/A N/A N/A Prescription Drugs: 30-day supply $10/$35/$60 Not Covered $15/$45/$75 Not Covered Prescription Drugs: day supply $20/$70/$120 Not Covered $30/$90/$150 Not Covered Contraceptives and Diabetic Supplies Included Not Covered Included Not Covered 90-Day Transition of Coverage Included Not Covered Included Not Covered (TOC) for Prior Authorization and Step-Therapy 4 Aetna Specialty CareRx SM Drugs 90% Not Covered 90% Not Covered M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G See page 17 for important plan provisions. 9

12 D E L AWA R E p l a n G U I D E P O S C O S T- S H A R I N G N O - R E F E R R A L P L A N O P T I O N S Plan Options DE POS COST-SHARING NO-REFERRAL 1.2 DE POS COST-SHARING NO-REFERRAL 2.2 ($1,000 Ded) +5 ($1,500 Ded) +5 Member Benefits In-Network Out-of-Network 1 In-Network Out-of-Network 1 No Referral Needed No Referral Needed No Referral Needed No Referral Needed Plan Coinsurance N/A 50% after deductible N/A 50% after deductible Plan Year Deductible 2 (Deductible applies only to in-network inpatient hospital-type services/outpatient surgery and out-of-network benefits unless state mandated.) $1,000 per member $2,000 family $5,000 per member $10,000 family $1,500 per member $3,000 family $5,000 per member $10,000 family Plan Year Out-of-Pocket Maximum 3 (Deductible does apply to the Out-of-Pocket Maximum. Prescription drugs do not apply toward the Out-of-Pocket Maximum.) $2,500 per member $5,000 family $10,000 per member $20,000 family $3,000 per member $6,000 family $10,000 per member $20,000 family Lifetime Maximum Benefit Unlimited Unlimited Wellness On Us SM Well-Baby/Child and Adult Physical Exams (Age and frequency schedules apply. In-network and out-of-network combined.) Routine GYN Exams (Limited to one exam and Pap smear per 365 days. In-network and out-of-network combined.) Routine Mammograms (One baseline mammogram for females age 35-39; and one mammogram per plan year for females age 40 and over. Innetwork and out-of-network combined.) Routine Eye Exam (One exam per 24 months. In-network and out-of-network combined.) $0 copay, deductible waived 50%, deductible waived $0 copay, deductible waived 50%, deductible waived $0 copay, deductible waived 50%, deductible waived $0 copay, deductible waived 50%, deductible waived $0 copay. deductible waived 50% after deductible $0 copay. deductible waived 50% after deductible $0 copay, deductible waived 50% after deductible $0 copay, deductible waived 50% after deductible Glasses and Contact Lens Reimbursement $100/24 month period. In-network and out-of-network combined. $100/24 month period. In-network and out-of-network combined. Aetna Vision SM Discount Program Included Not Covered Included Not Covered Primary Physician Office Visit Specialist Office Visit $20 copay, deductible waived $40 copay, deductible waived 50% after deductible $30 copay, deductible waived 50% after deductible $50 copay, deductible waived 50% after deductible 50% after deductible Outpatient Services Lab $0 copay, deductible waived 50% after deductible $0 copay, deductible waived 50% after deductible Outpatient Services X-Ray Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services (20 visits per plan year. In-network and out-of-network combined.) Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per plan year. In-network and out-of-network combined.) Outpatient Speech Therapy (30 visits per plan year. In-network and out-of-network combined.) Durable Medical Equipment ($2,500 Plan Year Maximum. In-network and out-of-network combined.) Inpatient Hospital $40 copay, deductible waived $200 copay, deductible waived $40 copay, deductible waived $40 copay, deductible waived $40 copay, deductible waived 50% after deductible $50 copay, deductible waived 50% after deductible $200 copay, deductible waived 50% after deductible $50 copay, deductible waived 50% after deductible $50 copay, deductible waived 50% after deductible $50 copay, deductible waived 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50%, deductible waived 50% after deductible 50%, deductible waived 50% after deductible $0 copay per admission after deductible 50% after deductible $0 copay per admission after deductible 50% after deductible Outpatient Surgery $0 copay after deductible 50% after deductible $0 copay after deductible 50% after deductible Emergency Room (Copay waived if admitted.) Urgent Care Mental Health Inpatient (Serious: Unlimited days per plan year. In-network and out-ofnetwork combined. Non-Serious: Limited to 30 days per plan year. In-network and out-of-network combined.) Substance Abuse Inpatient $200 copay, deductible waived $75 copay, deductible waived $0 copay per admission after deductible $0 copay per admission after deductible $200 copay, deductible waived $200 copay, deductible waived 50% after deductible $75 copay, deductible waived 50% after deductible $0 copay per admission after deductible 50% after deductible $0 copay per admission after deductible $200 copay, deductible waived 50% after deductible 50% after deductible 50% after deductible Prescription Drugs Prescription Drug Deductible N/A N/A N/A N/A Prescription Drugs: 30-day supply $15/$40/$70 Not Covered $15/$40/$70 Not Covered Prescription Drugs: day supply $30/$80/$140 Not Covered $30/$80/$140 Not Covered Contraceptives and Diabetic Supplies Included Not Covered Included Not Covered 90-Day Transition of Coverage Included Not Covered Included Not Covered (TOC) for Prior Authorization and Step-Therapy 4 Aetna Specialty CareRx SM Drugs 90% Not Covered 90% Not Covered See page 17 for important plan provisions. 10

13 P O S C O S T- S H A R I N G N O - R E F E R R A L P L A N O P T I O N S Plan Options DE POS COST-SHARING NO-REFERRAL 3.2 ($2,000 Ded) +5 Member Benefits In-Network Out-of-Network 1 No Referral Needed No Referral Needed Plan Coinsurance N/A 50% after deductible Plan Year Deductible 2 (Deductible applies only to in-network inpatient hospital-type services/outpatient surgery and out-of-network benefits unless state mandated.) Plan Year Out-of-Pocket Maximum 3 (Deductible does apply to the Out-of-Pocket Maximum. Prescription drugs do not apply toward the Out-of-Pocket Maximum.) Lifetime Maximum Benefit Wellness On Us SM Well-Baby/Child and Adult Physical Exams (Age and frequency schedules apply. In-network and out-ofnetwork combined.) Routine GYN Exams (Limited to one exam and Pap smear per 365 days. In-network and out-of-network combined.) Routine Mammograms (One baseline mammogram for females age 35-39; and one mammogram per plan year for females age 40 and over. Innetwork and out-of-network combined.) Routine Eye Exam (One exam per 24 months. In-network and out-of-network combined.) Glasses and Contact Lens Reimbursement $2,000 per member $4,000 family $4,000 per member $8,000 family Unlimited $5,000 per member $10,000 family $10,000 per member $20,000 family $0 copay, deductible waived 50%, deductible waived $0 copay, deductible waived 50%, deductible waived $0 copay. deductible waived 50% after deductible $0 copay, deductible waived 50% after deductible $100/24 month period. In-network and out-of-network combined. Aetna Vision SM Discount Program Included Not Covered Primary Physician Office Visit $30 copay, deductible waived 50% after deductible Specialist Office Visit $50 copay, deductible waived 50% after deductible Outpatient Services Lab $0 copay, deductible waived 50% after deductible Outpatient Services X-Ray $50 copay, deductible waived 50% after deductible Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services (20 visits per plan year. In-network and out-of-network combined.) Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per plan year. In-network and out-of-network combined.) Outpatient Speech Therapy (30 visits per plan year. In-network and out-of-network combined.) Durable Medical Equipment ($2,500 Plan Year Maximum. In-network and out-of-network combined.) Inpatient Hospital $200 copay, deductible waived 50% after deductible $50 copay, deductible waived 50% after deductible $50 copay, deductible waived 50% after deductible $50 copay, deductible waived 50% after deductible 50%, deductible waived 50% after deductible $0 copay per admission after deductible 50% after deductible Outpatient Surgery $0 copay after deductible 50% after deductible Emergency Room (Copay waived if admitted.) $200 copay, deductible waived $200 copay, deductible waived Urgent Care $75 copay, deductible waived 50% after deductible Mental Health Inpatient (Serious: Unlimited days per plan year. In-network and out-ofnetwork combined. Non-Serious: Limited to 30 days per plan year. In-network and out-of-network combined.) Substance Abuse Inpatient $0 copay per admission after deductible $0 copay per admission after deductible 50% after deductible 50% after deductible Prescription Drugs Prescription Drug Deductible N/A N/A Prescription Drugs: 30-day supply $15/$45/$75 Not Covered Prescription Drugs: day supply $30/$90/$150 Not Covered Contraceptives and Diabetic Supplies Included Not Covered 90-Day Transition of Coverage Included Not Covered (TOC) for Prior Authorization and Step-Therapy 4 Aetna Specialty CareRx SM Drugs 90% Not Covered M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G See page 17 for important plan provisions. 11

14 D E L AWA R E p l a n G U I D E C O N S U M E R - D I R E C T E D P O S C O N S U M E R - D I R E C T E D N O - R E F E R R A L P L A N O P T I O N Plan Options DE POS CONSUMER-DIRECTED NO-REFERRAL 1.2 ($1,500 Ded) +5 Member Benefits In-Network Out-of-Network 1 No Referral Needed No Referral Needed Plan Coinsurance N/A 50% after deductible Plan Year Deductible 2 (Deductible applies to all services unless indicated.) Plan Year Out-of-Pocket Maximum 3 (Deductible does apply to the Out-of-Pocket Maximum. Prescription drugs do not apply toward the Out-of-Pocket Maximum.) Lifetime Maximum Benefit Wellness On Us SM $1,500 Individual $3,000 Family $3,000 Individual $6,000 Family Unlimited $5,000 Individual $10,000 Family $10,000 Individual $20,000 Family Well-Baby/Child and Adult Physical Exams (Age and frequency schedules apply. In-network and out-ofnetwork combined.) Routine GYN Exams (Limited to one exam and Pap smear per 365 days. In-network and out-of-network combined.) Routine Mammograms (One baseline mammogram for females age 35-39; and one mammogram per plan year for females age 40 and over. Innetwork and out-of-network combined.) Routine Eye Exam (One exam per 24 months. In-network and out-of-network combined.) Glasses and Contact Lens Reimbursement $0 copay, deductible waived 50%, deductible waived $0 copay, deductible waived 50%, deductible waived $0 copay. deductible waived 50% after deductible $0 copay, deductible waived 50% after deductible $100/24 month period. In-network and out-of-network combined. Aetna Vision SM Discount Program Included Not Covered Primary Physician Office Visit $30 copay after deductible 50% after deductible Specialist Office Visit $50 copay after deductible 50% after deductible Outpatient Services Lab $50 copay after deductible 50% after deductible Outpatient Services X-Ray $50 copay after deductible 50% after deductible Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services (20 visits per plan year. In-network and out-of-network combined.) Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per plan year. In-network and out-of-network combined.) Outpatient Speech Therapy (30 visits per plan year. In-network and out-of-network combined.) Durable Medical Equipment ($2,500 Plan Year Maximum. In-network and out-of-network combined.) $200 copay after deductible 50% after deductible $50 copay after deductible 50% after deductible $50 copay after deductible 50% after deductible $50 copay after deductible 50% after deductible 50% after deductible 50% after deductible Inpatient Hospital $150 copay per day, 5 day copay maximum per admission, after deductible 50% after deductible Outpatient Surgery $150 copay after deductible 50% after deductible Emergency Room (Copay waived if admitted.) $200 copay after deductible $200 copay after deductible Urgent Care $75 copay after deductible 50% after deductible Mental Health Inpatient (Serious: Unlimited days per plan year. In-network and out-ofnetwork combined. Non-Serious: Limited to 30 days per plan year. In-network and out-of-network combined.) Substance Abuse Inpatient Prescription Drugs $150 copay per day, 5 day copay maximum per admission, after deductible $150 copay per day, 5 day copay maximum per admission, after deductible 50% after deductible 50% after deductible Prescription Drug Deductible N/A N/A Prescription Drugs: 30-day supply $15/$40/$70 Not Covered Prescription Drugs: day supply $30/$80/$140 Not Covered Contraceptives and Diabetic Supplies Included Not Covered 90-Day Transition of Coverage Included Not Covered (TOC) for Prior Authorization and Step-Therapy 4 Aetna Specialty CareRx SM Drugs 90% Not Covered See page 17 for important plan provisions. 12

15 C O N S U M E R - D I R E C T E D P O S H S A C O M PAT I B L E N O - R E F E R R A L P L A N O P T I O N S Plan Options DE POS HSA COMPATIBLE NO-REFERRAL 1.2 DE POS HSA COMPATIBLE NO-REFERRAL 2.2 ($1,500 Ded) +5 ($2,500 Ded) +5 Member Benefits In-Network Out-of-Network 1 In-Network Out-of-Network 1 No Referral Needed No Referral Needed No Referral Needed No Referral Needed Plan Coinsurance N/A 50% after deductible N/A 50% after deductible Plan Year Deductible 2 (All covered prescription drug and medical expenses, except preventive services, apply to the deductible.) Plan Year Out-of-Pocket Maximum 3 (All amounts paid as deductible, copayment and coinsurance for covered services and supplies apply toward the Out-of-Pocket Maximum.) $1,500 Individual $3,000 Family $3,000 Individual $6,000 Family $5,000 Individual $10,000 Family $10,000 Individual $20,000 Family $2,500 Individual $5,000 Family $5,000 Individual $10,000 Family Lifetime Maximum Benefit Unlimited Unlimited Wellness On Us SM Well-Baby/Child and Adult Physical Exams (Age and frequency schedules apply. In-network and out-ofnetwork combined.) Routine GYN Exams (Limited to one exam and Pap smear per 365 days. In-network and out-of-network combined.) Routine Mammograms (One baseline mammogram for females age 35-39; and one mammogram per plan year for females age 40 and over. Innetwork and out-of-network combined.) Routine Eye Exam (One exam per 24 months. In-network and out-of-network combined.) Glasses and Contact Lens Reimbursement $5,000 Individual $10,000 Family $10,000 Individual $20,000 Family $0 copay, deductible waived 100%, deductible waived $0 copay, deductible waived 100%, deductible waived $0 copay, deductible waived 100%, deductible waived $0 copay, deductible waived 100%, deductible waived $0 copay. deductible waived 100%, deductible waived $0 copay. deductible waived 100%, deductible waived $0 copay, deductible waived 100%, deductible waived $0 copay, deductible waived 100%, deductible waived $100/24 month period. In-network and out-of-network combined. $100/24 month period. In-network and out-of-network combined. Aetna Vision SM Discount Program Included Not Covered Included Not Covered Primary Physician Office Visit $30 copay after deductible 50% after deductible $30 copay after deductible 50% after deductible Specialist Office Visit $50 copay after deductible 50% after deductible $50 copay after deductible 50% after deductible Outpatient Services Lab $50 copay after deductible 50% after deductible $50 copay after deductible 50% after deductible Outpatient Services X-Ray $50 copay after deductible 50% after deductible $50 copay after deductible 50% after deductible Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services (20 visits per plan year. In-network and out-of-network combined.) Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per plan year. In-network and out-of-network combined.) Outpatient Speech Therapy (30 visits per plan year. In-network and out-of-network combined.) Durable Medical Equipment ($2,500 Plan Year Maximum. In-network and out-of-network combined.) Inpatient Hospital $300 copay per day, 5 day copay maximum per admission, after deductible $200 copay after deductible 50% after deductible $200 copay after deductible 50% after deductible $50 copay after deductible 50% after deductible $50 copay after deductible 50% after deductible $50 copay after deductible 50% after deductible $50 copay after deductible 50% after deductible $50 copay after deductible 50% after deductible $50 copay after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible $500 copay per day, 5 day copay maximum per admission, after deductible 50% after deductible Outpatient Surgery $300 copay after deductible 50% after deductible $500 copay after deductible 50% after deductible Emergency Room (Copay waived if admitted.) $200 copay after deductible $200 copay after deductible $200 copay after deductible $200 copay after deductible Urgent Care $75 copay after deductible 50% after deductible $75 copay after deductible 50% after deductible Mental Health Inpatient (Serious: Unlimited days per plan year. In-network and out-ofnetwork combined. Non-Serious: Limited to 30 days per plan year. In-network and out-of-network combined.) $300 copay per day, 5 day copay maximum per admission, after deductible Substance Abuse Inpatient $300 copay per day, 5 day copay maximum per admission, after deductible Prescription Drugs Prescription Drug Deductible Integrated with Medical Deductible 50% after deductible $500 copay per day, 5 day copay maximum per admission, after deductible 50% after deductible $500 copay per day, 5 day copay maximum per admission, after deductible N/A Integrated with Medical Deductible 50% after deductible 50% after deductible Prescription Drugs: 30-day supply $15/$45/$75 after deductible Not Covered $15/$45/$75 after deductible Not Covered Prescription Drugs: day supply $30/$90/$150 after deductible Not Covered $30/$90/$150 after deductible N/A Not Covered Contraceptives and Diabetic Supplies Included Not Covered Included Not Covered 90-Day Transition of Coverage Included Not Covered Included Not Covered (TOC) for Prior Authorization 4 Aetna Specialty CareRx SM Drugs 90% after deductible Not Covered 90% after deductible Not Covered M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G See page 17 for important plan provisions. 13

16 D E L AWA R E p l a n G U I D E C O N S U M E R - D I R E C T E D P P O H S A C O M PAT I B L E P L A N O P T I O N Plan Options DE PPO HSA COMPATIBLE 1.2 ($2,500 Ded) + Member Benefits In-Network Out-of-Network 1 No Referral Needed No Referral Needed Plan Coinsurance 80% after deductible 60% after deductible Plan Year Deductible 2 (All covered prescription drug and medical expenses, except preventive services, apply to the deductible.) Plan Year Out-of-Pocket Maximum 3 (All amounts paid as deductible, copayment and coinsurance for covered services and supplies apply toward the Out-of-Pocket Maximum.) Lifetime Maximum Benefit Wellness On Us SM $2,500 Individual $5,000 Family $5,000 Individual $10,000 Family Unlimited $5,000 Individual $10,000 Family $10,000 Individual $20,000 Family Well-Baby/Child and Adult Physical Exams (Age and frequency schedules apply. In-network and out-ofnetwork combined.) Routine GYN Exams (Limited to one exam and Pap smear per plan year. In-network and out-of-network combined.) Routine Mammograms (One baseline mammogram for females age 35-39; and one mammogram per plan year for females age 40 and over. Innetwork and out-of-network combined.) Routine Eye Exam (One exam per 24 months. In-network and out-of-network combined.) 100%, deductible waived 60%, deductible waived 100%, deductible waived 60%, deductible waived 100%, deductible waived 60%, deductible waived 100%, deductible waived 60%, deductible waived Glasses and Contact Lens Reimbursement $100/24 month period. In-network and out-of-network combined. Aetna Vision SM Discounts Program Included Not Covered Primary Physician Office Visit 80% after deductible 60% after deductible Specialist Office Visit 80% after deductible 60% after deductible Outpatient Services Lab 80% after deductible 60% after deductible Outpatient Services X-Ray 80% after deductible 60% after deductible Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services (20 visits per plan year. In-network and out-of-network combined.) Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per plan year. In-network and out-of-network combined.) Outpatient Speech Therapy (30 visits per plan year. In-network and out-of-network combined.) Durable Medical Equipment ($2,500 Plan Year Maximum. In-network and out-of-network combined.) 80% after deductible 60% after deductible 80% after deductible 60% after deductible 80% after deductible 60% after deductible 80% after deductible 60% after deductible 50% after deductible 50% after deductible Inpatient Hospital 80% after deductible 60% after deductible Outpatient Surgery 80% after deductible 60% after deductible Emergency Room 80% after deductible 80% after deductible Urgent Care 80% after deductible 60% after deductible Mental Health Inpatient (Serious: Unlimited days per plan year. In-network and out-ofnetwork combined. Non-Serious: Limited to 30 days per plan year. In-network and out-of-network combined.) 80% after deductible 60% after deductible Substance Abuse Inpatient 80% after deductible 60% after deductible Prescription Drugs Prescription Drug Deductible Integrated with Medical Deductible Prescription Drugs: 30-day supply $15/$45/$75 after deductible 80% after $15/$45/$75 and deductible Prescription Drugs: day supply $30/$90/$150 after deductible Not Covered Contraceptives and Diabetic Supplies Included Included 90-Day Transition of Coverage Included Included (TOC) for Prior Authorization 4 Aetna Specialty CareRx SM Drugs 90% after deductible Not Covered See page 17 for important plan provisions. 14

17 T R A D I T I O N A L - M A N D AT E D P L A N S H M O P L A N O P T I O N S Plan Options DE BASIC HMO 1.2 PLAN + DE STANDARD HMO 1.2 PLAN + Member Benefits See page 17 for important plan provisions. In-Network PCP Coordinated Plan Coinsurance N/A N/A Calendar Year Deductible N/A N/A Calendar Year Out-of-Pocket Maximum 200% of annual premium per calendar year In-Network PCP Coordinated Lifetime Maximum Benefit Unlimited Unlimited Wellness On Us SM Well-Baby/Child and Adult Physical Exams (Age and frequency schedules apply.) Routine GYN Exams (Limited to one annual exam and Pap smear.) Routine Mammograms (One baseline mammogram for females age 35-39; and one annual mammogram for females age 40 and over.) $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay Routine Eye Exam Not Covered Not Covered Glasses and Contact Lens Reimbursement Not Covered Not Covered Primary Physician Office Visit Specialist Office Visit Non-Surgical: $10 Copay Surgical: $50 Copay Non-Surgical: $20 Copay Surgical: $50 Copay Outpatient Services Lab $0 copay $0 copay Outpatient Services X-Ray $0 copay $0 copay Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) $0 copay $0 copay Chiropractic Services $20 copay $10 copay Outpatient Physical Therapy $20 copay $10 copay Outpatient Occupational Therapy $20 copay $10 copay Outpatient Speech Therapy $20 copay $10 copay 200% of annual premium per calendar year Non-Surgical: $10 Copay Surgical: $25 Copay Non-Surgical: $10 Copay Surgical: $25 Copay Durable Medical Equipment Not Covered Not Covered Inpatient Hospital $250 per day for each day of confinement for days 1-5 per calendar year; thereafter coverage is provided at 100% Outpatient Surgery $100 copay $50 copay Emergency Room (Copay waived if admitted.) $100 copay $50 copay Urgent Care $100 copay $50 copay Mental Health Inpatient Substance Abuse Inpatient $250 per day for each day of confinement for days 1-3 per calendar year; thereafter coverage is provided at 100% $250 per day for each day of confinement for days 1-5 per calendar year; thereafter coverage is provided at 100% $100 per day for each day of confinement for days 1-5 per calendar year; thereafter coverage is provided at 100% $100 per day for each day of confinement for days 1-10 per calendar year; thereafter coverage is provided at 100% Not Covered Prescription Drugs Prescription Drug Deductible N/A N/A Prescription Drug Out-of-Pocket Maximum N/A $500 per member per calendar year Prescription Drugs: Up to 90-day supply Not Covered Greater of $5 or 25% of the Negotiated Charge per prescription for generic and brand-name drugs Contraceptives and Diabetic Supplies Not Covered Included Self-Injectables: Up to 30-day supply Not Covered Greater of $5 or 25% of the Negotiated Charge per prescription M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 15

18 D E L AWA R E p l a n G U I D E T R A D I T I O N A L - M A N D AT E D P L A N S I N D E M N I T Y P L A N O P T I O N S Plan Options DE BASIC INDEMNITY 1.2 PLAN + DE STANDARD INDEMNITY 1.2 PLAN + Member Benefits Plan Coinsurance 70% after deductible 80% after deductible Calendar Year Deductible 2 $250 per member $500 family (2 person max) $150 per member $300 family (2 person max) Calendar Year Out-of-Pocket Maximum 3 (Deductible applies to the Out-of-Pocket Maximum.) $3,250 per member $6,500 family (2 person max) Lifetime Maximum Benefit Unlimited Unlimited Wellness On Us SM $2,650 per member $5,300 family (2 person max) Well-Baby/Child and Adult Physical Exams (Age and frequency schedules apply.) Routine GYN Exams (Limited to one annual exam and Pap smear.) Routine Mammograms (One baseline mammogram for females age 35-39; and one annual mammogram for females age 40 and over.) 100%, deductible waived 100%, deductible waived 100%, deductible waived 100%, deductible waived 100%, deductible waived 100%, deductible waived Routine Eye Exam Not Covered Not Covered Glasses and Contact Lens Reimbursement Not Covered Not Covered Primary Physician Office Visit 100% up to $150 per member per calendar year, then 70%, deductible waived Specialist Office Visit 100% up to $150 per member per calendar year, then 70%, deductible waived Outpatient Services Lab 70% after deductible 80% after deductible Outpatient Services X-Ray 70% after deductible 80% after deductible Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) 70% after deductible 80% after deductible Chiropractic Services 70% after deductible 80% after deductible Outpatient Physical Therapy (Limited to 20 visits per calendar year.) 70% after deductible 80% after deductible Outpatient Occupational Therapy 70% after deductible 80% after deductible Outpatient Speech Therapy 70% after deductible 80% after deductible Durable Medical Equipment Not Covered Not Covered Inpatient Hospital (Limited to 30 days per calendar year.) Facility Expenses: 70%, deductible waived 100% up to $150 per member per calendar year, then 80%, deductible waived 100% up to $150 per member per calendar year, then 80%, deductible waived Facility Expenses: 80%, deductible waived Outpatient Surgery Medical/Surgical Care: 100% after deductible Facility: 100% after deductible Medical/Surgical Care: 100% after deductible Facility: 100% after deductible Emergency Room (Copay waived if admitted.) Physician: 100% up to $150 per member per calendar year, then 70%, deductible waived Facility: 70% after $50 copay, deductible waived Physician: 100% up to $150 per member per calendar year, then 70%, deductible waived Physician: 100% up to $150 per member per calendar year, then 80%, deductible waived Facility: 80% after $50 copay, deductible waived Physician: 100% up to $150 per member per calendar year, then 80%, deductible waived Urgent Care Refer to Emergency Room Cost-Sharing Refer to Emergency Room Cost-Sharing Mental Health Inpatient 70% after deductible 80% after deductible Substance Abuse Inpatient Not Covered 80% after deductible Prescription Drugs Prescription Drug Deductible N/A N/A Prescription Drug Out-of-Pocket Maximum N/A $500 per member per calendar year Prescription Drugs: Up to 90-day supply Not Covered In-Network: Greater of $5 or 25% of the Negotiated Charge per prescription for generic and brand-name drugs Contraceptives and Diabetic Supplies Not Covered Included Out-of-Network: Greater of $5 or 25% of the Recognized Charge per prescription for generic and brand-name drugs Self-Injectables: Up to 30-day supply Not Covered In-Network: Greater of $5 or 25% of the Negotiated Charge per prescription Out-of-Network: Not Covered See page 17 for important plan provisions. 16

19 IMPORTANT PLAN PROVISIONS All Plan Options The federal health care reform legislation known as the Patient Protection and Affordable Care Act was signed into law on March 23, A number of new reforms are effective September 23, 2010, including coverage for dependents up to age 26, elimination of lifetime benefit dollar maximums, restriction of annual dollar maximums on essential health benefits, removal of cost sharing for preventive services and elimination of pre-existing condition exclusions for dependent children under 19 years of age. Your Aetna Avenue benefit program does comply with the new reform legislation. + This is a partial description of benefits available; for more information, refer to the specific plan design summary. The dollar amount copayments indicate what the member is required to pay and the percentage amounts indicate what Aetna is required to pay. 1 You may choose providers in our network (physicians and facilities) or may visit an out-of-network provider. Typically, you will pay substantially more money out of your own pocket if you choose to use an out-of-network doctor. The out-of-network provider will be paid based on Aetna s recognized charge. This is not the same as the billed charge from the doctor. Aetna pays a percentage of the recognized charge, as defined in Your plan. The recognized charge for out-of-network hospitals, doctors and other out-of-network health care providers is a percentage (100 percent or above) of the rate that Medicare pays them. You may have to pay the difference between the out-of-network provider s billed charge and Aetna s recognized charge, plus any coinsurance and deductibles due under the plan. Note that any amount the doctor or hospital bills you above Aetna s recognized charge does not count toward your deductible or out-of-pocket maximums. This benefit applies when you choose to get care out of network. When you have no choice in the doctors you see (for example, an emergency room visit after a car accident), your deductible and coinsurance for the in-network level of benefits will be applied, and you should contact Aetna if your doctor asks you to pay more. 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 pages Please refer to Aetna s Producer World website at for more detailed small business benefits descriptions. Or, for more information, please contact your licensed agent or Aetna Sales Representative. Traditional POS No-Referral and POS Cost-Sharing No-Referral Plan Options (Pages 9-11) 2 Once the family deductible is met, all family members will be considered as having met their deductible for the remainder of the plan year. No one family member may contribute more than the individual deductible amount to the family deductible. 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. 4 Transition of Coverage for Prior Authorizations and Step-Therapy 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 and step-therapy requirements will not apply to certain drugs. Once the 90 calendar days have expired, prior authorization and step-therapy edits will apply to all drugs requiring prior authorization and step-therapy as listed in the formulary guide. Members, who have claims paid for a drug requiring prior authorization and step-therapy 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 or approval for a medical exception for this drug. 5 No Referral Provision: A member will pay the Primary Physician Office Visit cost-share when the member obtains covered benefits from any participating primary care physician. Members will pay the Specialist Office Visit cost-share when the member obtains covered benefits from any participating specialist. Consumer-Directed POS Consumer-Directed No-Referral Plan Option (Page 12) 2 The Individual Deductible can only be met when a member is enrolled for self-only coverage with no dependent coverage. The Family Deductible can be met by a combination of family members or by any single individual within the family. Once the Family Deductible is met, all family members will be considered as having met their Deductible for the remainder of the plan year. 3 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 and Step-Therapy 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 and step-therapy requirements will not apply to certain drugs. Once the 90 calendar days have expired, prior authorization and step-therapy edits will apply to all drugs requiring prior authorization and step-therapy as listed in the formulary guide. Members, who have claims paid for a drug requiring prior authorization and step-therapy 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 or approval for a medical exception for this drug. 5 No Referral Provision: A member will pay the Primary Physician Office Visit cost-share when the member obtains covered benefits from any participating primary care physician. Members will pay the Specialist Office Visit cost-share when the member obtains covered benefits from any participating specialist. Consumer-Directed POS HSA Compatible No-Referral Plan Options (Page 13) 2 The Individual Deductible can only be met when a member is enrolled for self-only coverage with no dependent coverage. The Family Deductible can be met by a combination of family members or by any single individual within the family. Once the Family Deductible is met, all family members will be considered as having met their Deductible for the remainder of the plan year. 3 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 No Referral Provision: A member will pay the Primary Physician Office Visit cost-share when the member obtains covered benefits from any participating primary care physician. Members will pay the Specialist Office Visit cost-share when the member obtains covered benefits from any participating specialist. Consumer-Directed PPO HSA Compatible Plan Option (Page 14) 2 The Individual Deductible can only be met when a member is enrolled for self-only coverage with no dependent coverage. The Family Deductible can be met by a combination of family members or by any single individual within the family. Once the Family Deductible is met, all family members will be considered as having met their Deductible for the remainder of the plan year. 3 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. Traditional Mandated Plans Indemnity Plan Options (Page 15) 2 Once 2 individual members of a family each satisfy their Deductible amount separately, all family members will be considered as having met their Deductible for the remainder of the calendar year. 3 Once 2 individual members of a family each satisfy their Out-of-Pocket Maximum separately, all family members will be considered as having met their Out-of-Pocket Maximum for the remainder of the calendar year. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 17