Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Texas Plan guide The health of business, well planned. Plans effective December 1, 2011 For businesses with 2 100 eligible employees www.aetna.com 64.10.302.1-TX (2/12)
64.43.302.1-TX (2/12) Team with Aetna for the health of your business Introducing a new suite of products and services designed specifically for companies with 2 to 100 eligible employees. 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 were effective September 23, 2010, including coverage for dependents up to age 26, elimination of lifetime benefits dollar maximums, restriction of annual dollar maximums on essential health benefits, removal of cost sharing for preventive services and elimination of pre-existing conditions exclusions for dependent children under 19 years of age. Your Aetna benefits program does comply with the new reform legislation. Health/dental benefits and health/dental insurance plans, life and disability insurance/policies plans are offered, underwritten and/or administered by Aetna Health Inc., Aetna Health Insurance Company, Aetna Dental Inc. and/or Aetna Life Insurance Company (Aetna). Each insurer has sole financial responsibility for its own products. 2
You can count on Aetna to provide health plans that help simplify decision making and plan administration so you can focus on the health of your business. 64.44.302.1-TX (2/12) Aetna is committed to helping employers build healthy businesses. In today s rapidly changing economy, we recognize the need for less expensive, less complex health plan choices. Now, Aetna offers a variety of newly streamlined medical and dental benefits and insurance plans to provide more affordable options and to help simplify plan selection and administration. In this guide: 5 Small business commitment 5 Benefits for every stage of life 6 Provider network 8 Medical overview 12 Medical plan options 31 Dental overview 33 Dental plan options 41 Life and disability overview 44 Life plan options 45 Life and disability plan options 46 Underwriting guidelines 54 Product specifications 61 Limitations and exclusions 63 Small group enrollment checklist 3
Employers and their employees can benefit from Affordable plan options Online self-service tools and capabilities Enhanced services for consumer-directed health plans 24-hour access to Employee Assistance Program services Preventive care covered 100% Aetna disease management and wellness programs Options We provide a variety of health plan options to help meet your employees needs, including medical, dental, disability and life insurance. And, with access to a wide network of health care providers, you can be sure that employees have options in how they access their health care. Medical plans supporting members on their health care journey Traditional plans Preferred plans HSA-compatible plans Dental, life and disability plans providing valuable protection DMO Participating Dental Network (PDN) PDN Max Freedom-of-Choice plan design Dual Option Voluntary Term life insurance Packaged life and disability Simplicity We know that the health of your business is your top priority. Aetna s streamlined plans and variety of services make it easier for you to focus on your business by simplifying administration and management. Aetna makes it easy to manage health insurance benefits with simplified enrollment, billing and claims processing so you can focus on what matters most. Trust We work hard to provide health plan solutions you can trust. Our account executives, underwriters and customer service representatives are committed to providing businesses and their employees with service they can trust. Aetna resources are designed to fortify the health of your business Track medical claims and take advantage of online services with your Aetna Navigator secure member website. It features personal health records and printable temporary member ID cards. Get real cost and health information to help make the right care decision with an online Cost of Care Estimator. Manage your health records online with the Personal Health Record (PHR). Use of the Aetna Health Connections SM Disease Management Program, which provides personal support to members to help them manage their conditions. 24/7 access to a nurse to help with personal health-related questions. Help members work toward health goals with wellness initiatives, such as the Simple Steps to a Healthier Life online program. Take advantage of discount programs for vision, dental, and general health care that encourage use of plan offerings. 4
Aetna is committed to the health of your business We understand that your business has unique needs. That s why we have streamlined our health benefits and insurance plan options for employers with 2 to 100 employees. We are committed to providing you with value and quality you can count on. Our variety of products and services allows you to focus on the health of your business. Aetna s health plan options are designed with the health of your business in mind Basic plans Basic benefits for your employees Limiting the expense to your business Allow employees to buy up and share more of the cost --OAMC Basic 2500 --HNOption B3000 Preferred --HSA $5000 100% Value plans Encouraging employee responsibility in their health care decisions Tools and resources to support consumerism Innovative plan design --OAMC B3000 Preferred --HNOption B2000 Preferred -OAMC - B2500 Standard plans Standard benefits plans Limit the financial impact on employees --OAMC E1000 --OAMC B3000 100% --HSA $3000 90% Health insurance benefits for every stage of life For young individuals and couples without children Lower monthly payments Modest out-of-pocket costs Quality preventive care Prescription drug coverage Financial protection HSA-compatible plans Preferred plans For married couples and single parents with teens and college-aged children Checkups and care for injuries and illness Preventive care and screenings that promote a healthy lifestyle National network of health care providers Traditional plans Preferred plans For married couples and single parents with young children or teens Lower fees for office visits Lower monthly payments Caps on out-of-pocket expenses Quality preventive care for the entire family Traditional plans Preferred plans HSA-compatible plans For men and women 55 years of age and over with no children at home Financial security Quality prescription drug coverage Hospital inpatient/outpatient services Emergency care Traditional plans Preferred plans 5
6 Texas Provider Network* OAMC/Preferred Provider Benefits Plan (PPO) Network Anderson Andrews Angelina Archer Armstrong Bailey Bandera Baylor Blanco Borden Bosque Bowie Brazos Brewster Briscoe Brooks Brown Burleson Burnet Calhoun Callahan Cameron Camp Carson Cass Castro Cherokee Childress Clay Cochran Coke Coleman Collingsworth Comanche Concho Coryell Cottle Crane Crosby Crockett Culberson Dallam Dawson De Witt Deaf Smith Dickens Dimmit Donley Eastland Ector Edwards Falls Fayette Fisher Floyd Foard Franklin Freestone Frio Gaines Garza Gillespie Glasscock Goliad Gonzales Gray Gregg Hale Hall Hamilton Hansford Hardeman Harrison Hartley Haskell Hemphill Hidalgo Hockley Houston Howard Hudspeth Hutchinson Irion Jack Jackson Jasper Jim Hogg Jeff Davis Jones Karnes Kenedy Kent Kerr Kimble Kinney Knox La Salle Lamar Lamb Lavaca Lee Leon Limestone Lipscomb Llano Loving Lubbock Lynn Madison Marion Martin Mason Maverick McCullough Mclennan McMullen Menard Midland Milam Mills Mitchell Montague Moore Morris Motley Nacogdoches Newton Nolan Ochiltree Oldham Panola Parmer Pecos Polk Presidio Potter Randall Reagan Real Red River Reeves Refugio Roberts Robertson Runnels Rusk Sabine San Augustine San Saba Schleicher Scurry Shackelford Shelby Sherman Smith Starr Stephens Sterling Stonewall Sutton Swisher Taylor Terrell Terry Throckmorton Titus Tom Green Trinity Tyler Upshur Upton Uvalde Val Verde Victoria Ward Washington Webb Wheeler Wichita Wilbarger Willacy Winkler Wood Yoakum Young Zapata Zavala *Network subject to change.
Texas Provider Network* OAMC/PPO/CPOS/HMO Network Aransas Atascosa Austin Bastrop Bee Bell Bexar Brazoria Caldwell Chambers Collin Colorado Comal Cooke Dallas Delta Denton Duval El Paso Ellis Erath Fannin Fort Bend Galveston Grayson Grimes Guadalupe Hardin Harris Hays Henderson Hill Hood Hopkins Hunt Jefferson Jim Wells Johnson Kaufman Kendall Kleberg Liberty Live Oak Matagorda Medina Montgomery Navarro Nueces Orange Palo Pinto Parker Rains Rockwall San Jacinto San Patricio Somervell Tarrant Travis Van Zandt Walker Waller Wharton Williamson Wilson Wise *Network subject to change. 7
Aetna Medical Plans At Aetna, we are committed to putting the employee at the center of everything we do. You can count on Aetna to provide health plans that help simplify decision making and plan administration so you can focus on the health of your business. 8
Medical Overview Wellness On Us SM Wellness for your employees means a healthier business for you. Our small business health benefits and insurance plans in Texas include $0 copay in-network for preventive care. It s one more way to help your employees get a step closer to better health. Check out what your employees can get for $0: Routine vision screening $0 copay Routine physicals $0 copay Child wellness visits $0 copay Routine mammogram $0 copay Routine ob/gyn visits $0 copay Immunizations $0 copay Aetna Open Access Managed Choice (OAMC) plan For those who want the advantages of a managed care insurance plan while giving employees flexibility to visit any providers without a referral. No PCP selection required (members who prefer to have their family physician coordinate their care may designate a PCP if they choose). No referrals are required. Members can choose any provider from Aetna s extensive network for a covered service. Members may visit any out-of-network recognized provider for a covered service. For certain plans, members pay office visit copay each time member goes to a participating specialist or non-specialist physician. No Cost Health Incentive Credit Members can earn $50 in just a few simple steps Members earn a $50 credit toward their out-of-pocket expenses when they: --Complete or update their Health Assessment on Simple Steps To A Healthier Life, and --Complete one Online Wellness Program If the spouse is covered under the member s plan, he/she is also eligible for the same incentive credit. So a family could save $100 in out-of-pocket expenses each year. Incentive rewards will be credited toward the deductible and maximum out-of-pocket limit. This program is included at no additional cost on all plans except the HSA-compatible plans. Aetna Health Network Option SM plans No need for referrals, freedom to select provider of choice The Aetna Health Network Option (HNOption) plan offers all the health plan benefits of a point-of-service plan with two easy ways to access care when members need it. Members have the freedom to visit the participating doctor or hospital of their choice for covered services. Best of all, members seeking health care do not need referrals. This plan allows members to: Visit a participating primary care physician and pay the plan s copayment for covered benefits. Go directly to any specialist from within Aetna s network of providers and pay the applicable specialist copayment for covered benefits. Go directly to any licensed out-of-network physician, subject to payment of a deductible and coinsurance. Enjoy large provider networks. What makes Aetna s HSA plans unique? Aetna offers a choice of Health Savings Account (HSA) plans with embedded deductibles for lower out-of-pocket costs, or true individual/family deductibles for lower monthly premium costs. What is an embedded deductible? Unlike many HSA plans, with an Aetna HSA plan, each covered family member only needs to satisfy his/her individual deductible before plan coinsurance applies, not the entire family deductible. Many HSA plans in today s marketplace do not include embedded deductibles, thereby requiring enrolled members to satisfy the entire family deductible before plan coinsurance applies. Aetna High-Deductible Open Access Managed Choice (OAMC) (HSA-Compatible) The Aetna Open Access Managed Choice benefits plan insurance options that are compatible with an 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. 9
Aetna Preferred Provider Benefits plan (PPO) The Aetna Preferred Provider Benefits plan insurance offers members the freedom to go directly to any recognized provider for covered services, including specialists. No referrals are required. Emergency care coverage anywhere, anytime, 24 hours a day. Large provider network. No claim forms in network. If members choose a provider from Aetna s network of participating physicians and hospitals, out-of-pocket costs will be lower. If members choose a physician or hospital outside of the network, out-of-pocket costs will be higher. Members are able to receive emergency services at the in-network coinsurance/copay level. Aetna HMO plan Members access care through primary care physicians. With this health benefits plan, members begin by selecting a primary care physician (PCP) from Aetna s network of participating providers. Members select a PCP who will coordinate their health care needs for covered benefits or services. Each covered member of the family may choose his/her own PCP. Member s PCP coordinates his/her covered health care services No claim forms Emergency care coverage anywhere, anytime, 24 hours a day Large provider networks 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 Plan (POP) Employees can pay for their portion of the group health insurance expenses on a pretax basis. Flexible Spending 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 out-of-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 Indemnity plan This insurance plan option is available for employees who live outside of the network plan s service area. Individual coordinates his/her own health care. No PCP required. No referral required. Members can access any recognized physician or hospital for covered services. Employer may offer a Preferred Provider Benefits plan to in-area employees and the Indemnity plan to out-of-area employees. Deductibles and coinsurance apply. Annual and lifetime maximums may apply. No network providers. Members are responsible for paying provider directly and submitting claims for reimbursement. 10
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. Administrative Fees Fee description POP Fee Initial set-up* $175 Monthly fees $100 HRA and FSA fees** Initial set-up* 2 25 Employees $350 26 50 Employees $450 51 100 Employees $550 Renewal fee 2 25 Employees $225 26 50 Employees $275 51 100 Employees $325 Monthly Fees*** Additional set-up fee for stacked plans (those electing an Aetna HRA and FSA simultaneously) Participation fee for stacked participants Minimum fees $5.25 per participant $150 $10.25 per participant 0 25 Employees $25 per month minimum 26 100 Employees $50 per month minimum COBRA Annual fee 20 50 Employees $100 51 100 Employees $175 Per employee per month 20 50 Employees $0.88 51 100 Employees $1.02 Initial notice fee TRA Annual fee $350 Transit monthly fees Parking monthly fees $1.50 per notice (includes notices at time of implementation and during ongoing administration) $4.25 per participant $3.15 per participant * First year POP fees 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. *** 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 the 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. 11
Open Access Managed Choice (OAMC) Plan features TX OAMC E500-11 TX OAMC E1000-11 TX OAMC E1500-11 Member Benefits In Network Out of Network* In Network Out of Network* In Network Out of Network* Plan Coinsurance 80% 60% 80% 60% 80% 60% Calendar-Year Deductible** Individual $500 $1,000 $1,000 $2,000 $1,500 $3,000 Family $1,000 $2,000 $2,000 $4,000 $3,000 $6,000 Calendar-Year Out-of-Pocket Maximum*** Individual $2,500 $4,000 $3,000 $6,000 $3,500 $7,000 Family $5,000 $8,000 $6,000 $12,000 $7,000 $14,000 Lifetime Maximum Benefit Unlimited Unlimited Unlimited Office Visits (Primary physician/non-specialist) Office Visits (Specialist) Diagnostic Procedures Outpatient Lab Outpatient X-rays/Testing (Facility) $20 deductible $35 deductible $0 deductible $20 deductible 60% $25 deductible 60% $40 deductible 60% $0 deductible 60% $25 deductible 60% $35 deductible 60% $50 deductible 60% $0 deductible 60% $35 deductible Complex Imaging 80% 60% 80% 60% 80% 60% Outpatient Therapy Physical, Occupational and Spinal 20 visits per calendar year limit, combined Speech 20 visits per calendar-year limit; in network and out of network combined $35 deductible $35 deductible 60% $40 deductible 60% $40 deductible 60% $50 deductible 60% $50 deductible Inpatient Hospital Services 80% 60% 80% 60% 80% 60% Outpatient Surgery 80% 60% 80% 60% 80% 60% Emergency Room (Copay if admitted) Urgent Care Skilled Nursing Facility 60 days per calendar-year limit Hospice Care $100 deductible $50 deductible Paid as in network $150 deductible 60% $75 deductible Paid as in network $150 deductible 60% $75 deductible 60% 60% 60% 60% 60% 60% Paid as in network 80% 60% 80% 60% 80% 60% Inpatient 80% 60% 80% 60% 80% 60% Outpatient 80% 60% 80% 60% 80% 60% Home Health Care 60 visits per calendar-year limit Durable Medical Equipment ($2,500 per member, per calendar-year maximum) Preventive Care Includes well-child exams, adult physicals, routine gyn, routine mammograms Prescription Drugs Pharmacy Retail, 30-day supply includes oral contraceptives and diabetic supplies 80% 60% 80% 60% 80% 60% 80% 60% 80% 60% 80% 60% $0 deductible $15/$35/$50 Retail copay + 30% 60% $0 deductible $15/$35/$50 Retail copay + 30% 60% $0 deductible 60% 60% $15/$35/$50 Retail copay + 30% Pharmacy Deductible N/A N/A N/A N/A N/A N/A 90-Day Transition of Coverage (TOC) for pharmacy prior authorization N/A N/A N/A N/A N/A N/A See page 13 for footnotes. 12
Footnotes Plans are underwritten by Aetna Life Insurance Company. Please read the notes below. They contain important information about these health plans. * We cover the cost of services based on whether doctors are in network or out of network. We want to help you understand how much Aetna pays for your out of network care. At the same time, we want to make it clear how much more you will need to pay for this out-of-network care. You may choose a provider (doctor or hospital) in our network. You may choose to visit an out-of-network provider. If you choose a doctor who is out of network, your Aetna health plan may pay some of that doctor s bill. Most of the time, you will pay a lot more money out of your own pocket if you choose to use an out-of-network doctor or hospital. When you choose out-of-network care, Aetna limits the amount it will pay. This limit is called the recognized or allowed amount. When you choose out-of-network care, Aetna recognizes an amount based on what Medicare pays for these services. The government sets the Medicare rate. Your doctor sets his or her own rate to charge you. It may be higher sometimes much higher than what your Aetna plan recognizes. Your doctor may bill you for the dollar amount that Aetna doesn t recognize. You must also pay any copayments, coinsurance and deductibles under your plan. No dollar amount above the recognized charge counts toward your deductible or out-of-pocket maximums. To learn more about how we pay out-of-network benefits visit www.aetna.com. Type how Aetna pays in the search box. You can avoid these extra costs by getting your care from Aetna s broad network of health care providers. Go to www.aetna.com and click on Find a Doctor on the left side of the page. If you are already a member, sign on to your Aetna Navigator member site. This applies when you choose to get care out of network. When you have no choice (for example, emergency room visit after a car accident, or for other emergency services), we will pay the bill as if you got care in network. You pay cost sharing and deductibles for your in-network level of benefits. Contact Aetna if your provider asks you to pay more. You are not responsible for any outstanding balance billed by your providers for emergency services beyond your cost sharing and deductibles. ** All services subject to deductible unless otherwise noted. All covered expenses accumulate toward both the in-network and out-of-network deductible. Once the family deductible is met, all family members will be considered as having met their deductible for the remainder of the calendar year. No one family member may contribute more than the individual deductible amount to the family deductible. Deductible does not apply to the out-of-pocket maximum. *** All covered expenses accumulate toward both the in-network and out-of-network out-of-pocket maximum. Out-of-pocket maximum excludes deductible, copayments, pharmacy expenses, DME and, for small group plans only, mental health and substance abuse expenses. 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 calendar year. No one family member may contribute more than the individual out-of-pocket maximum amount to the family out-of-pocket maximum. This is a partial description of benefits available; for more information, refer to the specific plan design summary. All services are subject to deductible unless otherwise noted. The dollar-amount copayments indicate what the member is required to pay, and the percentage amounts indicate what Aetna is required to pay. Some benefits are subject to limitations or visit maximums. Members or providers may be required to precertify or obtain approval for certain services such as non-emergency hospital care. 13
Open Access Managed Choice (OAMC) Plan features TX OAMC B500-11 TX OAMC B1000-11 Member Benefits In Network Out of Network* In Network Out of Network* Plan Coinsurance 80% 60% 80% 60% Calendar-Year Deductible** Individual $500 per member $1,000 per member $1,000 per member $2,000 per member Family 3 member max 3 member max 3 member max 3 member max Calendar-Year Out-of-Pocket Maximum*** Individual $2,500 per member $4,000 per member $3,000 per member $6,000 per member Family 3 member max 3 member max 3 member max 3 member max Lifetime Maximum Benefit Unlimited Unlimited Office Visits (Primary physician/non-specialist) $20 deductible 60% $25 deductible 60% Office Visits (Specialist) $40 deductible 60% $40 deductible 60% Diagnostic Procedures Outpatient Lab $20 deductible 60% $25 deductible 60% Outpatient X-rays/Testing (Facility) $20 deductible 60% $25 deductible 60% Complex Imaging 80% 60% 80% 60% Outpatient Therapy Physical, Occupational and Spinal 20 visits per calendar year limit, combined Speech 20 visits per calendar year limit; in network and out of network combined 80% 60% 80% 60% 80% 60% 80% 60% Inpatient Hospital Services 80% 60% 80% 60% Outpatient Surgery 80% 60% 80% 60% Emergency Room (Copay if admitted) 80% after $150 deductible Paid as in network 80% after $150 deductible Urgent Care $50 deductible 60% $75 deductible 60% Skilled Nursing Facility 60 days per calendar-year limit Hospice Care 80% 60% 80% 60% Inpatient 80% 60% 80% 60% Outpatient 80% 60% 80% 60% Home Health Care 60 visits per calendar-year limit Durable Medical Equipment ($2,500 per member, per calendar-year maximum) Preventive Care Includes well-child exams, adult physicals, routine gyn, routine mammograms Prescription Drugs Pharmacy Retail, 30-day supply includes oral contraceptives and diabetic supplies 80% 60% 80% 60% 80% 60% 80% 60% $0 deductible 60% $0 deductible 60% Paid as in network $15/$35/$50/30% Retail copay + 30% $15/$35/$50/30% Retail copay + 30% Pharmacy Deductible N/A N/A N/A N/A 90-Day Transition of Coverage (TOC) for pharmacy prior authorization Applies Applies Applies Applies See page 20 for footnotes. 14
Open Access Managed Choice (OAMC) Plan features TX OAMC B1500-11 TX OAMC B2000-11 Member Benefits In Network Out of Network* In Network Out of Network* Plan Coinsurance 80% 60% 80% 60% Calendar-Year Deductible** Individual $1,500 per member $3,000 per member $2,000 per member $4,000 per member Family 3 member max 3 member max 3 member max 3 member max Calendar-Year Out-of-Pocket Maximum*** Individual $3,500 per member $7,000 per member $4,000 per member $8,000 per member Family 3 member max 3 member max 3 member max 3 member max Lifetime Maximum Benefit Unlimited Unlimited Office Visits (Primary physician/non-specialist) $30 deductible 60% $30 deductible 60% Office Visits (Specialist) $50 deductible 60% $50 deductible 60% Diagnostic Procedures Outpatient Lab $30 deductible 60% $30 deductible 60% Outpatient X-rays/Testing (Facility) $30 deductible 60% $30 deductible 60% Complex Imaging 80% 60% 80% 60% Outpatient Therapy Physical, Occupational and Spinal 20 visits per calendar year limit, combined Speech 20 visits per calendar year limit; in network and out of network combined 80% 60% 80% 60% 80% 60% 80% 60% Inpatient Hospital Services 80% 60% 80% 60% Outpatient Surgery 80% 60% 80% 60% Emergency Room (Copay if admitted) 80% after $150 deductible Paid as in network 80% after $150 deductible Urgent Care $75 deductible 60% $100 deductible 60% Skilled Nursing Facility 60 days per calendar-year limit Hospice Care 80% 60% 80% 60% Inpatient 80% 60% 80% 60% Outpatient 80% 60% 80% 60% Home Health Care 60 visits per calendar-year limit Durable Medical Equipment ($2,500 per member, per calendar-year maximum) Preventive Care Includes well-child exams, adult physicals, routine gyn, routine mammograms Prescription Drugs Pharmacy Retail, 30-day supply includes oral contraceptives and diabetic supplies 80% 60% 80% 60% 80% 60% 80% 60% $0 deductible 60% $0 deductible 60% Paid as in network $15/$40/$60/30% Retail copay + 30% $15/$40/$60/30% Retail copay + 30% Pharmacy Deductible N/A N/A N/A N/A 90-Day Transition of Coverage (TOC) for pharmacy prior authorization Applies Applies Applies Applies See page 20 for footnotes. 15
Open Access Managed Choice (OAMC) Plan features TX OAMC B2500-11 TX OAMC B2000 100%-11 Member Benefits In Network Out of Network* In Network Out of Network* Plan Coinsurance 80% 50% 100% 70% Calendar-Year Deductible** Individual $2,500 per member $5,000 per member $2,000 per member $4,000 per member Family 3 member max 3 member max 3 member max 3 member max Calendar-Year Out-of-Pocket Maximum*** Individual $5,000 per member $10,000 per member N/A $6,000 per member Family 3 member max 3 member max 3 member max Lifetime Maximum Benefit Unlimited Unlimited Office Visits (Primary physician/non-specialist) $30 deductible 50% $30 deductible 70% Office Visits (Specialist) $60 deductible 50% $50 deductible 70% Diagnostic Procedures Outpatient Lab $30 deductible 50% $30 deductible 70% Outpatient X-rays/Testing (Facility) $30 deductible 50% $30 deductible 70% Complex Imaging 80% 50% 100% 70% Outpatient Therapy Physical, Occupational and Spinal 20 visits per calendar year limit, combined Speech 20 visits per calendar year limit; in network and out of network combined 80% 50% 100% 70% 80% 50% 100% 70% Inpatient Hospital Services 80% 50% 100% 70% Outpatient Surgery 80% 50% 100% 70% Emergency Room (Copay if admitted) 80% after $200 deductible Paid as in network $200 deductible Paid as in network Urgent Care $100 deductible 50% $100 deductible 70% Skilled Nursing Facility 60 days per calendar-year limit Hospice Care 80% 50% 100% 70% Inpatient 80% 50% 100% 70% Outpatient 80% 50% 100% 70% Home Health Care 60 visits per calendar-year limit Durable Medical Equipment ($2,500 per member, per calendar-year maximum) Preventive Care Includes well-child exams, adult physicals, routine gyn, routine mammograms Prescription Drugs Pharmacy Retail, 30-day supply includes oral contraceptives and diabetic supplies 80% 50% 100% 70% 80% 50% 100% 70% $0 deductible 50% $0 deductible 70% $15/$40/$60/30% Retail copay + 30% $15/$40/$60/30% Retail copay + 30% Pharmacy Deductible N/A N/A N/A N/A 90-Day Transition of Coverage (TOC) for pharmacy prior authorization Applies Applies Applies Applies See page 20 for footnotes. 16
Open Access Managed Choice (OAMC) Plan features TX OAMC B3000 100%-11 TX OAMC B5000 100%-11 Member Benefits In Network Out of Network* In Network Out of Network* Plan Coinsurance 100% 70% 100% 70% Calendar-Year Deductible** Individual $3,000 per member $5,000 per member $5,000 per member $5,000 per member Family 3 member max 3 member max 3 member max 3 member max Calendar-Year Out-of-Pocket Maximum*** Individual N/A $7,000 per member N/A $10,000 per member Family 3 member max 3 member max Lifetime Maximum Benefit Unlimited Unlimited Office Visits (Primary physician/non-specialist) $30 deductible 70% $30 deductible 70% Office Visits (Specialist) $50 deductible 70% $50 deductible 70% Diagnostic Procedures Outpatient Lab $30 deductible 70% $30 deductible 70% Outpatient X-rays/Testing (Facility) $30 deductible 70% $30 deductible 70% Complex Imaging 100% 70% 100% 70% Outpatient Therapy Physical, Occupational and Spinal 20 visits per calendar year limit, combined Speech 20 visits per calendar year limit; in network and out of network combined 100% 70% 100% 70% 100% 70% 100% 70% Inpatient Hospital Services 100% 70% 100% 70% Outpatient Surgery 100% 70% 100% 70% Emergency Room (Copay if admitted) $250 deductible Paid as in network $250 deductible Paid as in network Urgent Care $100 deductible 70% $100 deductible 70% Skilled Nursing Facility 60 days per calendar-year limit 100% 70% 100% 70% Hospice Care Inpatient 100% 70% 100% 70% Outpatient 100% 70% 100% 70% Home Health Care 60 visits per calendar-year limit Durable Medical Equipment ($2,500 per member, per calendar-year maximum) Preventive Care Includes well-child exams, adult physicals, routine gyn, routine mammograms 100% 70% 100% 70% 100% 70% 100% 70% $0 deductible 70% $0 deductible 70% Prescription Drugs Pharmacy Retail, 30-day supply includes oral contraceptives and diabetic supplies $15/$40/$60/30% Retail copay + 30% $15/$40/$60/30% Retail copay + 30% Pharmacy Deductible N/A N/A N/A N/A 90-Day Transition of Coverage (TOC) for pharmacy prior authorization Applies Applies Applies Applies See page 20 for footnotes. 17
Open Access Managed Choice (OAMC) Plan features TX OAMC B2000 Preferred-11 TX OAMC B3000 Preferred-11 Member Benefits In Network Out of Network* In Network Out of Network* Plan Coinsurance 80% 50% 80% 50% Calendar-Year Deductible** Individual $2,000 per member $6,000 per member $3,000 per member $6,000 per member Family 3 member max 3 member max 3 member max 3 member max Calendar-Year Out-of-Pocket Maximum*** Individual $6,000 per member $10,000 per member $6,000 per member $10,000 per member Family 3 member max 3 member max 3 member max 3 member max Lifetime Maximum Benefit Unlimited Unlimited Office Visits (Primary physician/non-specialist) $30 deductible 50% $30 deductible 50% Office Visits (Specialist) $60 deductible 50% $60 deductible 50% Diagnostic Procedures Outpatient Lab $30 50% $30 50% Outpatient X-rays/Testing (Facility) $60 50% $60 50% Complex Imaging 50% 50% 50% 50% Outpatient Therapy Physical, Occupational and Spinal 20 visits per calendar year limit, combined Speech 20 visits per calendar year limit; in network and out of network combined $60 deductible 50% $60 deductible 50% $60 deductible 50% $60 deductible 50% Inpatient Hospital Services Outpatient Surgery Emergency Room (Copay if admitted) 20% professional/ 50% facility 20% professional/ 50% facility 20% Professional/ 50% facility after $250 copay Deductible 50% 20% professional/ 50% facility 50% 20% professional/ 50% facility Paid as in network 20% Professional/ 50% facility after $250 copay Deductible Urgent Care $100 deductible 50% $100 deductible 50% Skilled Nursing Facility 60 days per calendar-year limit Hospice Care Inpatient 20% professional/ 50% facility 20% professional/ 50% facility 50% 20% professional/ 50% facility 50% 20% professional/ 50% facility Outpatient 80% 50% 80% 50% Home Health Care 60 visits per calendar-year limit Durable Medical Equipment ($2,500 per member, per calendar-year maximum) Preventive Care Includes well-child exams, adult physicals, routine gyn, routine mammograms Prescription Drugs Pharmacy Retail, 30-day supply includes oral contraceptives and diabetic supplies 80% 50% 80% 50% 80% 50% 80% 50% $0 deductible 50% $0 deductible 50% 50% 50% Paid as in network $20/$40/$70/30%++ Retail copay + 30% $20/$40/$70/30%++ Retail copay + 30% Pharmacy Deductible N/A N/A N/A N/A 90-Day Transition of Coverage (TOC) for pharmacy prior authorization Applies Applies Applies Applies 50% 50% See page 20 for footnotes. 18
Open Access Managed Choice (OAMC) Plan features TX OAMC B5000 Preferred-11 TX Basic OAMC 2500-11 Member Benefits In Network Out of Network* In Network Out of Network* Plan Coinsurance 80% 50% 70% 50% Calendar-Year Deductible** Individual $5,000 per member $6,000 per member $2,500 per member $4,000 per member Family 3 member max 3 member max 3 member max 3 member max Calendar-Year Out-of-Pocket Maximum*** Individual $6,000 per member $10,000 per member $6,000 per member $10,000 per member Family 3 member max 3 member max 3 member max 3 member max Lifetime Maximum Benefit Unlimited Unlimited Office Visits (Primary physician/non-specialist) See page 20 for footnotes. $35 deductible 50% $35 deductible. See Office Visit Limit+ Office Visits (Specialist) $70 deductible 50% $35 deductible. See Office Visit Limit+ Diagnostic Procedures Outpatient Lab $35 50% 70% 50% Outpatient X-rays/Testing (Facility) $70 50% 70% 50% Complex Imaging 50% 50% 70% 50% Outpatient Therapy Physical, Occupational and Spinal 20 visits per calendar year limit, combined Speech 20 visits per calendar year limit; in network and out of network combined Inpatient Hospital Services Outpatient Surgery Emergency Room (Copay if admitted) $70 deductible 50% $35 deductible. See Office Visit Limit+ $70 deductible 50% $35 deductible. See Office Visit Limit+ 20% professional/ 50% facility 20% professional/ 50% facility 20% Professional/ 50% facility after $250 copay Deductible 50% 50% 50% 50% 50% 70% 50% 50% 70% 50% Paid as in network 70% Paid as in network Urgent Care $100 deductible 50% 70% 50% Skilled Nursing Facility 60 days per calendar-year limit Hospice Care Inpatient 20% professional/ 50% facility 20% professional/ 50% facility 50% 70% 50% 50% 70% 50% Outpatient 80% 50% 70% 50% Home Health Care 60 visits per calendar-year limit Durable Medical Equipment ($2,500 per member, per calendar-year maximum) Preventive Care Includes well-child exams, adult physicals, routine gyn, routine mammograms Prescription Drugs Pharmacy Retail, 30-day supply includes oral contraceptives and diabetic supplies 80% 50% 70% 50% 80% 50% 70% 50% $0 deductible 50% $0 deductible 50% $20/$40/$70/30%++ Retail copay + 30% $15 Generics - No coverage for Brand medications (member pays 100%)++ Pharmacy Deductible N/A N/A N/A N/A 90-Day Transition of Coverage (TOC) for pharmacy prior authorization Applies Applies Applies Applies Retail copay + 30% 19
Footnotes Plans are underwritten by Aetna Life Insurance Company. Please read the notes below. They contain important information about these health plans. * We cover the cost of services based on whether doctors are in network or out of network. We want to help you understand how much Aetna pays for your out-of-network care. At the same time, we want to make it clear how much more you will need to pay for this out-of-network care. You may choose a provider (doctor or hospital) in our network. You may choose to visit an out-of-network provider. If you choose a doctor who is out of network, your Aetna health plan may pay some of that doctor s bill. Most of the time, you will pay a lot more money out of your own pocket if you choose to use an out-of-network doctor or hospital. When you choose out-of-network care, Aetna limits the amount it will pay. This limit is called the recognized or allowed amount. When you choose out-of-network care, Aetna recognizes an amount based on what Medicare pays for these services. The government sets the Medicare rate. Your doctor sets his or her own rate to charge you. It may be higher sometimes much higher than what your Aetna plan recognizes. Your doctor may bill you for the dollar amount that Aetna doesn t recognize. You must also pay any copayments, coinsurance and deductibles under your plan. No dollar amount above the recognized charge counts toward your deductible or out-of-pocket maximums. To learn more about how we pay out-of-network benefits visit www.aetna.com. Type how Aetna pays in the search box. You can avoid these extra costs by getting your care from Aetna s broad network of health care providers. Go to www.aetna.com and click on Find a Doctor on the left side of the page. If you are already a member, sign on to your Aetna Navigator member site. This applies when you choose to get care out of network. When you have no choice (for example, emergency room visit after a car accident, or for other emergency services), we will pay the bill as if you got care in network. You pay cost sharing and deductibles for your in-network level of benefits. Contact Aetna if your provider asks you to pay more. You are not responsible for any outstanding balance billed by your providers for emergency services beyond your cost sharing and deductibles. ** All services subject to deductible unless otherwise noted. In-network and out-of-network expenses accumulate separately and do not cross apply. Three members must individually meet their deductible before the family deductible is considered to have been met. No one family member may contribute more than the individual deductible amount to the family deductible. Deductible does not apply to the out-of-pocket maximum. *** Out-of-pocket maximum excludes deductible, copayments, pharmacy expenses, DME and, for small group plans only, mental health and substance abuse expenses. All other covered expenses (in-network and out-of-network) accumulate separately toward the out-of-pocket maximum and do not cross apply. Three members must individually meet their out-of-pocket maximum before the family out-of-pocket maximum is considered to have been met. + Three in-network office visits per member per year, specialist and non-specialist combined at copay; additional office visits and OON subject to deductible and coinsurance. May be used for routine illness or injury. Preventive care visits do not accumulate toward the three-visit limit. ++Mandatory generics policy applies. This is a partial description of benefits available; for more information, refer to the specific plan design summary. All services are subject to deductible unless otherwise noted. The dollar-amount copayments indicate what the member is required to pay, and the percentage amounts indicate what Aetna is required to pay. Some benefits are subject to limitations or visit maximums. Members or providers may be required to precertify or obtain approval for certain services such as non-emergency hospital care. 20
Health Network Option (HNOption) Plan features TX Health Network Option E20-11 TX Health Network Option E500-11 Member Benefits In Network Out of Network* In Network Out of Network* Plan Coinsurance After deductible 80% 60% 80% 60% Calender-Year Deductible** Individual N/A $1,000 $500 $1,000 Family N/A $2,000 $1,000 $2,000 Out-of-Pocket Maximum*** Individual $2,000 $5,000 $2,500 $5,000 Family $4,000 $10,000 $5,000 $10,000 Lifetime Maximum Benefit Unlimited Unlimited Office Visits (Primary physician/non-specialist)+ $20 deductible 60% $20 deductible 60% Office Visits (Specialist) $40 deductible 60% $40 deductible 60% Diagnostic Procedures Outpatient Lab $0 deductible 60% $0 deductible 60% Outpatient X-rays/Testing (Facility) $20 deductible 60% $20 deductible 60% Complex Imaging 80% 60% 80% 60% Outpatient Therapy Physical and Occupational $40 deductible 60% $40 deductible 60% Speech $40 deductible 60% $40 deductible 60% Inpatient Hospital Services 80% 60% 80% 60% Outpatient Surgery 80% 60% 80% 60% Emergency Room (Copay if admitted) $100 deductible Paid as in network $100 deductible Paid as in network Urgent Care $50 deductible 60% $50 deductible 60% Skilled Nursing Facility 60 days per calendar-year limit 80% 60% 80% 60% Hospice Care Inpatient 80% 60% 80% 60% Outpatient 80% 60% 80% 60% Home Health Care 60 visits per calendar-year limit Durable Medical Equipment ($2,500 per member, per calendar-year maximum) Preventive Care Includes well-child exams, adult physicals, routine gyn, routine mammograms 80% 60% 80% 60% 80% 60% 80% 60% $0 deductible 60% $0 deductible 60% Prescription Drugs Pharmacy Retail, 30-day supply includes oral contraceptives and diabetic supplies $15/$25/$40 N/A $15/$25/$40 N/A Pharmacy Precertification and Step Therapy N/A N/A N/A N/A See page 22 for footnotes. 21
Footnotes Underwritten by Aetna Health Inc. and Aetna Health Insurance Company. Please read the notes below. They contain important information about these health plans. * We cover the cost of services based on whether doctors are in network or out of network. We want to help you understand how much Aetna pays for your out-of-network care. At the same time, we want to make it clear how much more you will need to pay for this out-of-network care. You may choose a provider (doctor or hospital) in our network. You may choose to visit an out-of-network provider. If you choose a doctor who is out of network, your Aetna health plan may pay some of that doctor s bill. Most of the time, you will pay a lot more money out of your own pocket if you choose to use an out-of-network doctor or hospital. When you choose out-of-network care, Aetna limits the amount it will pay. This limit is called the recognized or allowed amount. When you choose out-of-network care, Aetna recognizes an amount based on what Medicare pays for these services. The government sets the Medicare rate. Your doctor sets his or her own rate to charge you. It may be higher sometimes much higher than what your Aetna plan recognizes. Your doctor may bill you for the dollar amount that Aetna doesn t recognize. You must also pay any copayments, coinsurance and deductibles under your plan. No dollar amount above the recognized charge counts toward your deductible or out-of-pocket maximums. To learn more about how we pay out-of-network benefits visit www.aetna.com. Type how Aetna pays in the search box. You can avoid these extra costs by getting your care from Aetna s broad network of health care providers. Go to www.aetna.com and click on Find a Doctor on the left side of the page. If you are already a member, sign on to your Aetna Navigator member site. This applies when you choose to get care out of network. When you have no choice (for example, emergency room visit after a car accident, or for other emergency services), we will pay the bill as if you got care in network. You pay cost sharing and deductibles for your in-network level of benefits. Contact Aetna if your provider asks you to pay more. You are not responsible for any outstanding balance billed by your providers for emergency services beyond your cost sharing and deductibles. ** All services subject to deductible unless otherwise noted. All covered expenses accumulate toward both the in-network and out-of-network deductible. Once the family deductible is met, all family members will be considered as having met their deductible for the remainder of the calendar year. No one family member may contribute more than the individual deductible amount to the family deductible. Deductible does not apply to the out-of-pocket maximum. *** All covered expenses accumulate toward both the in-network and out-of-network out-of-pocket maximum. Out-of-pocket maximum excludes deductible, pharmacy expenses, DME and, for small group plans only, mental health and substance abuse expenses. 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 calendar year. No one family member may contribute more than the individual out-of-pocket maximum amount to the family out-of-pocket maximum. + Referrals are not required for a member to access in-network, covered services. Member will pay the primary physician office visit cost-share when for 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. This is a partial description of benefits available; for more information, refer to the specific plan design summary. All services are subject to deductible unless otherwise noted. The dollar-amount copayments indicate what the member is required to pay, and the percentage amounts indicate what Aetna is required to pay. Some benefits are subject to limitations or visit maximums. Members or providers may be required to precertify or obtain approval for certain services such as non-emergency hospital care. 22
Health Network Option (HNOption) Plan features TX Health Network Option B2000-11 TX Health Network Option B3000-11 Member Benefits In Network Out of Network* In Network Out of Network* Plan Coinsurance 100% 70% 100% 70% Calendar-Year Deductible** Individual $2,000 per member $5,000 per member $3,000 per member $5,000 per member Family 3 member max 3 member max 3 member max 3 member max Out-of-Pocket Maximum*** Individual $1,500 per member $10,000 per member $1,500 per member $10,000 per member Family 3 member max 3 member max 3 member max 3 member max Lifetime Maximum Benefit Unlimited Unlimited Office Visits (Primary physician/non-specialist)+ $35 deductible 70% $35 deductible 70% Specialty Care+ (Office Visit) $60 deductible 70% $60 deductible 70% Diagnostic Procedures Outpatient Lab $35 deductible 70% $35 deductible 70% Outpatient X-rays/Testing (Facility) $35 deductible 70% $35 deductible 70% Complex Imaging 100% 70% 100% 70% Outpatient Therapy Physical and Occupational 20 visits per calendar year limit, combined 100% 70% 100% 70% Speech - 20 visits per calendar year limit 100% 70% 100% 70% Inpatient Hospital Services 100% 70% 100% 70% Outpatient Surgery 100% 70% 100% 70% Emergency Room (Copay if admitted) $200 deductible Paid as in network $250 deductible Paid as in network Urgent Care $75 deductible 70% $75 deductible 70% Skilled Nursing Facility 60 days per calendar-year limit 100% 70% 100% 70% Hospice Care Inpatient 100% 70% 100% 70% Outpatient 100% 70% 100% 70% Home Health Care 60 visits per calendar-year limit Durable Medical Equipment ($2,500 per member, per calendar-year maximum) Preventive Care Includes well-child exams, adult physicals, routine gyn, routine mammograms 100% 70% 100% 70% 100% 70% 100% 70% $0 deductible 70% $0 deductible 70% Prescription Drugs Pharmacy Deductible N/A N/A N/A N/A Prescription Drugs Pharmacy Retail, 30-day supply includes oral contraceptives and diabetic supplies 90-Day Transition of Coverage (TOC) for pharmacy prior authorization and step therapy $20/$40/$70/30%++ N/A $15/$40/$60/30%++ N/A Yes N/A Yes N/A See page 25 for footnotes. 23
Health Network Option (HNOption) Plan features TX Health Network Option B2000 Preferred-11 TX Health Network Option B3000 Preferred-11 Member Benefits In Network Out of Network* In Network Out of Network* Plan Coinsurance 80% 50% 80% 50% Calendar-Year Deductible** $2,000 per member $6,000 per member $3,000 per member $6,000 per member Individual 3 member max 3 member max 3 member max 3 member max Family Out-of-Pocket Maximum*** $4,000 per member $10,000 per member $5,000 per member $12,000 per member Individual 3 member max 3 member max 3 member max 3 member max Family Unlimited Unlimited Lifetime Maximum Benefit $35 deductible 50% $35 deductible 50% Office Visits (Primary physician/non-specialist)+ $70 deductible 50% $70 deductible 50% Specialty Care+ (Office Visit) Diagnostic Procedures $35 50% $35 50% Outpatient Lab $70 50% $70 50% Outpatient X-rays/Testing (Facility) 80% 50% 80% 50% Complex Imaging Outpatient Therapy $70 deductible 50% $70 deductible 50% Physical and Occupational 20 visits per calendar year limit, combined $70 deductible 50% $70 deductible 50% Speech - 20 visits per calendar year limit 20% after $500 per confinement copay 50% after $500 per confinement copay 20% after $500 per confinement copay Inpatient Hospital Services 80% 50% 80% 50% Outpatient Surgery $250 + 20% Deductible Emergency Room (Copay if admitted) Urgent Care Skilled Nursing Facility 60 days per calendar-year limit Hospice Care Paid as in network $250 + 20% Deductible $100 deductible 50% $100 deductible 50% 20% after $500 per confinement copay 20% after $500 per confinement copay 50% after $500 per confinement copay 50% after $500 per confinement copay 20% after $500 per confinement copay 20% after $500 per confinement copay Inpatient 80% 50% 80% 50% Outpatient 80% 50% 80% 50% Home Health Care 60 visits per calendar-year limit Durable Medical Equipment ($2,500 per member, per calendar-year maximum) Preventive Care Includes well-child exams, adult physicals, routine gyn, routine mammograms 80% 50% 80% 50% $0 deductible 50% $0 deductible 50% Prescription Drugs N/A N/A N/A N/A Pharmacy Deductible Prescription Drugs $20/$40/$70/30%++ N/A $20/$40/$70++ N/A Pharmacy Retail, 30-day supply includes oral contraceptives and diabetic supplies 90-Day Transition of Coverage (TOC) for pharmacy prior authorization and step therapy Yes N/A Yes N/A Yes N/A Yes N/A 50% after $500 per confinement copay Paid as in network 50% after $500 per confinement copay 50% after $500 per confinement copay See page 25 for footnotes. 24
Footnotes Underwritten by Aetna Health Inc and Aetna Health Insurance Company. Please read the notes below. They contain important information about these health plans. * We cover the cost of services based on whether doctors are in network or out of network. We want to help you understand how much Aetna pays for your out of Network care. At the same time, we want to make it clear how much more you will need to pay for this out-of-network care. You may choose a provider (doctor or hospital) in our network. You may choose to visit an out-of-network provider. If you choose a doctor who is out of network, your Aetna health plan may pay some of that doctor s bill. Most of the time, you will pay a lot more money out of your own pocket if you choose to use an out-of-network doctor or hospital. When you choose out-of-network care, Aetna limits the amount it will pay. This limit is called the recognized or allowed amount. When you choose out-of-network care, Aetna recognizes an amount based on what Medicare pays for these services. The government sets the Medicare rate. Your doctor sets his or her own rate to charge you. It may be higher sometimes much higher than what your Aetna plan recognizes. Your doctor may bill you for the dollar amount that Aetna doesn t recognize. You must also pay any copayments, coinsurance and deductibles under your plan. No dollar amount above the recognized charge counts toward your deductible or out-of-pocket maximums. To learn more about how we pay out of network benefits visit www.aetna.com. Type how Aetna pays in the search box. You can avoid these extra costs by getting your care from Aetna s broad network of health care providers. Go to www.aetna.com and click on Find a Doctor on the left side of the page. If you are already a member, sign on to your Aetna Navigator member site. This applies when you choose to get care out of network. When you have no choice (for example, emergency room visit after a car accident, or for other emergency services), we will pay the bill as if you got care in network. You pay cost sharing and deductibles for your in-network level of benefits. Contact Aetna if your provider asks you to pay more. You are not responsible for any outstanding balance billed by your providers for emergency services beyond your cost sharing and deductibles. ** All services subject to deductible unless otherwise noted. Three members must individually meet their deductible before other family members will be considered to have met the limit. In-network and out-of-network expenses accumulate separately and do not cross apply. *** Out-of-pocket maximum excludes deductible, pharmacy expenses, DME and, for small group plans only, mental health and substance abuse expenses. All other covered expenses (in-network and out-of-network) accumulate separately toward the out- of-pocket maximum and do not cross apply. Three members must individually meet their out-of-pocket maximum before other family members will be considered to have met the maximum. + Referrals are not required for a member to access in-network, covered services. Member will pay the primary physician office visit cost-share when for 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. ++Mandatory generics policy applies. This is a partial description of benefits available; for more information, refer to the specific plan design summary. All services are subject to deductible unless otherwise noted. The dollar-amount copayments indicate what the member is required to pay, and the percentage amounts indicate what Aetna is required to pay. Some benefits are subject to limitations or visit maximums. Members or providers may be required to precertify or obtain approval for certain services such as non-emergency hospital care. 25
HMO & Health Network Only Plan features Plan Coinsurance After Deductible (applies to most services) TX Health Network Only E20-11 TX HMO E500-11 TX HMO E1000-11 80% 70% 70% Calendar Year Deductible** Individual N/A $500 $1,000 Family N/A $1,000 $2,000 Out-of-Pocket Maximum** Individual $2,500 $2,500 $4,000 Family $5,000 $5,000 $8,000 Lifetime Maximum Benefit Unlimited Unlimited Unlimited Office Visits (Primary physician/non-specialist)+ $20 $25 deductible $25 deductible Office Visits (Specialist) $40 $40 deductible $50 deductible Diagnostic Procedures Outpatient Lab $0 $0 deductible $0 deductible Outpatient X-rays/Testing (Facility) $20 $25 deductible $25 deductible Complex Imaging 80% 70% 70% Outpatient Therapy Physical and Occupational $40 $40 deductible $50 deductible Speech $40 $40 deductible $50 deductible Inpatient Hospital Services 80% 70% 70% Outpatient Surgery 80% 70% 70% Emergency Room (Copay if admitted) $100 $150 deductible $200 deductible Urgent Care $50 $75 deductible $75 deductible Skilled Nursing Facility (60 days per calendar-year limit) 80% 70% 70% Hospice Care Inpatient 80% 70% 70% Outpatient 80% 70% 70% Home Health Care (60 visits per calendar-year limit) Durable Medical Equipment ($2,500 per member, per calendar-year maximum) Preventive Care - Includes well-child exams, adult physicals, routine gyn, routine mammograms 80% 70% 70% 80% 80% 80% $0 $0 deductible $0 deductible Prescription Drugs Pharmacy Retail, 30-day supply includes oral contraceptives and diabetic supplies $15/$25/$40 $15/$35/$50 $15/$40/$60 Pharmacy Precertification and Step Therapy N/A N/A N/A Underwritten by Aetna Health Inc. Please read the notes below. They contain important information about these health plans. * All services subject to deductible unless otherwise noted. All covered expenses accumulate toward both the network and out-of-network deductible. Once the family deductible is met, all family members will be considered as having met their deductible for the remainder of the calendar year. No one family member may contribute more than the individual deductible amount to the family deductible. Deductible does not apply to the out-of-pocket maximum. ** Out-of-pocket maximum does not include deductible or expenses incurred for pharmacy, mental health, substance abuse or DME. Once the family out-ofpocket maximum is met, all family members will be considered as having met their out of pocket maximum for the remainder of the calendar year. + Primary physician (non-specialist) selection and referrals are not required on the TX Health Network Only E20-11. The TX HMO E500-11 and TX HMO E1000-11 plans require the election of PCP and referrals for specialist care. This is a partial description of benefits available; for more information refer to the specific plan design summary. All services are subject to deductible unless otherwise noted. The dollar-amount copayments indicate what the member is required to pay, and the percentage amounts indicate what Aetna is required to pay. Some benefits are subject to limitations or visit maximums. Members or providers may be required to precertify or obtain approval for certain services such as non-emergency hospital care. 26
Aetna Health Fund (AHF) Managed Choice Open Access - HSA/compatible plans Plan features TX HSA 1500 80%-11 TX HSA 3000 90%-11 TX HSA 3500 100%-12 TX HSA 5000 100%-11 Network In Network Out of Network* In Network Out of Network* In-Network Out-of- Network* In Network Plan Coinsurance 80% 60% 90% 70% 100% 70% 100% 70% Calendar-Year Deductible** Individual $1,500 $3,000 $3,000 $6,000 $3,500 $8,000 $5,000 $8,000 Out of Network* Family $3,000 $6,000 $6,000 $12,000 $7,000 $16,000 $10,000 $16,000 Out-of-Pocket Maximum*** Individual $3,000 $6,000 $5,950 $12,000 $3,500 $16,000 $5,000 $16,000 Family $6,000 $12,000 $11,900 $24,000 $7,000 $32,000 $10,000 $32,000 Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Office Visits (Primary physician/non-specialist) 80% 60% 90% 70% 100% 70% 100% 70% Office Visits (Specialist) 80% 60% 90% 70% 100% 70% 100% 70% Diagnostic Procedures Outpatient Lab 80% 60% 90% 70% 100% 70% 100% 70% Outpatient X-rays/Testing (Facility) 80% 60% 90% 70% 100% 70% 100% 70% Outpatient Complex Imaging 80% 60% 90% 70% 100% 70% 100% 70% Outpatient Therapy Physical and Occupational and Spinal - 20 visits per calendar year limit; in network and out of network combined Speech - 20 visits per calendar year limit; in network and out of network combined 80% 60% 90% 70% 100% 70% 100% 70% 80% 60% 90% 70% 100% 70% 100% 70% Inpatient Hospital Services 80% 60% 90% 70% 100% 70% 100% 70% Outpatient Surgery 80% 60% 90% 70% 100% 70% 100% 70% Emergency Room Copay/Coinsurance 80% Paid as in network 90% Paid as in network 100% Paid as in network 100% Paid as in network Urgent Care Copay/Coinsurance 80% 60% 90% 70% 100% 70% 100% 70% Skilled Nursing Facility 60 days per calendar-year limit Hospice Care 80% 60% 90% 70% 100% 70% 100% 70% Inpatient 80% 60% 90% 70% 100% 70% 100% 70% Outpatient 80% 60% 90% 70% 100% 70% 100% 70% Home Health Care 60 visits per calendar-year limit Durable Medical Equipment ($2,500 per member, per calendar-year maximum) Preventive Care Includes well-child exams, adult physicals, routine gyn, routine mammograms 80% 60% 90% 70% 100% 70% 100% 70% 80% 60% 90% 70% 100% 70% 100% 70% $0 deductible Prescription Drugs+ $15/$40/$60 after deductible 60% $0 deductible Retail copay +30% $15/$40/$60 after deductible 70% $0 Deductible Retail copay +30% 100% after deductible 70% $0 deductible 70% after deductible 100% after deductible Pharmacy Precertification and Step Therapy N/A N/A N/A N/A N/A N/A N/A N/A 70% 70% after deductible See page 28 for footnotes. 27
Footnotes Plans are underwritten by Aetna Life Insurance Company. Please read the notes below. They contain important information about these health plans. * We cover the cost of services based on whether doctors are in network or out of network. We want to help you understand how much Aetna pays for your out-of-network care. At the same time, we want to make it clear how much more you will need to pay for this out-of-network care. You may choose a provider (doctor or hospital) in our network. You may choose to visit an out-of-network provider. If you choose a doctor who is out of network, your Aetna health plan may pay some of that doctor s bill. Most of the time, you will pay a lot more money out of your own pocket if you choose to use an out-of-network doctor or hospital. When you choose out-of-network care, Aetna limits the amount it will pay. This limit is called the recognized or allowed amount. When you choose out-of-network care, Aetna recognizes an amount based on what Medicare pays for these services. The government sets the Medicare rate. Your doctor sets his or her own rate to charge you. It may be higher sometimes much higher than what your Aetna plan recognizes. Your doctor may bill you for the dollar amount that Aetna doesn t recognize. You must also pay any copayments, coinsurance and deductibles under your plan. No dollar amount above the recognized charge counts toward your deductible or out-of-pocket maximums. To learn more about how we pay out-of-network benefits visit www.aetna.com. Type how Aetna pays in the search box. You can avoid these extra costs by getting your care from Aetna s broad network of health care providers. Go to www.aetna.com and click on Find a Doctor on the left side of the page. If you are already a member, sign on to your Aetna Navigator member site. This applies when you choose to get care out of network. When you have no choice (for example, emergency room visit after a car accident, or for other emergency services), we will pay the bill as if you got care in network. You pay cost sharing and deductibles for your in-network level of benefits. Contact Aetna if your provider asks you to pay more. You are not responsible for any outstanding balance billed by your providers for emergency services beyond your cost sharing and deductibles. ** All services are subject to deductible except office visits for routine preventive services. For the HSA $3000 90%, HSA $3500 100% and HSA $5000 90% plans, once the family deductible is met, all family members will be considered as having met their deductible for the remainder of the calendar year. No one family member may contribute more than the individual deductible amount to the family deductible. For the HSA $1500 80% plan, the individual deductible 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 deductible is met, all family members will be considered as having met their deductible for the remainder of the calendar year. *** Out-of-pocket maximum includes deductible, member s share of coinsurance, copay (if applicable), and pharmacy expenses. For the HSA $3000 90%, HSA $3500 100%, and HSA $5000 100% plans, 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 calendar year. No one family member may contribute more than the individual out-of-pocket maximum to the family out-of-pocket maximum. For the HSA $1500 80% plan, 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 calendar year. + Prescription drug expenses are integrated with the medical plan (that is, subject to plan deductible and applied toward the out-of- pocket max). This is a partial description of benefits available; for more information, refer to the specific plan design summary. All services are subject to deductible unless otherwise noted. The dollar amount copayments indicate what the member is required to pay, and the percentage amounts indicate what Aetna is required to pay. Some benefits are subject to limitations or visit maximums. Members or providers may be required to precertify or obtain approval for certain services such as non-emergency hospital care. 28
Preferred Provider Organization (PPO) Traditional Choice Plan features TX PPO B1000-11 TX PPO B3000 100%-11 TX Indemnity-11 Member Benefits In Network Out of Network* In Network Out of Network* Plan Coinsurance 80% 60% 100% 70% 70% Calendar-Year Deductible** Individual $1,000 per member $2,000 per member $3,000 per member $5,000 per member $1,000 Family 3 member max 3 member max 3 member max 3 member max 3 member max Calendar-Year Out-of-Pocket Maximum*** Individual $3,000 per member $6,000 per member N/A $7,000 per member $3,000 per member Family 3 member max 3 member max 3 member max 3 member max 3 member max Lifetime Maximum Benefit Unlimited Unlimited Unlimited Office Visits (Primary physician Non-specialist) Office Visits (Specialist) Diagnostic Procedures Outpatient Lab Outpatient X-rays/Testing (Facility) $25 deductible $40 deductible $25 deductible $25 deductible 60% $30 deductible 60% $50 deductible 60% $30 deductible 60% $30 deductible 70% 70% 70% 70% 70% 70% 70% 70% Complex Imaging 80% 60% 100% 70% 70% Outpatient Therapy Physical, Occupational and Spinal 20 visits per calendar year limit, combined Speech - 20 visits per calendar year limit; in network and out of network combined 80% 60% 100% 70% 70% 80% 60% 100% 70% 70% Inpatient Hospital Services 80% 60% 100% 70% 70% Outpatient Surgery 80% 60% 100% 70% 70% Emergency Room (Copay if admitted) Urgent Care Skilled Nursing Facility 60 days per calendar-year limit Hospice Care 80% after $150 deductible $75 deductible Paid as in network $250 deductible 60% $100 deductible Paid as in network 70% 70% 70% 80% 60% 100% 70% 70% Inpatient 80% 60% 100% 70% 70% Outpatient 80% 60% 100% 70% 70% Home Health Care 60 visits per calendar-year limit Durable Medical Equipment ($2,500 per member, per calendar-year maximum) Preventive Care Includes well-child exams, adult physicals, routine gyn, routine mammograms Prescription Drugs Pharmacy Retail, 30-day supply includes oral contraceptives and diabetic supplies 80% 60% 100% 70% 70% 80% 60% 100% 70% 70% $0 deductible 60% $0 deductible 70% $0 deductible $15/$35/$50/30% Retail copay + 30% $15/$40/$60/30% Retail copay + 30% $15/$40/$60 Pharmacy Deductible N/A N/A N/A N/A N/A 90-Day Transition of Coverage (TOC) for Rx Prior Authorization Applies Applies Applies Applies Applies See page 30 for footnotes. 29
Footnotes Plans are underwritten by Aetna Life Insurance Company. Please read the notes below. They contain important information about these health plans. * We cover the cost of services based on whether doctors are in network or out of network. We want to help you understand how much Aetna pays for your out-of-network care. At the same time, we want to make it clear how much more you will need to pay for this out-of-network care. You may choose a provider (doctor or hospital) in our network. You may choose to visit an out-of-network provider. If you choose a doctor who is out of network, your Aetna health plan may pay some of that doctor s bill. Most of the time, you will pay a lot more money out of your own pocket if you choose to use an out-of-network doctor or hospital. When you choose out-of-network care, Aetna limits the amount it will pay. This limit is called the recognized or allowed amount. When you choose out-of-network care, Aetna recognizes an amount based on what Medicare pays for these services. The government sets the Medicare rate. Your doctor sets his or her own rate to charge you. It may be higher sometimes much higher than what your Aetna plan recognizes. Your doctor may bill you for the dollar amount that Aetna doesn t recognize. You must also pay any copayments, coinsurance and deductibles under your plan. No dollar amount above the recognized charge counts toward your deductible or out-of-pocket maximums. To learn more about how we pay out-of-network benefits visit www.aetna.com. Type how Aetna pays in the search box. You can avoid these extra costs by getting your care from Aetna s broad network of health care providers. Go to www.aetna.com and click on Find a Doctor on the left side of the page. If you are already a member, sign on to your Aetna Navigator member site. This applies when you choose to get care out of network. When you have no choice (for example, emergency room visit after a car accident, or for other emergency services), we will pay the bill as if you got care in network. You pay cost sharing and deductibles for your in-network level of benefits. Contact Aetna if your provider asks you to pay more. You are not responsible for any outstanding balance billed by your providers for emergency services beyond your cost sharing and deductibles. ** All services subject to deductible unless otherwise noted. In-network and out-of-network expenses accumulate separately and do not cross apply. Three members must individually meet their deductible before the family deductible is considered to have been met. No one family member may contribute more than the individual deductible amount to the family deductible. Deductible does not apply to the out-of-pocket maximum. *** Out-of-pocket maximum excludes deductible, copayments, pharmacy expenses, DME and, for small group plans only, mental health and substance abuse expenses. All other covered expenses (in-network and out-of-network) accumulate separately toward the out-of-pocket maximum and do not cross apply. Three members must individually meet their out-of-pocket maximum before the family out-of-pocket maximum is considered to have been met. This is a partial description of benefits available; for more information, refer to the specific plan design summary. All services are subject to deductible unless otherwise noted. The dollar-amount copayments indicate what the member is required to pay, and the percentage amounts indicate what Aetna is required to pay. Some benefits are subject to limitations or visit maximums. Members or providers may be required to precertify or obtain approval for certain services such as non-emergency hospital care. 30
Aetna Dental Plans 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. 31
Dental Overview The Mouth Matters SM Research suggests that serious gum disease, known as periodontitis, may be associated with many health problems. This is especially true if gum disease continues without treatment. 1,2 Now, here s the good news. Researchers are discovering that a healthy mouth may be important to your overall health. 1,2 The Aetna Dental/Medical Integration SM (DMI) program, available at no additional charge to plan sponsors that have both medical and dental coverage 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. 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. Participating Dental Network (PDN) plan Members have the choice of using a dentist who participates in Aetna s network or choosing a licensed dentist who is not in the network. Participating dentists have agreed to offer members covered services at a negotiated rate and will not balance bill members for covered services. PDN Max plan The PDN Max plan uses the same PDN network. When members use out-of-network dentists, however, the service will be covered based on the PDN fee schedule, rather than the reasonable-and-customary charge. This means that the member will share in more of the costs and will be balance billed. This plan design enables your customer to offer members a quality plan with a significantly lower premium that encourages in-network usage. 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 PDN 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 fifteenth of the month to be effective the following month. Dual Option* plan In the Dual Option plan design, the DMO may be packaged with any one of the PDN plans. Employees may choose between the DMO and PDN offerings at enrollment. Voluntary Dental option (2-9 group size) 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. 1 MayoClinic.com. Oral health: A window to your overall health. Available online at www.mayoclinic.com/health/dental/de00001. Accessed May 2010. 2 R.C. Williams, A.H. Barnett, N. Claffey, M. Davis, R. Gadsby, M. Kellett, G.Y.H. Lip, and S. Thackray. The potential impact of periodontal disease on general health: a consensus view. Current Medical Research and Opinion, Vol. 24, No. 6, 2008, 1635-1643. * Dual Option does not apply to Voluntary Dental plans (2-9 group size). DMI may not be available in all states. 32
2 9 Standard Dental Plans Option 1 DMO Access Option 2 Option 3 Freedom-of-Choice Monthly selection between the DMO and the PDN Max plans Copay Plan 42 DMO Plan 100/90/60 DMO Plan 100/90/60 Office Visit Copay $10 $5 $5 N/A Annual Deductible per Member (Does not apply to diagnostic and preventive services) PDN Max Plan 100/70/40 None None None $50; 3X Family Maximum Annual Maximum Benefit Unlimited Unlimited Unlimited $1,000 Diagnostic Services Oral Exams Periodic oral exam No Charge 100% 100% 100% Comprehensive oral exam No Charge 100% 100% 100% Problem-focused oral exam No Charge 100% 100% 100% X-rays Bitewing (single film) No Charge 100% 100% 100% Complete series No Charge 100% 100% 100% Preventive Services Adult Cleaning No Charge 100% 100% 100% Child Cleaning No Charge 100% 100% 100% Sealants (per tooth) $10 100% 100% 100% Fluoride application (with cleaning) No Charge 100% 100% 100% Space maintainers $100 100% 100% 100% Basic Services Amalgam filling (2 surfaces) $32 90% 90% 70% Resin filling (2 surfaces, anterior) $55 90% 90% 70% Oral Surgery Extraction (exposed root or erupted tooth) $30 90% 90% 70% Extraction of impacted tooth (soft tissue) $80 90% 90% 70% Major Services* Complete upper denture $500 60% 60% 40% Partial upper denture (resin base) $513 60% 60% 40% Crown Porcelain with noble metal 1 $488 60% 60% 40% Pontic Porcelain with noble metal 1 $488 60% 60% 40% Inlay Metallic (3 or more surfaces) $463 60% 60% 40% Oral Surgery Removal of impacted tooth partially bony $175** 60% 60% 40% Endodontic Services Bicuspid root canal therapy $195 90% 90% 40% Molar root canal therapy $435** 60% 60% 40% Periodontic Services Scaling and root planing (per quadrant) $65 90% 90% 40% Osseous surgery (per quadrant) $445** 60% 60% 40% Orthodontic Services* Not covered Not covered Not covered Not covered Orthodontic Lifetime Maximum Does not apply Does not apply Does not apply Does not apply See page 39 for footnotes. 33
2 9 Standard Dental Plans Option 4 Option 5 Option 6 Option 7 PDN Max Plan 100/80/50 PDN Plan 100/80/50 PDN Plan 100/80/50 Office Visit Copay N/A N/A N/A N/A Annual Deductible per Member (Does not apply to diagnostic and preventive services) PDN Max Plan 80/80/50 $50; 3X Family Maximum $50; 3X Family Maximum $50; 3X Family Maximum $50; 3X Family Maximum Annual Maximum Benefit $1,000 $1,500 $2,000 $1,000 Diagnostic Services Oral Exams Periodic oral exam 100% 100% 100% 80% Comprehensive oral exam 100% 100% 100% 80% Problem-focused oral exam 100% 100% 100% 80% X-rays Bitewing (single film) 100% 100% 100% 80% Complete series 100% 100% 100% 80% Preventive Services Adult Cleaning 100% 100% 100% 80% Child Cleaning 100% 100% 100% 80% Sealants (per tooth) 100% 100% 100% 80% Fluoride application (with cleaning) 100% 100% 100% 80% Space maintainers 100% 100% 100% 80% Basic Services Amalgam filling (2 surfaces) 80% 80% 80% 80% Resin filling (2 surfaces, anterior) 80% 80% 80% 80% Oral Surgery Extraction (exposed root or erupted tooth) 80% 80% 80% 80% Extraction of impacted tooth (soft tissue) 80% 80% 80% 80% Major Services* Complete upper denture 50% 50% 50% 50% Partial upper denture (resin base) 50% 50% 50% 50% Crown Porcelain with noble metal 1 50% 50% 50% 50% Pontic Porcelain with noble metal 1 50% 50% 50% 50% Inlay Metallic (3 or more surfaces) 50% 50% 50% 50% Oral Surgery Removal of impacted tooth partially bony 50% 50% 50% 50% Endodontic Services Bicuspid root canal therapy 50% 50% 80% 50% Molar root canal therapy 50% 50% 80% 50% Periodontic Services Scaling and root planing (per quadrant) 50% 50% 80% 50% Osseous surgery (per quadrant) 50% 50% 80% 50% Orthodontic Services* Not covered Not covered Not Covered Not covered Orthodontic Lifetime Maximum Does not apply Does not apply Does not apply Does not apply See page 39 for footnotes. 34
2 9 Voluntary Dental Plans Option 1 DMO Access (replacement) Option 2 (replacement) Option 3 Freedom-of-Choice Monthly selection between the DMO and the PDN Plan Copay Plan 42 DMO Plan 100/90/60 DMO Plan 100/90/60 Office Visit Copay $15 $10 $5 N/A Annual Deductible per Member (Does not apply to diagnostic and preventive services) PDN Max Plan 100/70/40 None None None $50; 3X Family Maximum Annual Maximum Benefit Unlimited Unlimited Unlimited $1,000 Diagnostic Services Oral Exams Periodic oral exam No Charge 100% 100% 100% Comprehensive oral exam No Charge 100% 100% 100% Problem-focused oral exam No Charge 100% 100% 100% X-rays Bitewing (single film) No Charge 100% 100% 100% Complete series No Charge 100% 100% 100% Preventive Services Adult Cleaning No Charge 100% 100% 100% Child Cleaning No Charge 100% 100% 100% Sealants (per tooth) $10 100% 100% 100% Fluoride application (with cleaning) No Charge 100% 100% 100% Space maintainers $100 100% 100% 100% Basic Services Amalgam filling (2 surfaces) $32 90% 90% 70% Resin filling (2 surfaces, anterior) $55 90% 90% 70% Oral Surgery Extraction (exposed root or erupted tooth) $30 90% 90% 70% Extraction of impacted tooth (soft tissue) $80 90% 90% 70% Major Services* Complete upper denture $500 60% 60% 40% Partial upper denture (resin base) $513 60% 60% 40% Crown Porcelain with noble metal 1 $488 60% 60% 40% Pontic Porcelain with noble metal 1 $488 60% 60% 40% Inlay Metallic (3 or more surfaces) $463 60% 60% 40% Oral Surgery Removal of impacted tooth partially bony $175** 60% 60% 40% Endodontic Services Bicuspid root canal therapy $195 90% 90% 40% Molar root canal therapy $435** 60% 60% 40% Periodontic Services Scaling and root planing (per quadrant) $65 90% 90% 40% Osseous surgery (per quadrant) $445** 60% 60% 40% Orthodontic Services* Not covered Not covered Not covered Not covered Orthodontic Lifetime Maximum Does not apply Does not apply Does not apply Does not apply See page 39 for footnotes. 35
2 9 Voluntary Dental Plans Option 4 Option 5 Option 6 (replacement) Option 7 (new) PDN Plan 100/80/50 PDN Plan 100/80/50 PDN Plan 100/80/50 Office Visit Copay N/A N/A N/A N/A Annual Deductible per Member (Does not apply to diagnostic and preventive services) PDN Max Plan 80/80/50 $50; 3X Family Maximum $50; 3X Family Maximum $50; 3X Family Maximum $50; 3X Family Maximum Annual Maximum Benefit $1,500 $2,000 $2,000 $1,000 Diagnostic Services Oral Exams Periodic oral exam 100% 100% 100% 80% Comprehensive oral exam 100% 100% 100% 80% Problem-focused oral exam 100% 100% 100% 80% X-rays Bitewing (single film) 100% 100% 100% 80% Complete series 100% 100% 100% 80% Preventive Services Adult Cleaning 100% 100% 100% 80% Child Cleaning 100% 100% 100% 80% Sealants (per tooth) 100% 100% 100% 80% Fluoride application (with cleaning) 100% 100% 100% 80% Space maintainers 100% 100% 100% 80% Basic Services Amalgam filling (2 surfaces) 80% 80% 80% 80% Resin filling (2 surfaces, anterior) 80% 80% 80% 80% Oral Surgery Extraction (exposed root or erupted tooth) 80% 80% 80% 80% Extraction of impacted tooth (soft tissue) 80% 80% 80% 80% Major Services* Complete upper denture 50% 50% 50% 50% Partial upper denture (resin base) 50% 50% 50% 50% Crown Porcelain with noble metal 1 50% 50% 50% 50% Pontic Porcelain with noble metal 1 50% 50% 50% 50% Inlay Metallic (3 or more surfaces) 50% 50% 50% 50% Oral Surgery Removal of impacted tooth partially bony 50% 50% 50% 50% Endodontic Services Bicuspid root canal therapy 50% 50% 80% 50% Molar root canal therapy 50% 50% 80% 50% Periodontic Services Scaling and root planing (per quadrant) 50% 50% 80% 50% Osseous surgery (per quadrant) 50% 50% 80% 50% Orthodontic Services* Not covered Not covered Not covered Not covered Orthodontic Lifetime Maximum Does not apply Does not apply Does not apply Does not apply See page 39 for footnotes. 36
10-100 Standard and Voluntary Dental Plans Option 1A DMO Fixed Copay Option 2A Freedom of Choice Monthly selection between the DMO and the PDN plans Option 3A PDN Max 1000 Copay Plan 67 DMO Plan 100/100/60 PDN Plan 100/80/50 Office Visit Copay $10 $10 N/A N/A Annual Deductible per Member (Does not apply to diagnostic and preventive services) PDN Max Plan 100/80/50 None None $50; 3X Family Maximum $50; 3X Family Maximum Annual Maximum Benefit Unlimited Unlimited $1,000 $1,000 Diagnostic Services Oral Exams Periodic oral exam No Charge 100% 100% 100% Comprehensive oral exam No Charge 100% 100% 100% Problem-focused oral exam No Charge 100% 100% 100% X-rays Bitewing (single film) No Charge 100% 100% 100% Complete series No Charge 100% 100% 100% Preventive Services Adult Cleaning No Charge 100% 100% 100% Child Cleaning No Charge 100% 100% 100% Sealants (per tooth) $10 100% 100% 100% Fluoride application with cleaning No Charge 100% 100% 100% Space maintainers $80 100% 100% 100% Basic Services Amalgam filling (2 surfaces) No Charge 100% 80% 80% Resin filling (2 surfaces, anterior) No Charge 100% 80% 80% Endodontic Services Bicuspid root canal therapy $180 100% 80% 80% Periodontic Services Scaling and root planing - per quadrant $60 100% 80% 80% Oral Surgery Extraction (exposed root or erupted tooth) No Charge 100% 80% 80% Extraction of impacted tooth (soft tissue) $60 100% 80% 80% Major Services* Complete upper denture $320 60% 50% 50% Partial upper denture (resin base) $320 60% 50% 50% Crown Porcelain with noble metal 1 $315 60% 50% 50% Pontic Porcelain with noble metal 1 $315 60% 50% 50% Inlay Metallic (3 or more surfaces) $225 60% 50% 50% Oral Surgery Removal of impacted tooth partially bony $80 60% 50% 50% Endodontic Services Molar root canal therapy $300 60% 50% 50% Periodontic Services Osseous surgery (per quadrant) $375 60% 50% 50% Orthodontic Services* $2,400 copay $2,300 copay 50% 50% Orthodontic Lifetime Maximum Does not apply Does not apply $1,000 $1,000 See page 40 for footnotes. 37
10-100 Standard and Voluntary Dental Plans Option 4A PDN 1000 Option 5 Option 5A PDN 1500 PDN Plan 100/80/50 PDN Plan 100/80/50 Office Visit Copay N/A N/A N/A Annual Deductible per Member (Does not apply to diagnostic and preventive services) PDN Plan 100/80/50 $50; 3X Family Maximum $50; 3X Family Maximum $50; 3X Family Maximum Annual Maximum Benefit $1,000 $1,500 $2,000 Diagnostic Services Oral Exams Periodic oral exam 100% 100% 100% Comprehensive oral exam 100% 100% 100% Problem-focused oral exam 100% 100% 100% X-rays Bitewing (single film) 100% 100% 100% Complete series 100% 100% 100% Preventive Services Adult Cleaning 100% 100% 100% Child Cleaning 100% 100% 100% Sealants (per tooth) 100% 100% 100% Fluoride application with cleaning 100% 100% 100% Space maintainers 100% 100% 100% Basic Services Amalgam filling (2 surfaces) 80% 80% 80% Resin filling (2 surfaces, anterior) 80% 80% 80% Endodontic Services Bicuspid root canal therapy 80% 80% 80% Periodontic Services Scaling and root planing - per quadrant 80% 80% 80% Oral Surgery Extraction (exposed root or erupted tooth) 80% 80% 80% Extraction of impacted tooth (soft tissue) 80% 80% 80% Major Services* Complete upper denture 50% 50% 50% Partial upper denture (resin base) 50% 50% 50% Crown Porcelain with noble metal 1 50% 50% 50% Pontic Porcelain with noble metal 1 50% 50% 50% Inlay Metallic (3 or more surfaces) 50% 50% 50% Oral Surgery Removal of impacted tooth partially bony 50% 50% 80% Endodontic Services Molar root canal therapy 50% 80% 80% Periodontic Services Osseous surgery (per quadrant) 50% 80% 80% Orthodontic Services* 50% 50% 50% Orthodontic Lifetime Maximum $1,000 $1,500 $1,500 See page 40 for footnotes. 38
Footnotes 2 9 Standard Dental Plans * 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 1-3. ** Specialist procedures are not covered by the plan when performed by a participating specialist. However, the service is available to the member at a discount. The copay amounts, including the office visit and ortho copays, on the DMO in Plan Options 1, 2 and 3 are member responsibility. 1 There will be an additional patient charge for the actual cost for gold/high noble metal for these procedures on the DMO in Plan Option 1. Most oral surgery, endodontic and periodontic services are covered as basic services on the DMO in Plan Options 1-3. All endodontic and periodontic services are covered as basic services on the PDN in Plan Option 6. Plan Options 3, 4, and 7 PDN 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. The DMO in Plan Options 1 and 2 can be offered with any one of the plans in Plan Options 4, 5-7 in a Dual Option package. DMO Access: Apart from the DMO network and DMO plan of benefits, members under this plan also have access to the Aetna Dental Access network. This network provides access to providers who participate in the Aetna Dental Access network and have agreed to charge a negotiated discounted fee. Members can access this network for any service. However, the DMO benefits do not apply. In situations where the dentist participates in both the Aetna Dental Access network and the Aetna DMO network, DMO benefits take precedence over all other discounts including discounts through the Aetna Dental Access network. Aetna Dental Access network is not insurance or a benefits plan. It only provides access to discounted fees for dental services obtained from providers who participate in the Aetna Dental Access network. Members are solely responsible for all charges incurred using this access, and are expected to make payment to the provider at the time of treatment. Above list of covered services is representative. Full list with limitations as determined by Aetna appears in the plan booklet/ certificate. For a summary list of Limitations and Exclusions, refer to page 62. 2 9 Voluntary Dental Plans * 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 1-3. ** Specialist procedures are not covered by the plan when performed by a participating specialist. However, the service is available to the member at a discount. The copay amounts, including the office visit and ortho copays, on the DMO in Voluntary Plan Options 1, 2 and 3 are member responsibility. 1 There will be an additional patient charge for the actual cost for gold/high noble metal for these procedures on the DMO in Plan Option 1. Most oral surgery, endodontic and periodontic services are covered as basic services on the DMO in Voluntary Options 2 and 3. All endodontic and periodontic services are covered as basic services on the PDN in Plan Voluntary Option 6. Voluntary Plan Options 3, and 7; PDN 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. 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. 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 62. 39
Footnotes 10 100 Standard and Voluntary Dental Plans The copay amounts, including the office visit and ortho copays on the DMO in Plan Options 1A and 2A are member responsibility. 1 There will be an additional patient charge for the actual cost for gold/high noble metal for these procedures on the DMO in Plan Option 1A. Most oral surgery, endodontic and periodontic services are covered as basic services. All endodontic and periodontic services are covered as basic services on the PDN in Plan Options 5A & 6A. Coverage for implants is included on the PDN in Plan Options 2A, and 6A. Plan Option 3A: PDN 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. The DMO in Plan Option 1A can be offered with any one of the plans in Plan Options 3A - 6A in a Dual Option package. Orthodontic coverage is available on the DMO in Plan Options 1A and 2A to adults and children. Orthodontic coverage is available on the PPO in Plan Options 2A - 6A to dependent children only. Plan features and availability may vary by location and are subject to change. Information is believed to be accurate as of the production date; however, it is subject to change. Voluntary Plans: 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. Above list of covered services is representative. Full list with limitations as determined by Aetna appears in the plan booklet/ certificate. For a summary list of Limitations and Exclusions, refer to page 62. 40
Aetna Life & Disability Group life and disability is an affordable way to provide life insurance and disability benefits to employees that will help them establish financial protection for themselves and their families. 41
Life & Disability Overview Aetna Life Insurance Company (Aetna) Small Group packaged life and disability insurance plans include a range of flat-dollar insurance options bundled together in one monthly per-employee rate. These products are easy to understand and offer affordable benefits to help your employees protect their families in the event of illness, injury or death. You ll benefit from streamlined plan installation, administration and claims processing, and all of the benefits of our stand-alone life and disability products for small groups. Or, simply choose from our portfolio of group basic term life and disability insurance plans. For groups with 51-100 eligibles, please consult your Aetna representative. Life insurance We know that life insurance is an important part of the benefits package you offer your employees. That s why our products and programs are designed to meet your needs for: Flexibility Added value Cost-efficiency Experienced support We help you give employees what they re looking for in lifestyle protection, through our selected group life insurance options. And we look beyond the benefit payout to include useful enhancements through the Aetna Life Essentials SM program. 42