Pln Effective Dte: 08/01/2012 PLAN FEATURES Network Primry Cre Physicin Selection Deductible (per clendr yer) Mnged Choice POS Not Applicble (Open Access) Not Applicble Not Applicble $3,000 Individul $6,000 Fmily Unless otherwise indicted, the Deductible must be met prior to benefits being pyble. All covered expenses ccumulte towrd both the Network nd Out-of-Network Deductible. Once the Fmily Deductible is met, ll fmily members will be considered s hving met their Deductible for the reminder of the clendr yer. No one fmily member my contribute more thn the Individul Deductible mount to the Fmily Deductible. Member Coinsurnce (pplies to ll expenses unless otherwise stted) 30% 50% Coinsurnce Mximum (per clendr yer, excludes deductible) $1,500 Individul $3,000 Fmily $3,000 Individul $6,000 Fmily All covered expenses ccumulte seprtely towrd the Network nd Out-of-Network Coinsurnce Mximum. Certin member cost shring elements my not pply towrd the Coinsurnce Mximum. Amounts over llowble, copys, DME, filure to pre-certify penlty, infertility, non-smi-sed mentl disorders, Rx (including self-injectbles) nd substnce buse do not pply towrd the Coinsurnce Mximum nd continue to be pyble fter the mximum is reched. Once the Fmily Coinsurnce Mximum is met, ll fmily members will be considered s hving met their Coinsurnce Mximum for the reminder of the clendr yer. No one fmily member my contribute more thn the Individul Coinsurnce Mximum mount to the Fmily Coinsurnce Mximum. Helth Incentive Credit Progrm/Simple Steps Helth Assessment nd one Online Wellness Progrm Rewrd of $50.00 per employee nd/or spouse with fmily limit of $100.00 per yer for completion of the Helth Assessment nd one Online Wellness Progrm. Incentive Rewrds will be credited towrds the deductible nd coinsurnce mximum. Lifetime Mximum Pyment for Out-of-Network Cre* Certifiction Requirements Not Applicble Unlimited Professionl: 100% of Medicre Fcility: 100% of Medicre Certifiction for certin types of Out-of-Network cre must be obtined to void reduction in benefits pid for tht cre. Certifiction for Hospitl Admissions, Tretment Fcility Admissions, Convlescent Fcility Admissions, Home Helth Cre, nd Hospice Cre is required. Benefits will be reduced by $400 per occurrence if Certifiction is not obtined. Referrl Requirement PHYSICIAN SERVICES Office Visits to Non-Specilist None None $30 copy; deductible wived Includes services of n internist, generl physicin, fmily prctitioner or peditricin for routine cre s well s dignosis nd tretment of n illness or injury nd in-office surgery. 14.06.579.1-CA Aetn Life Insurnce Compny Pge 1
Specilist Office Visits Pln Effective Dte: 08/01/2012 $30 copy; deductible wived The first four office visits per member per clendr yer for non-specilist, specilist nd wlk-in clinics combined re subject to copy, deductible wived. Any visits over this limit re covered t pln deductible nd coinsurnce. E-Visits - Primry Cre & Specilist Physicins An E-visit is n online internet consulttion between physicin nd n estblished ptient bout non-emergency helthcre mtter. This visit must be conducted through n Aetn uthorized internet E-visit service vendor. Register t www.relyhelth.com. Wlk-in Clinics $30 copy; deductible wived Wlk-in Clinics re network, free-stnding helth cre fcilities. They re n lterntive to physicin's office visit for tretment of unscheduled, non-emergency illnesses nd injuries nd the dministrtion of certin immuniztions. It is not n lterntive for emergency room services or the ongoing cre provided by physicin. Neither n emergency room, nor n outptient deprtment of hospitl, shll be considered Wlk-in Clinic. Pre-Ntl Mternity Mternity - Delivery Post-Prtum Cre Surgery (in office) nd $10 copy; deductible wived Allergy Testing (given by physicin) Allergy Injections (not given by physicin) PREVENTIVE CARE Routine Adult Physicl Exms nd Immuniztions Limited to 1 exm every 12 months for members ge 18 nd older. Well Child Exms nd Immuniztions Provides coverge for 9 exms from birth up to ge 3; 1 exm per 12 months from ge 3 through ge 17. Routine Gynecologicl Exms Includes Pp smer, HPV screening nd relted lb fees. Frequency schedule pplies. Routine Mmmogrms For covered femles ge 40 nd over. Frequency schedule pplies. Women's Helth Includes: Screening for gesttionl dibetes; HPV (Humn Ppillomvirus) DNA testing, counseling for sexully trnsmitted infections; counseling nd screening for humn immunodeficiency virus; screening nd counseling for interpersonl nd domestic violence; brestfeeding support, supplies nd counseling; nd contrceptive methods nd counseling. Limittions my pply. Member cost shring is bsed on the type of service performed nd the plce of service where it is rendered 14.06.579.1-CA Aetn Life Insurnce Compny Pge 2
Pln Effective Dte: 08/01/2012 Routine Digitl Rectl Exm / Prostte-Specific Antigen Test For covered mles ge 40 nd over. Frequency schedule pplies. Colorectl Cncer Screening Sigmoidoscopy nd Double Contrst Brium Enem - 1 every 5 yers for ll members ge 50 nd over. Preventive Colonoscopy - 1 every 10 yers for ll members ge 50 nd over. Fecl Occult Blood Testing - 1 every yer for ll members ge 50 nd over. Colonoscopy (non-preventive) Routine Eye nd Hering Screenings See Outptient Surgery Benefit Pid s prt of routine physicl exm. See Outptient Surgery Benefit Pid s prt of routine physicl exm. Routine Eye Exms (Refrction) Limited to 1 exm every 24 months. DIAGNOSTIC PROCEDURES Outptient Dignostic Lbortory nd X-ry (except for Complex Imging Services) $30 copy; deductible wived Outptient Dignostic X-ry for Complex Imging Services Including, but not limited to, MRI, MRA, PET nd CT Scns. Precertifiction required. EMERGENCY MEDICAL CARE Urgent Cre Provider (Benefit Avilbility my vry by loction.) Non-Urgent Use of Urgent Cre Provider Emergency Room Non-Emergency cre in n Emergency Room Emergency Ambulnce HOSPITAL CARE Inptient Coverge Including mternity (prentl, delivery nd postprtum) & trnsplnts Outptient Surgery Provided in n outptient hospitl deprtment Outptient Surgery Provided in freestnding surgicl fcility Outptient Hospitl Services other thn Surgery Including, but not limited to, physicl therpy, speech therpy, occuptionl therpy, spinl mnipultion, dilysis, rdition therpy.. Mximum pyment of $800 per service. Pid s Network Cre Pid s Network Cre. Mximum pyment of $750 per dy.. Mximum pyment of $400 per surgery.. Mximum pyment of $400 per surgery.. Mximum pyment of $300 per visit. 14.06.579.1-CA Aetn Life Insurnce Compny Pge 3
Pln Effective Dte: 08/01/2012 MENTAL HEALTH SERVICES Inptient Serious Mentl Illness or Serious Emotionl Disturbnces of Child Outptient Serious Mentl Illness or Serious See office visit benefit Emotionl Disturbnces of Child Inptient Other thn Serious Mentl Illness or Serious Emotionl Disturbnces of Child Outptient Other thn Serious Mentl Illness See office visit benefit or Serious Emotionl Disturbnces of Child Limited to 20 visits per member per clendr yer. Network nd Out-of-Network combined. ALCOHOL / DRUG ABUSE SERVICES Inptient Detoxifiction Limited to 3 dys per dmission, 2 dmissions per clendr yer. Network nd Out-of- Network combined. Outptient Detoxifiction Inptient nd Outptient Rehbilittion OTHER SERVICES AND PLAN DETAILS Autism Tretment Member cost shring is bsed on the type of service performed nd the plce rendered Skilled Nursing Fcility Limited to 60 dys per member per clendr yer. Network nd Out-of-Network combined. Home Helth Cre Limited to 90 visits per member per clendr yer. Network nd Out-of-Network combined; 1 visit equls period of 4 hours or less. Infusion Therpy Provided in the home or physicin's office Infusion Therpy Provided in n outptient hospitl deprtment or freestnding fcility Inptient Hospice Cre. Mximum pyment of $175 per dy. Member cost shring is bsed on the type of service performed nd the plce rendered. Mximum benefit of $100 per visit.. Mximum pyment of $750 per dy.. Mximum benefit of $100 per visit.. Mximum benefit of $200 per dy.... Mximum benefit of $300 per dy. 14.06.579.1-CA Aetn Life Insurnce Compny Pge 4
Pln Effective Dte: 08/01/2012 Outptient Hospice Cre Privte Duty Nursing - Outptient Outptient Short-Term Rehbilittion Includes physicl, occuptionl nd chiroprctic therpy (if provided in the outptient hospitl deprtment, pid under outptient hospitl benefit). Limited to 24 visits per member per clendr yer. Network nd Out-of-Network combined. PT/OT limits do not pply to utism.. Mximum benefit of $50 per visit. Outptient Speech Therpy (if provided in the outptient hospitl deprtment, pid under outptient hospitl benefit) Limited to 20 visits per member per clendr yer. Network nd Out-of-Network combined. Limits do not pply to utism. Acupuncture Limited to 12 visits per member per clendr yer. Durble Medicl Equipment Mximum benefit of $2,000 per member per clendr yer. Limit does not pply to prosthetics or orthotics. Network nd Out-of- Network combined. Dibetic Supplies not obtinble t phrmcy FAMILY PLANNING Infertility Tretment Covered only for the dignosis nd tretment of the underlying medicl condition Voluntry Steriliztion - Vsectomy Voluntry Steriliztion - Tubl Ligtion. $30 copy; deductible wived. Covered sme s ny other medicl expense Member cost shring is bsed on the type of service performed nd the plce rendered Member cost shring is bsed on the type of service performed nd the plce rendered No chrge Covered sme s ny other medicl expense Member cost shring is bsed on the type of service performed nd the plce rendered Member cost shring is bsed on the type of service performed nd the plce rendered 50%; deductible wived PHARMACY - PRESCRIPTION DRUG BENEFITS Prescription drug clendr yer deductible (must be stisfied before ny prescription drug benefits re pid) Retil Up to 30-dy supply PARTICIPATING PHARMACIES Integrted with Medicl Deductible $20 copy for generic drugs, $40 copy for brnd nme formulry drugs, nd $70 copy for brnd nme nonformulry drugs NON-PARTICIPATING PHARMACIES Not Applicble 14.06.579.1-CA Aetn Life Insurnce Compny Pge 5
Mil Order Delivery Up to 90-dy supply Specilty Cre Rx SM Includes self-injectble, infused nd orl specilty drugs (retil nd mil order up to 30-dy supply, excludes insulin, does not ccumulte towrds the coinsurnce mximum). Pln Effective Dte: 08/01/2012 $40 copy for generic drugs, $80 copy for brnd nme formulry drugs, nd $140 copy for brnd nme nonformulry drugs 30% up to $250 per prescription for formulry nd non-formulry drugs Formulry generic FDA-pproved Women s Contrceptives covered 100% in network. Specilty CreRx SM - First Prescription for self-injectble drug must be filled t prticipting retil phrmcy or Aetn Specilty Phrmcy. Subsequent fills must be through Aetn Specilty Phrmcy. Mndtory Generic with DAW override (MG w/daw Override) - The member pys the pplicble copy only, if the physicin requires brnd. If the member requests brnd when generic is vilble, the member pys the pplicble copy plus the difference between the generic price nd the brnd price. Pln includes: Contrceptive drugs nd devices obtinble from phrmcy nd dibetic supplies obtinble from phrmcy. Lifestyle/performnce drugs limited to 4 pills per month. Precertifiction included nd 90-dy Trnsition of Cre (TOC) for Precertifiction included. *We cover the cost of services bsed on whether doctors re "in-network" or "out-of-network". We wnt to help you understnd how much Aetn pys for your out-of-network cre. At the sme time, we wnt to mke it cler how much more you will need to py for this "out-of-network" cre. You my choose provider (doctor or hospitl) in our network. You my choose to visit n out-of-network provider. If you choose doctor who is out-of-network, your Aetn helth pln my py some of tht doctor's bill. Most of the time, you will py lot more money out of your own pocket if you choose to use n out-of-network doctor or hospitl. When you choose out-of-network cre, Aetn limits the mount it will py. This limit is clled the "recognized" or "llowed" mount. When you choose out-of-network cre, Aetn "recognizes" n mount bsed on wht Medicre pys for these services. The government sets the Medicre rte. Your doctor sets his or her own rte to chrge you. It my be higher - sometimes much higher - thn wht your Aetn pln "recognizes". Your doctor my bill you for the dollr mount tht Aetn doesn't "recognize". You must lso py ny copyments, coinsurnce nd deductibles under your pln. No dollr mount bove the "recognized chrge" counts towrd your deductible or out-of-pocket mximums. To lern more bout how we py out-of-network benefits visit Aetn.com. Type "how Aetn pys" in the serch box. You cn void these extr costs by getting your cre from Aetn's brod network of helth cre providers. Go to www.etn.com nd click on "Find Doctor" on the left side of the pge. If you re lredy member, sign on to your Aetn Nvigtor member site. This pplies when you choose to get cre out-of-network. When you hve no choice (for exmple: emergency room visit fter cr ccident, or for other emergency services), we will py the bill s if you got cre in-network. You py cost shring nd deductibles for your in-network level of benefits. Contct Aetn if your provider sks you to py more. You re not responsible for ny outstnding blnce billed by your providers for emergency services beyond your cost shring nd deductibles. 14.06.579.1-CA Aetn Life Insurnce Compny Pge 6
Pln Effective Dte: 08/01/2012 Wht's This pln does not cover ll helth cre expenses nd includes exclusions nd limittions. Members should refer to their pln documents to determine which helth cre services re covered nd to wht extent. The following is prtil list of services nd supplies tht re generlly not covered. However, your pln documents my contin exceptions to this list bsed on stte mndtes or the pln design purchsed. All medicl or hospitl services not specificlly covered in, or which re limited or excluded in the pln documents; Chrges relted to ny eye surgery minly to correct refrctive errors; Cosmetic surgery, including brest reduction; Custodil cre; Dentl cre nd x-rys; Donor egg retrievl; Experimentl nd investigtionl procedures; Hering ids; Immuniztions for trvel or work; Infertility services, including, but not limited to, rtificil insemintion nd dvnced reproductive technologies such s IVF, ZIFT, GIFT, ICSI nd other relted services, unless specificlly listed s covered in your pln documents; Non-mediclly necessry services or supplies; Orthotics except s specified in the pln; Over-the-counter medictions nd supplies; Reversl of steriliztion; Services for the tretment of sexul dysfunction or indequcies, including therpy, supplies, counseling nd prescription Specil duty nursing; nd Tretment of those services for or relted to tretment of obesity or for diet or weight control. Pre-existing Conditions Exclusion Provision This pln imposes pre-existing conditions exclusion, which my be wived in some circumstnces (tht is, creditble coverge) nd my not be pplicble to you. A pre-existing conditions exclusion mens tht if you hve medicl condition before coming to our pln, you might hve to wit certin period of time before the pln will provide coverge for tht condition. This exclusion pplies only to conditions for which medicl dvice, dignosis or tretment ws recommended or received or for which the individul took prescribed drugs within 6 months. Generlly, this period ends the dy before your coverge becomes effective. However, if you were in witing period for coverge, the 6 month period ends on the dy before the witing period begins. The exclusion period, if pplicble, my lst up to 6 months from your first dy of coverge, or, if you were in witing period, from the first dy of your witing period. If you hd less thn 6 months of group or three months of individul (including Medicre, Medicid nd Medi-Cl) of creditble coverge immeditely before the dte you enrolled, your pln's pre-existing conditions exclusion period will be reduced by the mount (tht is, number of dys) of tht prior coverge. If you hd no prior creditble coverge within the 6 months for group or 3 months for individul prior to your enrollment dte (either becuse you hd no prior coverge or becuse there ws more thn 6 months of group or 3 months of individul gp from the dte your prior coverge terminted to your enrollment dte), we will pply your pln's pre-existing conditions exclusion. 14.06.579.1-CA Aetn Life Insurnce Compny Pge 7
Pln Effective Dte: 08/01/2012 In order to reduce or possibly eliminte your exclusion period bsed on your creditble coverge, you should provide us copy of ny Certifictes of Creditble Coverge you hve. Plese contct your Aetn Member Services representtive t 1-888-802-3862 for MC plns if you need ssistnce in obtining Certificte of Creditble Coverge from your prior crrier or if you hve ny questions on the informtion noted bove. The pre-existing condition exclusion does not pply to pregnncy or to child under the ge of 19. Note: For lte enrollees, coverge will be delyed until the pln's next open enrollment; the pre-existing exclusion will be pplied from the individul's effective dte of coverge. This mteril is for informtionl purposes only nd is neither n offer of coverge nor medicl dvice. It contins only prtil, generl description of pln benefits or progrms nd does not constitute contrct. Aetn does not provide helth cre services nd, therefore, cnnot gurntee results or outcomes. Consult the pln documents (i.e. Group Insurnce Certificte nd/or Group Policy) to determine governing contrctul provisions, including procedures, exclusions nd limittion relting to the pln. With the exception of Aetn Rx Home Delivery, ll preferred providers nd vendors re independent contrctors in privte prctice nd re neither employees nor gents of Aetn or its ffilites. Aetn Rx Home Delivery, LLC, is subsidiry of Aetn Inc. The vilbility of ny prticulr provider cnnot be gurnteed, nd provider network composition is subject to chnge without notice. Certin services require precertifiction, or prior pprovl of coverge. Filure to precertify for these services my led to substntilly reduced benefits or denil of coverge. Some of the benefits requiring precertifiction my include, but re not limited to, inptient hospitl, inptient mentl helth, inptient skilled nursing, outptient surgery, substnce buse (detoxifiction, inptient nd outptient rehbilittion). When the Member s preferred provider is coordinting cre, the preferred provider will obtin the precertifiction. Precertifiction requirements my vry. If your pln covers outptient prescription drugs, your pln my include drug formulry (preferred drug list). A formulry is list of prescription drugs generlly covered under your prescription drug benefits pln on preferred bsis subject to pplicble limittions nd conditions. Your phrmcy benefit is generlly not limited to the drugs listed on the formulry. The medictions listed on the formulry re subject to chnge in ccordnce with pplicble stte lw. For informtion regrding how medictions re reviewed nd selected for the formulry, formulry informtion, nd informtion bout other phrmcy progrms such s precertifiction nd step-therpy, plese refer to Aetn's website t Aetn.com, or the Aetn Mediction Formulry Guide. Aetn receives rebtes from drug mnufcturers tht my be tken into ccount in determining Aetn's Preferred Drug List. Rebtes do not reduce the mount member pys the phrmcy for covered prescriptions. In ddition, in circumstnces where your prescription pln utilizes copyments or coinsurnce clculted on percentge bsis or deductible, use of formulry drugs my not necessrily result in lower costs for the member. Members should consult with their treting physicins regrding questions bout specific medictions. Refer to your pln documents or contct Member Services for informtion regrding the terms nd limittions of coverge. Aetn Rx Home Delivery refers to Aetn Rx Home Delivery, LLC, subsidiry of Aetn, Inc., tht is licensed phrmcy providing mil-order phrmcy services. Aetn's negotited chrge with Aetn Rx Home Delivery my be higher thn Aetn Rx Home Delivery's cost of purchsing drugs nd providing mil-order phrmcy services. While this informtion is believed to be ccurte s of the print dte, it is subject to chnge. In cse of emergency, cll 911 or your locl emergency hotline, or go directly to n emergency cre fcility. Plns re provided by Aetn Life Insurnce Compny. For more informtion bout Aetn plns, refer to www.etn.com. 2012 14.06.579.1-CA Aetn Life Insurnce Compny Pge 8