Aetna Avenue Your Destination for Small Business Solutions GEORGIA PLAN GUIDE Plans effective OCTOBER 1, 2010 For businesses with 2-99 eligible employees 14.02.970.1-GA A (6/10)
G e o r g i a 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 Provider network 5 Medical overview 9 Medical plan options 16 Dental overview 19 Dental plan options 26 Life & disability overview 28 Life plan options 28 Life & disability plan options 30 Underwriting guidelines 34 Product specifications 40 Limitations and exclusions 44 Group enrollment checklist 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 benefits and insurance 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/Dental benefits and health/dental insurance plans are offered, underwritten or administered by Aetna Health Inc., Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna).
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 100% plans Traditional plans HSA-compatible plans Consumer-Directed Health Plans Dental, life and disability plans providing valuable protection DMO PPO PPO Max Freedom-of-Choice plan design 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 Simple Steps To A Healthier Life, an online health and wellness program Temporary ID cards available for members to print as needed 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
G e o r g i a 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 2-99 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 Simply Savings plans (1943, 1944, 1945) 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 HSA-compatible plans (1935, 1936, 1937) Simply Savings (1945) Traditional benefits plans These plans fit Limiting the financial impact on employees You might be a Traditionalist Traditional plans (1902, 1903, 1904, 1905) 100% plans (1912, 1913, 1914) 2
Y o u n g S i n g l e s Consumer-directed health plans HSA-compatible plans Y o u n g Fa m i l i e s Traditional plans 100% plans E s ta b l i s h e d FA M I L I E S Consumer-directed health plans Traditional plans 100% plans E m p t y N e s t e r s Consumer-directed health plans HSA-compatible plans He alth insu r ance 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
G e o r g i a p l a n G U I D E GEORG I A Prov ider Net work* County POS MC Appling Atkinson Bacon Baker Baldwin Banks Barrow Bartow Ben Hill Berrien Bibb Bleckley Brantley Brooks Bryan Bulloch Burke Butts Calhoun Camden Candler Carroll Catoosa Charlton Chatham Chattahoochee Chattooga Cherokee Clarke Clay Clayton Clinch Cobb Coffee Colquitt Columbia Cook Coweta Crawford Crisp Dade Dawson Decatur Dekalb Dodge Dooly Dougherty Douglas Early Echols Edgefield Effingham Elbert Emanuel County POS MC Evans Fannin Fayette Floyd Forsyth Franklin Fulton Gilmer Glascock Glynn Gordon Grady Greene Gwinnett Harbersham Hall Hancock Haralson Harris Hart Heard Henry Houston Irwin Jackson Jasper Jeff Davis Jefferson Jenkins Johnson Jones Lamar Lanier Laurens Lee Liberty Lincoln Long Lowndes Lumpkin Macon Madison Marion McDuffie McIntosh Meriwether Miller Mitchell Monroe Montgomery Morgan Murray Muscogee Newton County POS MC Oconee Oglethorpe Paulding Peach Pickens Pierce Pike Polk Pulaski Putnam Quitman Rabun Randolph Richmond Rockdale Schley Screven Seminole Spalding Stephens Stewart Sumter Talbot Taliaferro Tattnall Taylor Telfair Terrell Thomas Tift Toombs Towns Treutlen Troup Turner Twiggs Union Upson Walker Walton Ware Warren Washington Wayne Webster Wheeler White Whitfield Wilcox Wilkes Wilkinson Worth *Network subject to change. 4
Aetna Avenue Medic al Overv iew Product Name Open Access Point of Service (POS OA) Aetna Open Access Managed Choice (MC OA) Traditional Choice (Indemnity) Product Description PCP Required Aetna Choice POS (CPOS) 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. No No Managed Choice 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. No No Referrals Required This indemnity plan option is available for employees who live outside the plan s network service area. Members coordinate their own health care and may access any recognized provider for covered services without a referral. No No N/A Network Aetna Choice POS (Open Access)/Open Access Aetna Health Network Option Managed Choice POS (Open Access) 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
G e o r g i a p l a n G U I D E What is ValuePick? ValuePick* is the Aetna suite of plans designed specifically for small businesses. ValuePick offers reduced minimum participation and employer contribution requirements. ValuePick offers the following advantages: Lower participation and contribution requirements Value plans have lower participation and contribution requirements, except when offered with a non-value plan.** Greater employee choice Employers can offer up to three of the Value plans. Total freedom Aetna is committed to providing solutions to help meet the needs of small businesses. Employers can now offer quality coverage at affordable prices. Easy administration Setting up this program is simple: 1. The employer chooses up to three of the Value plans to offer on the Employer Application. 2. The employer chooses how much to contribute. 3. Each employee chooses the plan that s right for him or her. Flexibility and affordability By choosing a Value plan, employers are now able to offer benefits to help meet the needs of their employees. Va l u e P i c k Target audience Small businesses Plan choices Up to 3 of the 4 ValuePick plans Minimum participation 4 or more enrolled employees Employer contribution 25% of the employee premium or $50 per employee Employee participation 50% *Available with four or more enrolled employees. ** If an employer chooses a ValuePick plan to offer with a non-value plan, the standard participation and contribution requirements on the non-value plan will apply to both plans offered. 6
He alth Sav i ngs Account ( HSA) No set-up or administrative fees The Aetna HealthFund HSA, when coupled with a HSA-compatible highdeductible 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. Aetna high - deduc t ible pl ans ( HSA- compat ible ) The Aetna insurance options that are compatible with a Health Savings Account (HSA) 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. You own your HSA Contribute tax free H S A Ac c o u n t You choose how and when to use your dollars Roll it over each year and let it grow Earns interest, tax free MEMBER S HSA Pl an 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% 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
G e o r g i a p l a n G U I D E Administrative fees FEE DESCRIPTION FEE HSA Initial Set-Up $0 Monthly Fees $0 POP* Initial Set-Up** $150 Renewal $75 HRA and FSA*** Initial Set-Up* 2-25 Employees $350 26-50 Employees $450 51-99 Employees $550 Renewal Fee 50% of the initial set-up fee Monthly Fees $5.00 per participant Additional Set-Up Fee $150 for stacked plans (those electing an Aetna HRA and FSA simultaneously) Participation Fee for stacked participants Minimum Fees $9.75 per participant 0-25 Employees $10 per month minimum 26-99 Employees $50 per month minimum TRA Annual Fee $350 Transit Monthly Fees $4.25 per participant Parking Monthly Fees $3.15 per participant COBRA 20-50 Employees: 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 out-of-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. COBR A administr at i on 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. Annual Fee $50 Per employee per $0.85 month 51-99 Employees: Annual Fee $415 Per employee per $0.98 month Per employee per month $0.96 (Excludes initial notices for all employees at set-up.) * First year POP fees waived with the purchase of medical with 5-plus enrolled employees. ** Non-discrimination testing provided annually after open enrollment for POP and FSA only. Additional off-cycle testing available at employer request for $75 fee. Non-discrimination testing only available for FSA and POP products. *** Aetna FSA pricing is inclusive for POP. Debit cards are available for FSA only. Contact Aetna for further information. For HRA, if the employer opts out of Streamline, the fee is increased $1.50 per participant. 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 subject to change. Aetna reserves the right to change any of the above fees and to impose additional fees upon prior written notice. 8
T r a d i t i o n a l D e d u c t i b l e & C o i n s u r a n c e P l a n s GEORGIA (2-99 Employees) 1902 1903 1904 1905 Plan or Calendar Year Calendar Calendar Calendar Calendar Deductible Type Embedded Embedded Embedded Embedded Lifetime Maximum Unlimited Unlimited Unlimited Unlimited IN NETWORK SERVICES Coinsurance 80% 80% 80% 70% Annual Deductible: Individual/Family (* indicates deductible applies to OOP) See page 13 for endnotes. $500/$1,500 $1,000/$3,000 $1,500/$4,500 $2,000/$6,000 Annual Out-of-Pocket (OOP): Individual/Family $2,500/$7,500 $3,000/$9,000 $3,000/$9,000 $2,000/$6,000 Wellness On US TM Preventive Care, including Adult Physicals, Well Women Visits, Mammograms, Colorectal Cancer Screening and other preventive care services. Well Child Care (Age/Frequency schedules apply, includes coverage for immunizations) Physician Services $0, ded waived $0, ded waived $0, ded waived $0, ded waived $0, ded waived $0, ded waived $0, ded waived $0, ded waived Primary Care Physician Office visit $25, ded waived $30, ded waived $30, ded waived $40, ded waived Specialist Office Visit $40, ded waived $50, ded waived $50, ded waived $60, ded waived Outpatient Mental Health* $40, ded waived $50, ded waived $50, ded waived $60, ded waived Inpatient Services Hospital Inpatient 80%, ded applies 80%, ded applies 80%, ded applies 70%, ded applies Mental Health Inpatient 80%, ded applies 80%, ded applies 80%, ded applies 70%, ded applies Outpatient/Other Services Diagnostic Lab $25, ded waived $30, ded waived $30, ded waived $40, ded waived Diagnostic X-Ray $60, ded waived $75, ded waived $75, ded waived $100, ded waived Diagnostic Complex Imaging (CAT, MRI, MRA/MRS and PET scans) $300, ded waived 80%, ded waived 80%, ded waived 70%, ded applies Outpatient Surgery 80%, ded applies 80%, ded applies 80%, ded applies 70%, ded applies Emergency Room (Copay waived if admitted) $150, ded waived $150, ded waived $200, ded waived $200, ded waived Urgent Care $75, ded waived $75, ded waived $75, ded waived $75, ded waived Ambulance (emergency transport) 80%, ded applies 80%, ded applies 80%, ded applies 70%, ded applies Outpatient Rehabilitative Therapy (30 visits per year) Durable Medical Equipment ($5000 maximum per year) Chiropractic Services (20 visits per year) PHARMACY Retail Pharmacy Copay Mail Order Drugs (MOD) available at 2.5X copay for up to a 90 day supply Out-of-Network (OON) Services $40, ded waived $50, ded waived $50, ded waived $60, ded waived 80%, ded applies 80%, ded applies 80%, ded applies 70%, ded applies $40, ded waived $50, ded waived $50, ded waived $60, ded waived $15/$45/$60 $15/$45/$60 $15/$45/$60 $15/$45/$60 Coinsurance 60% 60% 60% 50% + Annual Deductible: Individual/Family (*deductible applies to OOP) $1,500/$4,500 $2,000/$6,000 $2,000/$6,000 $4,000/$12,000 Annual Out-of-Pocket (OOP): Individual/Family $4,000/$12,000 $6,000/$18,000 $6,000/$18,000 $8,000/$24,000 Emergency Room Paid as In-Network Paid as In-Network Paid as In-Network Paid as In-Network Ambulance (emergency transport) All other Medical Services 60%, ded applies 60%, ded applies 60%, ded applies 50%, ded applies + Retail Pharmacy (Note: OON Pharmacy is not a covered benefit on POS plans) PLAN OPTIONS AVAILABLE (all open access no referrals) Not Covered $15/$45/$60 $15/$45/$60 $15/$45/$60 POS Available X X X X MC Available X X X 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 9
G e o r g i a p l a n G U I D E 1 0 0 % P l a n s GEORGIA (2-99 Employees) 1912 1913 1914 Plan or Calendar Year Calendar Calendar Calendar Deductible Type Embedded Embedded Embedded Lifetime Maximum Unlimited Unlimited Unlimited IN NETWORK SERVICES Coinsurance 100% 100% 100% Annual Deductible: Individual/Family (* indicates deductible applies to OOP) $1,000/$3,000 * $1,500/$4,500 * $2,500/$7,500 * Annual Out-of-Pocket (OOP): Individual/Family $1,000/$3,000 $1,500/$4,500 $2,500/$7,500 Wellness On US TM Preventive Care, including Adult Physicals, Well Women Visits, Mammograms, Colorectal Cancer Screening and other preventive care services. Well Child Care (Age/Frequency schedules apply, includes coverage for immunizations) $0, ded waived $0, ded waived $0, ded waived $0, ded waived $0, ded waived $0, ded waived Physician Services Primary Care Physician Office visit $20, ded waived $30, ded waived $40, ded waived Specialist Office Visit $40, ded waived $50, ded waived $60, ded waived Outpatient Mental Health * $40, ded waived $50, ded waived $60, ded waived Inpatient Services Hospital Inpatient 100%, ded applies 100%, ded applies 100%, ded applies Mental Health Inpatient 100%, ded applies 100%, ded applies 100%, ded applies Outpatient/Other Services Diagnostic Lab $20, ded waived $30, ded waived $40, ded waived Diagnostic X-Ray $60, ded waived $75, ded waived $100, ded waived Diagnostic Complex Imaging (CAT, MRI, MRA/MRS and PET scans) 100%, ded applies 100%, ded applies 100%, ded applies Outpatient Surgery 100%, ded applies 100%, ded applies 100%, ded applies Emergency Room (Copay waived if admitted) $200, ded waived $200, ded waived $250, ded waived Urgent Care $75, ded waived $75, ded waived $75, ded waived Ambulance (emergency transport) 100%, ded applies 100%, ded applies 100%, ded applies Outpatient Rehabilitative Therapy (30 visits per year) Durable Medical Equipment ($5000 maximum per year) Chiropractic Services (20 visits per year) $40, ded waived $50, ded waived $60, ded waived 100%, ded applies 100%, ded applies 100%, ded applies $40, ded waived $50, ded waived $60, ded waived PHARMACY Retail Pharmacy Copay Mail Order Drugs (MOD) available at 2.5X copay for up to a 90 day supply $15/$35/$50 $15/$45/$60 $15/$45/$60 Out-of-Network (OON) Services Coinsurance 70% 70% 70% Annual Deductible: Individual/Family (*deductible applies to OOP) $3,000/$9,000 $4,000/$12,000 $4,000/$12,000 Annual Out-of-Pocket (OOP): Individual/Family $6,000/$18,000 $10,000/$30,000 $10,000/$30,000 Emergency Room Paid as In-Network Paid as In-Network Paid as In-Network Ambulance (emergency transport) All other Medical Services 70%, ded applies 70%, ded applies 70%, ded applies Retail Pharmacy (Note: OON Pharmacy is not a covered benefit on POS plans) Not Covered $15/$45/$60 $15/$45/$60 PLAN OPTIONS AVAILABLE (all open access no referrals) POS Available X X X MC Available X X See page 13 for endnotes. 10
H S A C o m pat i b l e P l a n s GEORGIA (2-99 Employees) 1935 (HDHP) 1936 (HDHP) 1937 (HDHP) Plan or Calendar Year Calendar Calendar Calendar Deductible Type Non-Embedded Non-Embedded Non-Embedded Lifetime Maximum Unlimited Unlimited Unlimited IN NETWORK SERVICES Coinsurance 80% 70% 100% Annual Deductible: Individual/Family (* indicates deductible applies to OOP) See page 13 for endnotes. $2,500/$5,000 * $3,000/$6,000* $5,950/$11,900 * Annual Out-of-Pocket (OOP): Individual/Family $5,000/$10,000 $5,950/$11,900 $5,950/$11,900 Wellness On US TM Preventive Care, including Adult Physicals, Well Women Visits, Mammograms, Colorectal Cancer Screening and other preventive care services. Well Child Care (Age/Frequency schedules apply, includes coverage for immunizations) Physician Services $0, ded waived $0, ded waived $0, ded waived $0, ded waived $0, ded waived $0, ded waived Primary Care Physician Office visit 80%, ded applies 70%, ded applies 100%, ded applies Specialist Office Visit 80%, ded applies 70%, ded applies 100%, ded applies Outpatient Mental Health * 80%, ded applies 70%, ded applies 100%, ded applies Inpatient Services Hospital Inpatient 80%, ded applies 70%, ded applies 100%, ded applies Mental Health Inpatient 80%, ded applies 70%, ded applies 100%, ded applies Outpatient/Other Services Diagnostic Lab 80%, ded applies 70%, ded applies 100%, ded applies Diagnostic X-Ray 80%, ded applies 70%, ded applies 100%, ded applies Diagnostic Complex Imaging (CAT, MRI, MRA/MRS and PET scans) 80%, ded applies 70%, ded applies 100%, ded applies Outpatient Surgery 80%, ded applies 70%, ded applies 100%, ded applies Emergency Room (Copay waived if admitted) 80%, ded applies 70%, ded applies 100%, ded applies Urgent Care 80%, ded applies 70%, ded applies 100%, ded applies Ambulance (emergency transport) 80%, ded applies 70%, ded applies 100%, ded applies Outpatient Rehabilitative Therapy (30 visits per year) Durable Medical Equipment ($5000 maximum per year) Chiropractic Services (20 visits per year) PHARMACY Retail Pharmacy Copay Mail Order Drugs (MOD) available at 2.5X copay for up to a 90 day supply Out-of-Network (OON) Services 80%, ded applies 70%, ded applies 100%, ded applies 80%, ded applies 70%, ded applies 100%, ded applies 80%, ded applies 70%, ded applies 100%, ded applies $15/$45/$60 $20/$50/$70 Discount Card Available Coinsurance 60% 50% 70% Annual Deductible: Individual/Family (*deductible applies to OOP) $3,500/$7,000 $4,000/$12,000 $8,000/$16,000 Annual Out-of-Pocket (OOP): Individual/Family $7,000/$14,000 $8,000/$16,000 $12,000/$24,000 Emergency Room Paid as In-Network Paid as In-Network Paid as In-Network Ambulance (emergency transport) All other Medical Services 60%, ded applies 50%, ded applies 70%, ded applies Retail Pharmacy (Note: OON Pharmacy is not a covered benefit on POS plans) PLAN OPTIONS AVAILABLE (all open access no referrals) $15/$45/$60 Not Covered Not Covered POS Available X X X MC Available X 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 11
G e o r g i a p l a n G U I D E S i m p ly S av i n g s GEORGIA (2-99 Employees) 1943 1944 1945 Plan or Calendar Year Calendar Calendar Calendar Deductible Type Embedded Embedded Embedded Lifetime Maximum Unlimited Unlimited Unlimited IN NETWORK SERVICES Coinsurance 70% 70% 100% Annual Deductible: Individual/Family (* indicates deductible applies to OOP) $2,250/$6,750 $3,000/$9,000 $10,000/$10,000 * Annual Out-of-Pocket (OOP): Individual/Family $3,000/$9,000 $3,000/$9,000 $10,000/$10,000 Wellness On US TM Preventive Care, including Adult Physicals, Well Women Visits, Mammograms, Colorectal Cancer Screening and other preventive care services. Well Child Care (Age/Frequency schedules apply, includes coverage for immunizations) $0, ded waived $0, ded waived $0, ded waived $0, ded waived $0, ded waived $0, ded waived Physician Services Primary Care Physician Office visit $40, ded waived $40, ded waived $35, ded waived Specialist Office Visit $60, ded waived $60, ded waived 100%, ded applies Outpatient Mental Health * $60, ded waived $60, ded waived 100%, ded applies Inpatient Services Hospital Inpatient 70% after $1,000/admit, ded applies 70% after $1,000/admit, ded applies 100%, ded applies Mental Health Inpatient 70% after $1,000/admit, ded applies 70% after $1,000/admit, ded applies 100%, ded applies Outpatient/Other Services Diagnostic Lab $40, ded waived $40, ded waived 100%, ded applies Diagnostic X-Ray $100, ded waived $100, ded waived 100%, ded applies Diagnostic Complex Imaging (CAT, MRI, MRA/MRS and PET scans) 70%, ded applies 70%, ded applies 100%, ded applies Outpatient Surgery 70% after $500, ded applies 70% after $500, ded applies 100%, ded applies Emergency Room (Copay waived if admitted) $200, ded waived $250, ded waived 100%, ded applies Urgent Care $75, ded waived $75, ded waived 100%, ded applies Ambulance (emergency transport) 70%, ded applies 70%, ded applies 100%, ded applies Outpatient Rehabilitative Therapy (30 visits per year) Durable Medical Equipment ($5000 maximum per year) Chiropractic Services (20 visits per year) $60, ded waived $60, ded waived 100%, ded applies 70%, ded applies 70%, ded applies 100%, ded applies $60, ded waived $60, ded waived 100%, ded applies PHARMACY Retail Pharmacy Copay Mail Order Drugs (MOD) available at 2.5X copay for up to a 90 day supply $15/$45/$70 $20/$50/$70 $20/$50/$70 Out-of-Network (OON) Services Coinsurance 50% + 50% 70% Annual Deductible: Individual/Family (*deductible applies to OOP) $4,000/$12,000 $4,000/$12,000 $10,000/$10,000 Annual Out-of-Pocket (OOP): Individual/Family $6,000/$18,000 $6,000/$18,000 $15,000/$30,000 Emergency Room Paid as In-Network Paid as In-Network Paid as In-Network Ambulance (emergency transport) All other Medical Services 50%, ded applies + 50%, ded applies 70%, ded applies Retail Pharmacy (Note: OON Pharmacy is not a covered benefit on POS plans) $20/$50/$70 Not Covered $20/$50/$70 PLAN OPTIONS AVAILABLE (all open access no referrals) POS Available X X X MC Available X X See page 13 for endnotes. 12
I n d e m n i t y GEORGIA (2-99 Employees) 1900 Plan or Calendar Year Deductible Type Lifetime Maximum IN NETWORK SERVICES Calendar Embedded Unlimited Coinsurance 80% Annual Deductible: Individual/Family (* indicates deductible applies to OOP) $500/$1,500 Annual Out-of-Pocket (OOP): Individual/Family $7,000/$21,000 Wellness On US TM Preventive Care, including Adult Physicals, Well Women Visits, Mammograms, Colorectal Cancer Screening and other preventive care services. Well Child Care (Age/Frequency schedules apply, includes coverage for immunizations) Physician Services Primary Care Physician Office visit Specialist Office Visit Outpatient Mental Health * Inpatient Services Hospital Inpatient Mental Health Inpatient Outpatient/Other Services Diagnostic Lab Diagnostic X-Ray Diagnostic Complex Imaging (CAT, MRI, MRA/MRS and PET scans) Outpatient Surgery Emergency Room (Copay waived if admitted) Urgent Care Ambulance (emergency transport) Outpatient Rehabilitative Therapy (30 visits per year) Durable Medical Equipment ($5000 maximum per year) Chiropractic Services (20 visits per year) PHARMACY Retail Pharmacy Copay Mail Order Drugs (MOD) available at 2.5X copay for up to a 90 day supply Out-of-Network (OON) Services Coinsurance Annual Deductible: Individual/Family (*deductible applies to OOP) Annual Out-of-Pocket (OOP): Individual/Family Emergency Room Ambulance (emergency transport) All other Medical Services Retail Pharmacy (Note: OON Pharmacy is not a covered benefit on POS plans) PLAN OPTIONS AVAILABLE (all open access no referrals) POS Available MC Available $0, ded waived $0, ded waived 80%, ded applies 80%, ded applies 80%, ded applies 80%, ded applies 80%, ded applies 80%, ded applies 80%, ded applies 80%, ded applies 80%, ded applies 80%, ded applies 80%, ded applies 80%, ded applies 80%, ded applies 80%, ded applies 80%, ded applies $15/$45/$60 Same as In Network Benefits Indemnity ENDNOTES The federal health care reform legislation known as the Patient Protection and Affordable Care Act was signed into law on March 23, 2010. 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 plans and 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 copayments indicate what Aetna is required to pay unless otherwise noted. NOTE: Some benefits are subject to limitations or visit maximums. Members or Providers may be required to precertify or obtain prior approval for certain services such as non-emergency hospital care. For a summary list of Limitations and Exclusions, refer to pages 40-41. Federal Mental Health Parity applies to groups with 51+ employees effective October 1, 2009. Inpatient and outpatient mental health benefits shall be treated as any other illness and not subject to annual limits (except for Residential Treatment programs) on all plans 2-99, however different cost sharing may apply to outpatient mental health office visits services on certain plans with 51+ members. A 90-Day Transition of Coverage (TOC) for Prior Authorization and Step Therapy included on pharmacy plans. Transition of coverage for Prior Authorization 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/Step Therapy requirements will not apply to certain drugs. Once the 90 calendar days has expired, Prior Authorization/Step Therapy edits will apply to all drugs requiring Prior Authorization/Step Therapy as listed in the formulary guide. Members, who have claims paid for a drug requiring Prior Authorization or 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/Step Therapy or approval for a medical exception for this drug. 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 outof-network doctor or hospital. 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. Generally, you are not responsible for any outstanding balance billed by your doctors in an emergency situation. +MC OA Plans 1905 and 1943 Out of Network Coinsurance is 60% for all services except Emergency Care and Emergency Ambulance services (paid at in network benefit levels). 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 13
G e o r g i a p l a n G U I D E P l a n Va l u e $ $ $ $ $ $ $ $ $ $ GA POS OA 1945 (Simply Savings) GA POS OA 1937 (HSA Compatible) GA POS OA 1936 (HSA Compatible) GA POS OA 1944 (Simply Savings) GA MC OA 1945 (Simply Savings) GA POS OA 1935 (HSA Compatible) GA POS OA 1943 (Simply Savings) GA MC OA 1935 (HSA Compatible) GA POS OA 1905 (Traditional) GA MC OA 1943 (Simply Savings) GA POS OA 1914 (100% Plan) GA POS OA 1904 (Traditional) GA POS OA 1903 (Traditional) GA POS OA 1913 (100% Plan) GA MC OA 1905 (Traditional) GA POS OA 1902 (Traditional) GA MC OA 1914 (100% Plan) GA POS OA 1912 (100% Plan) GA MC OA 1904 (Traditional) GA MC OA 1903 (Traditional) GA MC OA 1913 (100% Plan) GA Ind 1900 (Indemnity Plan) 14
NOTES 15
G e o r g i a p l a n G U I D E Aetna Avenue dental Overv iew Aetna Dental pl ans Small business decision makers can choose from a variety of plan design options that help you offer a dental benefits and dental insurance plan that s just right for your employees. The Mouth Matters SM Research shows that more than 90 percent of all medical illnesses are detectable in the mouth and that 75 percent of people over the age of 35 have periodontal (gum) disease. 1 Untreated oral diseases can have a big impact on the quality of life. This means that a dentist may be the first health care provider to diagnose a health problem! Aetna Dental/Medical Integration SM (DMI) program,* available at no additional charge to plan sponsors that have both medical and dental coverages with Aetna, focuses on those who are pregnant or have diabetes, coronary artery disease (heart disease) or cerebrovascular disease (stroke) and have not had a recent dental visit. We proactively educate those at-risk members about the impact oral health care can have on their condition. Our member outreach has been proven to successfully motivate those at-risk members who do not normally seek dental care to visit the dentist. 2 Once at the dentist, these at-risk members will receive enhanced dental benefits including an extra cleaning and full coverage for certain periodontal services. The Dental Maintenance Organization (DMO ) Members select a primary care dentist to coordinate their care from the available managed dental network. Each family member may choose a different primary care dentist and may switch dentists at any time via Aetna Navigator or with a call to Member Services. If specialty care is needed, a member s primary care dentist can refer the member to a participating specialist. However, members may visit orthodontists without a referral. There are virtually no claim forms to file, and benefits are not subject to deductibles or annual maximums. 1 The professional entity, Academy of General Dentistry, 2007. 2 Dental/medical integration, Improved oral health can lead to a better overall health Smart Business Chicago (1/07). *DMI may not be available in all states. 16
Preferred Provider Organization (PPO) plan Members can choose a dentist who participates in the network or choose a licensed dentist who does not. Participating dentists have agreed to offer our members services at a negotiated rate and will not balance-bill members.* PPO Max plan While the PPO Max dental insurance plan uses the PPO network, when members use out-of-network dentists the service will be covered based on the Aetna PPO fee schedule, rather than the reasonable and customary charge. The member will share in more of the costs and may be balance-billed. This plan offers members a quality dental insurance plan with a significantly lower premium that encourages in-network usage. *Discounts for non-covered services may not be available. Freedom-of-Choice plan design option Get maximum flexibility with our two-in-one dental plan design. The Freedom-of-Choice plan design option provides the administrative ease of one plan, yet members get to choose between the DMO and PPO Max plans on a monthly basis. One blended rate is paid. Members may switch between the plans on a monthly basis by calling Member Services. Plan changes must be made by the 15th of the month to be effective the following month. 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
G e o r g i a p l a n G U I D E Aetna Avenue dental Overv iew Dual Option* plan In the Dual Option plan design the DMO may be packaged with any one of the PPO plans. Employees may choose between the DMO and PPO offerings at annual enrollment. Voluntary Dental option The Voluntary Dental option provides a solution to meet the individual needs of members in the face of rising health care costs. Administration is easy, and members benefit from low group rates and the convenience of payroll deductions. Employers choose how the plan is funded. It can be entirely member-paid or employers can contribute up to 50 percent. Aetna Dental Preventive Care SM Plan The Preventive Care plan is a lowcost dental plan that covers preventive and diagnostic procedures. Members pay nothing for these services and may get a discount on the network dentist s charges for non-covered services when visiting an Aetna PPO dentist. This includes orthodontic work for adults and teeth whitening.** * Dual Option does not apply to the Preventive and all Voluntary Dental plans. Discounts are not insurance. **Discounts for non-covered services may not be available. 18
A e t n a S m a l l G r o u p D e n ta l P l a n s Available With an Aetna Medical Plan to Groups with 2-99 Eligible Employees Available Without Medical Plan (Dental Standalone) to Groups with 3-99 Eligible Employees DMO Plan 100/80/50 Option 1 DMO Option 2 Freedom of Choice Monthly selection between DMO and PPO Max DMO Plan 100/90/60 PPO Max Plan 100/70/40 Option 3 Freedom of Choice Monthly selection between DMO and PPO DMO Plan 100/90/60 PPO Plan 100/80/50 Office Visit Copay $5 $5 N/A $5 N/A Annual Deductible per Member does not apply to Diagnostic & Preventive Services None None $50; 3X Family Maximum None $50; 3X Family Maximum Annual Maximum Benefit Unlimited Unlimited $1,000 Unlimited $1,000 Diagnostic Services Oral Exams Periodic oral exam 100% 100% 100% 100% 100% Comprehensive oral exam 100% 100% 100% 100% 100% Problem-focused oral exam 100% 100% 100% 100% 100% X-rays Bitewing single film 100% 100% 100% 100% 100% Complete series 100% 100% 100% 100% 100% Preventive Services Adult Cleaning 100% 100% 100% 100% 100% Child Cleaning 100% 100% 100% 100% 100% Sealants per tooth 100% 100% 100% 100% 100% Fluoride application with cleaning 100% 100% 100% 100% 100% Space maintainers fixed 100% 100% 100% 100% 100% Basic Services Amalgam filling 2 surfaces 80% 90% 70% 90% 80% Resin filling 2 surfaces, anterior 80% 90% 70% 90% 80% Oral Surgery Extraction exposed root or erupted tooth 80% 90% 70% 90% 80% Extraction of impacted tooth soft tissue 80% 90% 70% 90% 80% *Major Services Complete upper denture 50% 60% 40% 60% 50% Partial upper denture 50% 60% 40% 60% 50% Crown Porcelain with noble metal ** 50% 60% 40% 60% 50% Pontic Porcelain with noble metal ** 50% 60% 40% 60% 50% Inlay Metallic (3 or more surfaces) 50% 60% 40% 60% 50% Oral Surgery Removal of impacted tooth partially bony 50% 60% 40% 60% 50% Endodontic Services Bicuspid root canal therapy 50% 90% 40% 90% 80% Molar root canal therapy 50% 60% 40% 60% 50% Periodontic Services Scaling & root planing per quadrant 80% 90% 40% 90% 80% Osseous surgery per quadrant 50% 60% 40% 60% 50% *Orthodontic Services $2300 copay $2300 copay Not covered $2300 copay Not covered Orthodontic Lifetime Maximum Does not apply Does not apply Does not apply Does not apply Does not apply * Coverage Waiting Period: Must be an enrolled member of the Plan for 12 months before becoming eligible for coverage of any Major Service including Orthodontic Services. Does not apply to the DMO in Plan Options 1, 2 & 3 and the PPO in Plan Option 7. Access to negotiated discounts: On the PPO plans in Plan Options 2-7, members may be eligible to receive non-covered services at the PPO negotiated rate when visiting a participating PPO dentist at any time, including during the Coverage Waiting Period. Most Oral Surgery, Endodontic and Periodontic services are covered as Basic Services on the DMO in Options 1, 2 & 3 and on the PPO in Options 3 & 6. Out-of-Network plan payments are limited by geographic area on the PPO in Plan Options 3 & 5 to the prevailing fees at the 80th percentile and the 90th percentile in Plan Option 6. Plan Options 2 & 4; PPO Non-Preferred (Out-of-Network) Coverage is limited to a maximum of the Plan s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area. The DMO in Plan Option 1 can be offered with any one of the PPO plans in Plan Options 4-6 in a Dual Option package. Fixed dollar amounts on the DMO in Plan Options 1-3 including the Office Visit and Ortho copays are member responsibility. Orthodontic coverage is available on Plan Options 1, 2, 3, & 5 to groups with 10 or more eligibles and for Dependent Children Only. Adults and Dependent Children in Plan Option 6. Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/certificate. For a summary list of Limitations and Exclusions, refer to page 41. 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 19
G e o r g i a p l a n G U I D E A e t n a S m a l l G r o u p D e n ta l P l a n s Available With an Aetna Medical Plan to Groups with 2-99 Eligible Employees Available Without Medical Plan (Dental Standalone) to Groups with 3-99 Eligible Employees Option 4 PPO Max PPO Max Plan 100/80/50 Option 5 Passive PPO PPO Plan 100/80/50 Option 6 Passive PPO PPO Plan 100/80/50 Option 7 Preventive Care PPO Max Plan 100/0/0 Office Visit Copay N/A N/A N/A N/A Annual Deductible per Member does not apply $50; 3X Family Maximum $50; 3X Family Maximum $50; 3X Family Maximum None to Diagnostic & Preventive Services Annual Maximum Benefit $1,500 $1,500 $2,000 Unlimited Diagnostic Services Oral Exams Periodic oral exam 100% 100% 100% 100% Comprehensive oral exam 100% 100% 100% 100% Problem-focused oral exam 100% 100% 100% 100% X-rays Bitewing single film 100% 100% 100% 100% Complete series 100% 100% 100% 100% Preventive Services Adult Cleaning 100% 100% 100% 100% Child Cleaning 100% 100% 100% 100% Sealants per tooth 100% 100% 100% 100% Fluoride application with cleaning 100% 100% 100% 100% Space maintainers fixed 100% 100% 100% 100% Basic Services Amalgam filling 2 surfaces 80% 80% 80% Not covered Resin filling 2 surfaces, anterior 80% 80% 80% Not covered Oral Surgery Extraction exposed root or erupted tooth 80% 80% 80% Not covered Extraction of impacted tooth soft tissue 80% 80% 80% Not covered *Major Services Complete upper denture 50% 50% 50% Not covered Partial upper denture 50% 50% 50% Not covered Crown Porcelain with noble metal ** 50% 50% 50% Not covered Pontic Porcelain with noble metal ** 50% 50% 50% Not covered Inlay Metallic (3 or more surfaces) 50% 50% 50% Not covered Oral Surgery Removal of impacted tooth partially bony 50% 50% 50% Not covered Endodontic Services Bicuspid root canal therapy 50% 50% 80% Not covered Molar root canal therapy 50% 50% 50% Not covered Periodontic Services Scaling & root planing per quadrant 50% 50% 80% Not covered Osseous surgery per quadrant 50% 50% 50% Not covered *Orthodontic Services Not covered 50% 50% Not covered Orthodontic Lifetime Maximum Does not apply $1,000 $1,000 Does not apply * Coverage Waiting Period: Must be an enrolled member of the Plan for 12 months before becoming eligible for coverage of any Major Service including Orthodontic Services. Does not apply to the DMO in Plan Options 1, 2 & 3 and the PPO in Plan Option 7. Access to negotiated discounts: On the PPO plans in Plan Options 2-7, members may be eligible to receive non-covered services at the PPO negotiated rate when visiting a participating PPO dentist at any time, including during the Coverage Waiting Period. Most Oral Surgery, Endodontic and Periodontic services are covered as Basic Services on the DMO in Options 1, 2 & 3 and on the PPO in Options 3 & 6. Out-of-Network plan payments are limited by geographic area on the PPO in Plan Options 3 & 5 to the prevailing fees at the 80th percentile and the 90th percentile in Plan Option 6. Plan Options 2 & 4; PPO Non-Preferred (Out-of-Network) Coverage is limited to a maximum of the Plan s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area. The DMO in Plan Option 1 can be offered with any one of the PPO plans in Plan Options 4-6 in a Dual Option package. Fixed dollar amounts on the DMO in Plan Options 1-3 including the Office Visit and Ortho copays are member responsibility. Orthodontic coverage is available on Plan Options 1, 2, 3, & 5 to groups with 10 or more eligibles and for Dependent Children Only. Adults and Dependent Children in Plan Option 6. Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/certificate. For a summary list of Limitations and Exclusions, refer to page 41. 20
A e t n a S m a l l G r o u p V o l u n ta ry D e n ta l P l a n s Available With an Aetna Medical Plan to Groups with 3-99 Eligible Employees Available Without Medical Plan (Dental Standalone) to Groups with 3-99 Eligible Employees DMO Plan 100/80/50 Voluntary Option 1 DMO Voluntary Option 2 Freedom of Choice Monthly selection between the DMO and PPO DMO Plan 100/90/60 PPO Max Plan 100/70/40 Voluntary Option 3 Freedom of Choice Monthly selection between the DMO and PPO DMO Plan 100/90/60 PPO Plan 100/80/50 Office Visit Copay $10 $10 N/A $10 N/A Annual Deductible per Member does not apply to Diagnostic & Preventive Services None None $75; 3X Family Maximum None $75; 3X Family Maximum Annual Maximum Benefit Unlimited Unlimited $1,000 Unlimited $1,000 Diagnostic Services Oral Exams Periodic oral exam 100% 100% 100% 100% 100% Comprehensive oral exam 100% 100% 100% 100% 100% Problem-focused oral exam 100% 100% 100% 100% 100% X-rays Bitewing single film 100% 100% 100% 100% 100% Complete series 100% 100% 100% 100% 100% Preventive Services Adult Cleaning 100% 100% 100% 100% 100% Child Cleaning 100% 100% 100% 100% 100% Sealants per tooth 100% 100% 100% 100% 100% Fluoride application with cleaning 100% 100% 100% 100% 100% Space maintainers 100% 100% 100% 100% 100% Basic Services Amalgam filling 2 surfaces 80% 90% 70% 90% 80% Resin filling 2 surfaces, anterior 80% 90% 70% 90% 80% Oral Surgery Extraction exposed root or erupted tooth 80% 90% 70% 90% 80% Extraction of impacted tooth soft tissue 80% 90% 70% 90% 80% *Major Services Complete upper denture 50% 60% 40% 60% 50% Partial upper denture (resin base) 50% 60% 40% 60% 50% **Crown Porcelain with noble metal 50% 60% 40% 60% 50% **Pontic Porcelain with noble metal 50% 60% 40% 60% 50% Inlay Metallic (3 or more surfaces) 50% 60% 40% 60% 50% Oral Surgery Removal of impacted tooth partially bony 50% 60% 40% 60% 50% Endodontic Services Bicuspid root canal therapy 80% 90% 40% 90% 80% Molar root canal therapy 50% 60% 40% 60% 50% Periodontic Services Scaling & root planing per quadrant 80% 90% 40% 90% 80% Osseous surgery per quadrant 50% 60% 40% 60% 50% *Orthodontic Services $2400 copay $2400 copay Not covered $2400 copay Not covered Orthodontic Lifetime Maximum Does not apply Does not apply Does not apply Does not apply Does not apply * Coverage Waiting Period: Must be an enrolled member of the Plan for 12 months before becoming eligible for coverage of any Major Service including Orthodontic Services. Does not apply to the DMO in Voluntary Plan Options 1, 2 & 3 and to the PPO in Voluntary Plan Option 5. Fixed dollar amounts on the DMO in Voluntary Plan Options 1-3 including the Office Visit and Ortho copays are member responsibility. Access to negotiated discounts: On the PPO plans in Voluntary Plan Options 2-5, members may be eligible to receive non-covered services at the PPO negotiated rate when visiting a participating PPO dentist at any time, including during the Coverage Waiting Period. Most Oral Surgery, Endodontic and Periodontic services are covered as Basic Services on the DMO in Voluntary Options 1, 2 & 3 and on the PPO in Voluntary Option 3. Voluntary Plan Options 2, 4 & 5; PPO Max Non-Preferred (Out-of-Network) Coverage is limited to a maximum of the Plan s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area. All voluntary plans require a minimum of 3 to enroll. Orthodontic coverage is available on the DMO in Voluntary Options 1-3 to groups with 10 or more eligibles and for dependent children only. If there is a lapse in coverage, members may not re-enroll in the plan for a period of two years from the date of termination. If they are eligible for coverage at that time, they may re-enroll, subject to all provisions of the plan, including, but not limited to, the Coverage Waiting Period. Voluntary Dual Option plans are not available. Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/certificate. For a summary list of Limitations and Exclusions, refer to page 41. 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 21