Innovation Health Plan Guide For businesses with 51 100 eligible employees Plans effective January 1, 2014 innovation-health.com 71.02.302.1-IH (11/13)
Team up with us for the health of your business. Introducing a new suite of products and services designed to transform the way health care is delivered. Innovation Health is the brand name used for products and services provided by Innovation Health Insurance Company and Innovation Health Plan, Inc. Health benefits and health insurance plans are offered and/or underwritten by Innovation Health Plan, Inc. and Innovation Health Insurance Company. Innovation Health Insurance Company and Innovation Health Plan, Inc. (Innovation Health) are affiliates of Inova and Aetna Life Insurance Company (Aetna) and its affiliates. Aetna provides certain administrative services to Innovation Health.
You can count on us to provide health plans that help simplify decision making and plan administration so you can focus on the health of your business. Innovation Health is the result of a unique partnership between two industry leaders: Inova and Aetna. As leaders in health, we are redefining the future. Through innovation in technology, information sharing, advanced health care delivery systems and aligned incentives, our unique partnership will allow us to offer a health benefits and insurance plan that supports better health and an improved health care experience at an affordable price. One way this will be achieved is to provide access to a variety of Aetna programs and services. With Aetna providing certain management services for your plan, you now have access to the following Aetna Programs. In this guide: 4 Innovation Health Aetna and Inova Partnership 7 Medical overview 10 Managing health care expenses 12 Medical plan options 27 Dental overview 28 Dental plan options 33 Life & disability overview 35 Underwriting guidelines 42 Product specifications 47 Limitations and exclusions 3
Aetna and Inova: A unique partnership to provide affordable, quality health care benefits Innovation Heath A whole new way of looking at health care Innovation Health is the result of a unique partnership between Aetna and Inova designed to deliver a health plan that facilitates an integrated, enhanced patient experience at a lower cost. When we bring the right people and technology together, patients benefit and costs go down. By fundamentally changing how health care is delivered, Innovation Health is creating innovative, long-term health care solutions. Bringing quality and value to our customers and community through this unique partnership. We will do this by: Focusing on avoiding duplicate tests and treatments Providing tools that help prevent harmful drug interactions Focusing on identifying gaps in care before expensive intervention is needed Coaching and supporting patients to follow treatment plans Delivering wellness programs to help keep employees healthy and productive Identifying and reaching out to employees who need preventive screenings Helping providers to effectively treat the whole person 4
Coordinated care management that works for you Enhanced communication and coordination between the health care teams eventually leads to more effective patient care and lower costs. We leverage our services, tools and technology to focus on promoting wellness and improving patient outcomes. The change is about redefining the future of health care. Here s what s different. Innovation Health will: Employ a team-based care management approaches with stronger collaboration and communication between health professionals in the system Use technology to identify patients who need help and support earlier in order to avoid complications Improve care management by giving doctors up-to-date information and a complete picture of patient health to help them make smarter, more informed health care decisions Provide a personalized health care experience with access to wellness programs and health care services tailored to individual member s needs Patient-focused, quality-focused, health care solutions The Aetna and Inova partnership combines long-standing local, regional and national experience to deliver sustainable solutions for quality, affordable health care. Aetna s broad national network includes: More than 1 million health care professionals More than 587,000 primary care doctors and specialists More than 5,400 hospitals The existing Aetna network in Northern Virginia consists of 21 hospitals, 6,000 physicians and providers, and 200 facilities and ancillaries, such as urgent care, home health, radiology centers and ambulatory surgery centers The Inova System includes: Five hospitals with over 1,877 licensed beds More than 3,720 affiliated physicians More than 80 ambulatory care locations (non-hospital sites of care) All five of Inova s hospitals have been recognized by as Best Hospital for 2012 13 Inova s hospitals have received multiple Gold Seals of Approval from The Joint Commission Visit www.inova.org/awards to learn more about Inova s awards and accreditations For more information, call your broker or your Aetna/Innovation Health sales representative at 1-855-228-0510, or visit online at innovation-health.com. 5
As leaders in health, we are redefining the future Through innovation in technology, information sharing, advanced health care delivery systems and aligned incentives, our unique partnership will allow us to deliver better health and an improved health care experience at an affordable price. Our mission is to improve the health of the diverse community we serve through excellence in patient care, stated Knox Singleton, CEO, Inova Health System. This innovative relationship with Aetna responsibly addresses long-standing challenges related to the quality and expense of care, physician participation and patient satisfaction. Together, we are streamlining the process to empower patients while better engaging payers and physicians. Taken as a whole, we are forging a higher standard of health care for Northern Virginia consumers. Both Inova and Aetna believe that shared accountability translates into a powerful new value proposition for consumers, said Mark T. Bertolini, Aetna chairman, CEO and president. This joint venture with the region s largest health system signals a new level of Aetna s commitment to payment reform and stronger provider collaboration. It is a significant step forward for our customers and members. Through our joint arrangement we will deliver a better, more affordable health care experience. 2012: Employers health costs have risen 20% in five years, 9.3% just in the last year.1 2006: Medication-related injuries harm 1.5 million people per year and cost $3.5 billion.2 2010: The United States ranks 31 st internationally for infant mortality.3 12012 Towers Watson/National Business Group on Health Employer Survey. 2 June 2010 Academy of Managed Care Pharmacy, The Academy of Managed Care Pharmacy s Concepts in Managed Care Pharmacy Medication Errors. 32010 Adapted from Organization for Economic Cooperation and Development, OECD Health Data. 6
Medical Overview We are committed to putting the employee at the center of everything we do. You can count on us to provide health plans that help simplify decision making and plan administration so you can focus on the health of your business. Virginia Provider Network* Great coverage begins with a solid network. Aetna s large and diverse network of health care professionals gives your employees many options for quality and cost-effective care. Participating pharmacies include leading chains like Rite Aid, CVS, Eckerd, Wal-Mart and many supermarket pharmacies. Throughout Virginia, Maryland and DC,** the provider network includes: Service for over 120 counties and communities across the state. A system of more than 180 hospitals and clinics. More than 1,500 physicians. Virginia Provider Network Area Loudoun City of Fairfax Falls Church Manassas Park Manassas Fairfax Prince William Arlington Alexandria Stafford Fredericksburg Spotsylvania *Network subject to change. **Data as of August 2011. Actual provider count is dependent on specific network participation. 7
High HSA-compatible plans These insurance plan options are compatible with a health savings account (HSA). These plans 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 help cover their future medical and dental expenses. HSA accounts can be funded by the employer or employee and are portable. Fund contributions may be tax (limits apply). When funds are used to cover qualified out-of-pocket medical and dental expenses, they are not taxed. Plan Name Product Description PCP Required Referrals Required Network HMO Open HMO Open HMO Option A health maintenance organization (HMO) uses a network of participating providers. Each enrolled family member selects a primary care physician (PCP) participating in the network. The PCP provides routine and preventive care and helps coordinate the member s total health care. The PCP refers members to participating specialists and facilities for medically necessary specialty care. Only services provided or referred by the PCP are covered, except for emergency, urgently needed care or direct-access benefits, unless approved by the HMO in advance of receiving services. A health maintenance organization (Open HMO) uses a network of participating providers. Each enrolled family member may select a primary care physician (PCP) participating in the network to provide routine and preventive care and help coordinate the member s total health care. Members never need a referral when visiting a participating specialist for covered services. Only services rendered by a participating provider are covered, except for emergency or urgently needed care. Open HMO Option is a two-tiered product that allows members to access care in or out of network. Members have lower out-of-pocket costs when they use the in-network tier of the plan. Member cost sharing increases if members decide to go out of network. Members may go to their PCP or directly to a participating specialist without a referral. It is their choice, each time they seek care. Yes Yes HMO Optional No Open HMO Optional No Open HMO Option 8
Plan Name Product Description PCP Required Referrals Required Network Open HMO Option Health Fund HRA Open POS Plus PPO Indemnity The Open HMO Option Health Fund HRA plan blends traditional health coverage with a fund benefit to help pay for eligible medical expenses. This health insurance plan offers members the freedom to seek care from any licensed health care professional without a referral, and a fund to help pay for services that are covered under the plan. Members can stretch their fund by seeking the most cost-effective care and services. The Open HMO Option plan provides: An opportunity to build the fund and apply it toward future medical expenses. Traditional coverage for eligible expenses over the fund amount. A cap that limits the total amount a member pays annually for eligible expenses. How it works: Use the health fund to pay for medical expenses. Unused fund balance rolls over to next year s fund balance, as long as the member remains in the plan and with his or her current employer. If the fund is depleted, the member pays for remaining or future expenses until the is met. If the fund is depleted and the is met, the base medical benefits plan begins meaning the member pays a coinsurance and/or copayment for remaining covered expenses. Open POS Plus members can access any recognized provider for covered services without a referral. Each time members seek health care, they have the freedom to choose either network providers at lower out-of-pocket costs, or non-network providers at higher out-of-pocket costs. PPO plan members can access any recognized provider for covered services without a referral. Each time members seek health care, they have the freedom to choose either network providers at lower out-of-pocket costs, or non-network providers at higher out-of-pocket costs. The indemnity plan option is available for employees who live outside the plan s network service area. Members coordinate their own health care and may access any recognized provider for covered services without a referral. Optional No Open HMO Option Optional No Open POS Plus No No PPO No No N/A 9
Group Situs Medical benefits and rates are based on the group s headquarters location, subject to applicable state laws. Eligible employees who live or work in VA, MD and DC will receive the same rates and benefits as the headquarters location in Virginia. No-Cost-Health Incentive* Members can earn $50 in just a few simple steps Members earn a $50 credit toward their and coinsurance when they: Complete or update their Simple Steps To A Healthier Life health assessment, and Complete one online wellness program If the employee's spouse is covered under the plan, he or 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 and coinsurance amounts. This program is included at no additional cost on all plans, except with VA IH Open HMO 250A, VA IH Open HMO 500A and HSA-compatible plans. Health Savings Account (HSA) No set-up or administrative fees The Health Fund HSA, when coupled with an HSA-compatible, high- health benefits and health insurance plan, is a tax-advantaged savings account. Once the employee is enrolled, either the employee or the employer can make account contributions. The HSA can be used to pay for qualified expenses tax free. Member s HSA plan Health Savings Account Member owns it Member and employer may contribute tax free Member chooses how and when to use HSA dollars Roll it over each year and let it grow Earns interest, tax free Today Use for qualified expenses with tax-free dollars Future Plan for future and retiree health-related costs High- health plan Eligible in-network preventive care services will not be subject to the Member pays 100 percent until is met, then only pays a share of the cost Once member meets out-of-pocket maximum, then plan pays 100 percent of in-network care 10
Health Reimbursement Arrangement (HRA) The Health Fund HRA combines the protection of a -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 and fund rollover. 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. Our consumer-directed health products and services give members the information and resources they need to help make informed health care decisions for themselves and their families while helping lower employers costs. COBRA administration Innovation Health COBRA administration offers a full range of notification, documentation and record keeping processes that can help employers manage the complex billing and notification processes required for COBRA compliance, while also helping to save them time and money. Section 125 Cafeteria Plans and Section 132 Transit Reimbursement accounts Employees can reduce their taxable income, and employers can pay less in payroll taxes. There are three ways to save: Premium-Only Plans (POP) Employees can pay for their portion of the group health insurance expenses on a pretax basis. Flexible Savings Account (FSA) FSAs give employees a chance to save for health expenses with pretax money. Health care spending accounts allow employees to set aside pretax dollars to pay for 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. Administrative Fees Fee description HSA Fee Initial set-up $0 Monthly fees $0 Premium-Only Plan (POP) Initial set-up* $190 Renewal $125 Health Reimbursement Arrangement (HRA) and Flexible Spending Account (FSA)** Initial set-up 51 100 employees $560 $335 Monthly fees*** Additional set-up fee for stacked plans (those electing an Innovation Health HRA and FSA simultaneously) Participation fee for stacked participants $5.45 per participant $150 $10.45 per participant Renewal fee Minimum fees 51 100 employees $50 per month minimum COBRA Services Annual fee 51 100 employees $230 Per employee per month 51 100 employees $1.05 Initial notice fee $3.00 per notice (includes notices at time of implementation and during ongoing administration) Minimum fees 51 100 employees $50 per month minimum Transit Reimbursement Account (TRA) Annual fee $350 Transit monthly fees $4.25 per participant Parking monthly fees $3.15 per participant * Nondiscrimination testing provided annually after open enrollment for POP and FSA only. Additional off-cycle testing available at employer request for $100 fee. Nondiscrimination testing only available for FSA and POP products. ** Innovation Health FSA pricing is inclusive for POP. Debit cards are available for FSA only. Contact Innovation Health for more information. *** For HRA, if the employer opts out of Streamline, the fee is increased $1.50 per participant. For FSA, the debit card is available for an additional $1 per participant per month. Mailing reimbursement checks direct to employee homes is an additional $1 per participant per month. Innovation Health HRAs are subject to employer-defined use and forfeiture rules. Innovation Health reserves the right to change any of the above fees and to impose additional fees upon prior written notice. Aetna provides certain management services in connection with the Innovation Health benefit plans. These services include but are not limited to: tax advantaged accounts, COBRA services, medical management programs provided by Aetna as well as programs that Aetna secures from third parties. You may receive letters, e-mails and/or phone calls from Aetna or third parties related to such services or programs. Investment services are independently offered by the HSA administrator. 11
Traditional Open HMO Plans Plan Name VA IH Open HMO 250A* VA IH Open HMO 500A* VA IH Open HMO 90%* VA IH Open HMO 80%* Member Benefits Participating Providers Participating Providers Participating Providers Participating Providers Plan Year Deductible 2 Plan Year Out-of-Pocket Limit $0 Individual/ $0 Family $3,000 Individual/ $6,000 Family $0 Individual/ $0 Family $3,000 Individual/ $6,000 Family $0 Individual/ $0 Family $4,000 Individual/ $8,000 Family $0 Individual/ $0 Family $4,000 Individual/ $8,000 Family Deductible and Out-of-Pocket Limit Embedded Embedded Embedded Embedded Accumulation 3 Not Included In Out-of-Pocket Limit Non-covered expenses Non-covered expenses Non-covered expenses Non-covered expenses Primary Care Physician Office Visit $20 copay $20 copay $25 copay $25 copay Specialist Office Visit $30 copay $40 copay $50 copay $50 copay Walk-In Clinic Visit $20 copay $20 copay $25 copay $25 copay Chiropractic Services (20 visits per plan year) 25% 25% 25% 25% Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) $0 copay $0 copay $0 copay $0 copay Diagnostic Testing: Lab $0 copay $0 copay $0 copay $0 copay Diagnostic Testing: X-ray $30 copay $40 copay $50 copay $50 copay Imaging (MRA/MRS, MRI, PET and CAT scans) $100 copay $200 copay $200 copay $200 copay Prescription Drug Deductible Not applicable Not applicable Not applicable Not applicable Prescription Drugs (Up to 30-day supply) 4 : Preferred generic drugs/preferred brand drugs/ Non-preferred generic and brand drugs. Two-times the 30-day supply cost-sharing for up to 90-day supply. Aetna Specialty CareRx SM Drugs 4 (Up to 30-day supply for self-injectable, infused and oral specialty drugs, excludes insulin) Option 1: $10/$25/$50 Option 2: $10/$35/$60 Option 1: $100 copay Option 2: $200 copay Option 1: $10/$25/$50 Option 2: $10/$35/$60 Option 1: $100 copay Option 2: $200 copay $10/$35/$60 $10/$35/$60 $200 copay $200 copay Outpatient Surgery $50 copay $300 copay 10% 20% Emergency room (Copay is waived if admitted.) $150 copay $200 copay $200 copay $200 copay Urgent Care $50 copay $75 copay $75 copay $75 copay Inpatient Hospital Facility Rehabilitation services (PT/OT/ST) (30 visits per plan year, PT/OT combined, and 30 visits per plan year, ST) $250 copay per admission $500 copay per admission 10% 20% $30 copay $40 copay $50 copay $50 copay Refer to pages 25 26 for important plan provisions. 12
Traditional Open HMO Plans Plan Name VA IH Open HMO 70%* VA IH Open HMO 60%* VA IH Open HMO 2000 70%* Member Benefits Participating Providers Participating Providers Participating Providers Plan Year Deductible 2 Plan Year Out-of-Pocket Limit $0 Individual/ $0 Family $4,000 Individual/ $8,000 Family $0 Individual/ $0 Family $4,000 Individual/ $8,000 Family $2,000 Individual/ $4,000 Family $5,000 Individual/ $10,000 Family Deductible and Out-of-Pocket Limit Embedded Embedded Embedded Accumulation 3 Not Included In Out-of-Pocket Limit Non-covered expenses Non-covered expenses Non-covered expenses Primary Care Physician Office Visit $25 copay $25 copay $25 copay, waived Specialist Office Visit $50 copay $50 copay $50 copay, waived Walk-In Clinic Visit $25 copay $25 copay $25 copay, waived Chiropractic Services (20 visits per plan year) 25% 25% 25% after Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) $0 copay $0 copay $0 copay, waived Diagnostic Testing: Lab $0 copay $0 copay $0 copay after Diagnostic Testing: X-ray $50 copay $50 copay $50 copay after Imaging (MRA/MRS, MRI, PET and CAT scans) $200 copay $200 copay $200 copay after Prescription Drug Deductible Not applicable Not applicable Not applicable Prescription Drugs (Up to 30-day supply) 4 : Preferred generic drugs/preferred brand drugs/ Non-preferred generic and brand drugs. Two-times the 30-day supply cost-sharing for up to 90-day supply. Aetna Specialty CareRx SM Drugs 4 (Up to 30-day supply for self-injectable, infused and oral specialty drugs, excludes insulin) $10/$35/$60 $10/$35/$60 $10/$35/$60 $200 copay $200 copay $200 copay Outpatient Surgery 30% 40% 30% after Emergency room (Copay is waived if admitted.) $200 copay $200 copay $200 copay after Urgent Care $75 copay $75 copay $75 copay after Inpatient Hospital Facility 30% 40% 30% after Rehabilitation services (PT/OT/ST) (30 visits per plan year, PT/OT combined, and 30 visits per plan year, ST) $50 copay $50 copay $50 copay after Refer to pages 25 26 for important plan provisions. 13
Consumer-Directed Open HMO HSA-Compatible Plans Plan Name VA IH Open HMO 1500 HSA* VA IH Open HMO 2500 HSA* Member Benefits Participating Providers Participating Providers Plan Year Deductible 2 Plan Year Out-of-Pocket Limit $1,500 Individual/ $3,000 Family $3,000 Individual/ $6,000 Family $2,500 Individual/ $5,000 Family $5,000 Individual/ $10,000 Family Deductible and Out-of-Pocket Limit Non-embedded Non-embedded Accumulation 3 Not Included In Out-of-Pocket Limit Non-covered expenses Non-covered expenses Primary Care Physician Office Visit Specialist Office Visit Walk-In Clinic Visit $20 copay after $40 copay after $20 copay after $30 copay after $50 copay after $30 copay after Chiropractic Services (20 visits per plan year) 25% after 25% after Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) Diagnostic Testing: Lab Diagnostic Testing: X-ray Imaging (MRA/MRS, MRI, PET and CAT scans) Prescription Drug Deductible Prescription Drugs (Up to 30-day supply) 4 : Preferred generic drugs/preferred brand drugs/ Non-preferred generic and brand drugs. Two-times the 30-day supply cost-sharing for up to 90-day supply. Aetna Specialty CareRx SM Drugs 4 (Up to 30-day supply for self-injectable, infused and oral specialty drugs, excludes insulin) Outpatient Surgery Emergency room (Copay is waived if admitted.) Urgent Care Inpatient Hospital Facility Rehabilitation services (PT/OT/ST) (30 visits per plan year, PT/OT combined, and 30 visits per plan year, ST) $0 copay, waived $40 copay after $40 copay after $200 copay after Integrated with medical $10/$35/$60 after $200 copay after $300 copay after $200 copay after $75 copay after $500 copay per admission after $40 copay after $0 copay, waived $50 copay after $50 copay after $200 copay after Integrated with medical $10/$35/$60 after $200 copay after $200 copay after $200 copay after $75 copay after $300 copay per day, 5 day copay max per admission, after $50 copay after Refer to pages 25 26 for important plan provisions. 14
Traditional Open HMO Option Plans Plan Name VA IH Open HMO Option 100/80 250A* VA IH Open HMO Option 100/70 500A* Member Benefits Participating Providers Non-Participating Participating Providers Non-Participating Providers 1 Providers 1 Plan Year Deductible 2 Plan Year Out-of-Pocket Limit $0 Individual/ $0 Family $3,000 Individual/ $6,000 Family $500 Individual/ $1,000 Family $5,000 Individual/ $10,000 Family $0 Individual/ $0 Family $3,000 Individual/ $6,000 Family $500 Individual/ $1,000 Family $5,000 Individual/ $10,000 Family Deductible and Out-of-Pocket Limit Embedded Embedded Embedded Embedded Accumulation 3 Not Included In Out-of-Pocket Limit Non-covered expenses, balance-billed charges and failure to precertify penalties Non-covered expenses, balance-billed charges and failure to precertify penalties Primary Care Physician Office Visit $20 copay 20% after $20 copay 30% after Specialist Office Visit $30 copay 20% after $40 copay 30% after Walk-In Clinic Visit $20 copay 20% after $20 copay 30% after Chiropractic Services (20 visits per plan year. Participating and Non-Participating combined.) Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply. Participating and Non-Participating combined.) 20% 20% after 25% 25% after $0 copay Well-child exams and immunizations: 0%, waived. Other preventive care: 20% after, except waived for routine gyn exam $0 copay Well-child exams and immunizations: 0%, waived. Other preventive care: 30% after, except waived for routine gyn exam Diagnostic Testing: Lab $0 copay 20% after $0 copay 30% after Diagnostic Testing: X-ray $30 copay 20% after $40 copay 30% after Imaging (MRA/MRS, MRI, PET and CAT scans) $100 copay 20% after $200 copay 30% after Prescription Drug Deductible Not applicable Not applicable Not applicable Not applicable Prescription Drugs (Up to 30-day supply) 4 : Preferred generic drugs/preferred brand drugs/ Non-preferred generic and brand drugs. Two-times the 30-day supply cost-sharing for up to 90-day supply. Aetna Specialty CareRx SM Drugs 4 (Up to 30-day supply for self-injectable, infused and oral specialty drugs, excludes insulin) Option 1: $10/$25/$50 Option 2: $10/$35/$60 Option 1: $100 copay Option 2: $200 copay Not covered $10/$35/$60 Not covered Not covered $200 copay Not covered Outpatient Surgery $50 copay 20% after $300 copay 30% after Emergency room (Copay is waived if admitted.) $150 copay $200 copay Urgent Care $50 copay 20% after $75 copay 30% after Inpatient Hospital Facility Rehabilitation services (PT/OT/ST) (30 visits per plan year, PT/OT combined, and 30 visits per plan year, ST. Participating and Non-Participating combined.) $250 copay per admission 20% after $500 copay per admission 30% after $30 copay 20% after $40 copay 30% after Refer to pages 25 26 for important plan provisions. 15
Traditional Open HMO Option Plans Plan Name VA IH Open HMO Option 90/70* VA IH Open HMO Option 80/50* Member Benefits Participating Providers Non-Participating Participating Providers Non-Participating Providers 1 Providers 1 Plan Year Deductible 2 Plan Year Out-of-Pocket Limit $0 Individual/ $0 Family $4,000 Individual/ $8,000 Family $1,000 Individual/ $2,000 Family $6,000 Individual/ $12,000 Family $0 Individual/ $0 Family $4,000 Individual/ $8,000 Family $2,000 Individual/ $4,000 Family $6,000 Individual/ $12,000 Family Deductible and Out-of-Pocket Limit Embedded Embedded Embedded Embedded Accumulation 3 Not Included In Out-of-Pocket Limit Non-covered expenses, balance-billed charges and failure to precertify penalties Non-covered expenses, balance-billed charges and failure to precertify penalties Primary Care Physician Office Visit $25 copay 30% after $25 copay 50% after Specialist Office Visit $50 copay 30% after $50 copay 50% after Walk-In Clinic Visit $25 copay 30% after $25 copay 50% after Chiropractic Services (20 visits per plan year. Participating and Non-Participating combined.) Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply. Participating and Non-Participating combined.) 25% 25% after 25% 25% after $0 copay Well-child exams and immunizations: 0%, waived. Other preventive care: 30% after, except waived for routine gyn exam $0 copay Well-child exams and immunizations: 0%, waived. Other preventive care: 50% after, except waived for routine gyn exam Diagnostic Testing: Lab $0 copay 30% after $0 copay 50% after Diagnostic Testing: X-ray $50 copay 30% after $50 copay 50% after Imaging (MRA/MRS, MRI, PET and CAT scans) $200 copay 30% after $200 copay 50% after Prescription Drug Deductible Not applicable Not applicable Not applicable Not applicable Prescription Drugs (Up to 30-day supply) 4 : Preferred generic drugs/preferred brand drugs/ Non-preferred generic and brand drugs. Two-times the 30-day supply cost-sharing for up to 90-day supply. Aetna Specialty CareRx SM Drugs 4 (Up to 30-day supply for self-injectable, infused and oral specialty drugs, excludes insulin) $10/$35/$60 Not covered $10/$35/$60 Not covered $200 copay Not covered $200 copay Not covered Outpatient Surgery 10% 30% after 20% 50% after Emergency room (Copay is waived if admitted.) $200 copay $200 copay Urgent Care $75 copay 30% after $75 copay 50% after Inpatient Hospital Facility 10% 30% after 20% 50% after Rehabilitation services (PT/OT/ST) (30 visits per plan year, PT/OT combined, and 30 visits per plan year, ST. Participating and Non-Participating combined.) $50 copay 30% after $50 copay 50% after Refer to pages 25 26 for important plan provisions. 16
Consumer-Directed Open HMO Option HRA Plan Plan Name VA IH Open HMO Option 2500 HRA* Member Benefits Participating Providers Non-Participating Providers 1 Plan Year Deductible 2 Plan Year Out-of-Pocket Limit $2,500 Individual/ $5,000 Family $6,000 Individual/ $12,000 Family $5,000 Individual/ $10,000 Family $10,000 Individual/ $20,000 Family Deductible and Out-of-Pocket Limit Non-embedded Non-embedded Accumulation 3 Not Included In Out-of-Pocket Limit Non-covered expenses, balance-billed charges and failure to precertify penalties Primary Care Physician Office Visit $30 copay after 30% after Specialist Office Visit $50 copay after 30% after Walk-In Clinic Visit $30 copay after 30% after Chiropractic Services (20 visits per plan year. Participating and Non-Participating combined.) Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply. Participating and Non-Participating combined.) 25% after 25% after $0 copay, waived Well-child exams and immunizations: 0%, waived. Other preventive care: 20% after, except waived for routine gyn exam Diagnostic Testing: Lab $50 copay after 30% after Diagnostic Testing: X-ray $50 copay after 30% after Imaging (MRA/MRS, MRI, PET and CAT scans) $200 copay after 30% after Prescription Drug Deductible Not applicable Not applicable Prescription Drugs (Up to 30-day supply) 4 : Preferred generic drugs/preferred brand drugs/ Non-preferred generic and brand drugs. Two-times the 30-day supply cost-sharing for up to 90-day supply. Aetna Specialty CareRx SM Drugs 4 (Up to 30-day supply for self-injectable, infused and oral specialty drugs, excludes insulin) $10/$35/$60 Not covered $200 copay Not covered Outpatient Surgery $200 copay after $200 copay plus 30% after Emergency room (Copay is waived if admitted.) $200 copay after Urgent Care $75 copay after 30% after Inpatient Hospital Facility Rehabilitation services (PT/OT/ST) (30 visits per plan year, PT/OT combined, and 30 visits per plan year, ST. Participating and Non-Participating combined.) Health Fund Amount/Administration (Per plan year. Fund changes between tiers requires a life status change qualifying event.) $300 copay per day, 5 day copay max per admission, after $300 copay per day, 5 day copay max per admission, plus 30% after $50 copay after 30% after $500 Individual/$1,000 Family Participating and non-participating combined. Any remaining health fund benefit amount at the end of the plan year is rolled over into next year s health fund benefit amount. The fund will be used to pay for the member s responsibility. Once the is met, the underlying medical plan provides coverage and if a fund balance still exists, the fund will pay the members responsibility until the plan year out-of-pocket limit has been reached or the fund has been exhausted, whichever comes first. Preventive services and prescription drug benefits will not be eligible for reimbursement by the fund. Refer to pages 25 26 for important plan provisions. 17
Traditional PPO Plans Plan Name VA IH PPO 100/80 250A* VA IH PPO 100/70 500A* Member Benefits Participating Providers Non-Participating Participating Providers Non-Participating Providers 1 Providers 1 Plan Year Deductible 2 Plan Year Out-of-Pocket Limit $0 Individual/ $0 Family $3,000 Individual/ $6,000 Family $500 Individual/ $1,000 Family $5,000 Individual/ $10,000 Family $0 Individual/ $0 Family $3,000 Individual/ $6,000 Family $500 Individual/ $1,000 Family $5,000 Individual/ $10,000 Family Deductible and Out-of-Pocket Limit Embedded Embedded Embedded Embedded Accumulation 3 Not Included In Out-of-Pocket Limit Non-covered expenses, balance-billed charges and failure to precertify penalties Non-covered expenses, balance-billed charges and failure to precertify penalties Primary Care Physician Office Visit $20 copay 20% after $20 copay 30% after Specialist Office Visit $30 copay 20% after $40 copay 30% after Walk-In Clinic Visit $20 copay 20% after $20 copay 30% after Chiropractic Services (20 visits per plan year. Participating and Non-Participating combined.) Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply. Participating and Non-Participating combined.) 20% 20% after 25% 25% after $0 copay Well-child exams and immunizations: 0%, waived. Other preventive care: 20% after, except waived for routine gyn exam $0 copay Well-child exams and immunizations: 0%, waived. Other preventive care: 30% after, except waived for routine gyn exam Diagnostic Testing: Lab $30 copay 20% after $40 copay 30% after Diagnostic Testing: X-ray $30 copay 20% after $40 copay 30% after Imaging (MRA/MRS, MRI, PET and CAT scans) $100 copay 20% after $200 copay 30% after Prescription Drug Deductible Not applicable Not applicable Not applicable Not applicable Prescription Drugs (Up to 30-day supply) 4 : Preferred generic drugs/preferred brand drugs/ Non-preferred generic and brand drugs. Two-times the 30-day supply cost-sharing for up to 90-day supply. Aetna Specialty CareRx SM Drugs 4 (Up to 30-day supply for self-injectable, infused and oral specialty drugs, excludes insulin) Option 1: $10/$25/$50 Option 2: $10/$35/$60 Option 1: $100 copay Option 2: $200 copay Option 1: $10/$25/$50 + 30% Option 2: $10/$35/$60 + 30% Not covered Option 1: $10/$25/$50 Option 2: $10/$35/$60 Option 1: $100 copay Option 2: $200 copay Option 1: $10/$25/$50 + 30% Option 2: $10/$35/$60 + 30% Not covered Outpatient Surgery $50 copay 20% after $300 copay 30% after Emergency room (Copay is waived if admitted.) $150 copay $200 copay Urgent Care $50 copay 20% after $75 copay 30% after Inpatient Hospital Facility Rehabilitation services (PT/OT/ST) (30 visits per plan year, PT/OT combined, and 30 visits per plan year, ST. Participating and Non-Participating combined.) $250 copay per admission 20% after $500 copay per admission 30% after $30 copay 20% after $40 copay 30% after Refer to pages 25 26 for important plan provisions. 18
Traditional PPO Plans Plan Name VA IH PPO 90/70* VA IH PPO 80/50* Member Benefits Participating Providers Non-Participating Participating Providers Non-Participating Providers 1 Providers 1 Plan Year Deductible 2 Plan Year Out-of-Pocket Limit $0 Individual/ $0 Family $4,000 Individual/ $8,000 Family $1,000 Individual/ $2,000 Family $6,000 Individual/ $12,000 Family $0 Individual/ $0 Family $4,000 Individual/ $8,000 Family $2,000 Individual/ $4,000 Family $6,000 Individual/ $12,000 Family Deductible and Out-of-Pocket Limit Embedded Embedded Embedded Embedded Accumulation 3 Not Included In Out-of-Pocket Limit Non-covered expenses, balance-billed charges and failure to precertify penalties Non-covered expenses, balance-billed charges and failure to precertify penalties Primary Care Physician Office Visit $25 copay 30% after $25 copay 50% after Specialist Office Visit $50 copay 30% after $50 copay 50% after Walk-In Clinic Visit $25 copay 30% after $25 copay 50% after Chiropractic Services (20 visits per plan year. Participating and Non-Participating combined.) Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply. Participating and Non-Participating combined.) 25% 25% after 25% 25% after $0 copay Well-child exams and immunizations: 0%, waived. Other preventive care: 30% after, except waived for routine gyn exam $0 copay Well-child exams and immunizations: 0%, waived. Other preventive care: 50% after, except waived for routine gyn exam Diagnostic Testing: Lab $50 copay 30% after $50 copay 50% after Diagnostic Testing: X-ray $50 copay 30% after $50 copay 50% after Imaging (MRA/MRS, MRI, PET and CAT scans) $200 copay 30% after $200 copay 50% after Prescription Drug Deductible Not applicable Not applicable Not applicable Not applicable Prescription Drugs (Up to 30-day supply) 4 : Preferred generic drugs/preferred brand drugs/ Non-preferred generic and brand drugs. Two-times the 30-day supply cost-sharing for up to 90-day supply. Aetna Specialty CareRx SM Drugs 4 (Up to 30-day supply for self-injectable, infused and oral specialty drugs, excludes insulin) $10/$35/$60 $10/$35/$60 + 30% $10/$35/$60 $10/$35/$60 + 30% $200 copay Not covered $200 copay Not covered Outpatient Surgery 10% 30% after 20% 50% after Emergency room (Copay is waived if admitted.) $200 copay $200 copay Urgent Care $75 copay 30% after $75 copay 50% after Inpatient Hospital Facility 10% 30% after 20% 50% after Rehabilitation services (PT/OT/ST) (30 visits per plan year, PT/OT combined, and 30 visits per plan year, ST. Participating and Non-Participating combined.) $50 copay 30% after $50 copay 50% after Refer to pages 25 26 for important plan provisions. 19
Traditional Open POS Plus Plans Plan Name VA IH Open POS Plus 1000 80/50* VA IH Open POS Plus 2000 80/50* Member Benefits Participating Providers Non-Participating Participating Providers Non-Participating Providers 1 Providers 1 Plan Year Deductible 2 Plan Year Out-of-Pocket Limit $1,000 Individual/ $2,000 Family $4,000 Individual/ $8,000 Family $2,000 Individual/ $4,000 Family $6,000 Individual/ $12,000 Family $2,000 Individual/ $4,000 Family $5,000 Individual/ $10,000 Family $4,000 Individual/ $8,000 Family $10,000 Individual/ $20,000 Family Deductible and Out-of-Pocket Limit Embedded Embedded Embedded Embedded Accumulation 3 Not Included In Out-of-Pocket Limit Primary Care Physician Office Visit Specialist Office Visit Walk-In Clinic Visit Chiropractic Services (20 visits per plan year. Participating and Non-Participating combined.) Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply. Participating and Non-Participating combined.) Non-covered expenses, balance-billed charges and failure to precertify penalties $30 copay, waived $50 copay, waived $30 copay, waived 50% after $30 copay, waived 50% after $50 copay, waived 50% after $30 copay, waived Non-covered expenses, balance-billed charges and failure to precertify penalties 50% after 50% after 50% after 25% after 25% after 25% after 25% after $0 copay, waived Well-child exams and immunizations: 0%, waived. Other preventive care: 50% after, except waived for routine gyn exam $0 copay, waived Well-child exams and immunizations: 0%, waived. Other preventive care: 50% after, except waived for routine gyn exam Diagnostic Testing: Lab 20% after 50% after 20% after 50% after Diagnostic Testing: X-ray 20% after 50% after 20% after 50% after Imaging (MRA/MRS, MRI, PET and CAT scans) 20% after 50% after 20% after 50% after Prescription Drug Deductible Not applicable Not applicable Not applicable Not applicable Prescription Drugs (Up to 30-day supply) 4 : Preferred generic drugs/preferred brand drugs/ Non-preferred generic and brand drugs. Two-times the 30-day supply cost-sharing for up to 90-day supply. Aetna Specialty CareRx SM Drugs 4 (Up to 30-day supply for self-injectable, infused and oral specialty drugs, excludes insulin) $10/$35/$60 $10/$35/$60 + 30% $10/$35/$60 $10/$35/$60 + 30% $200 copay Not covered $200 copay Not covered Outpatient Surgery 20% after 50% after 20% after 50% after Emergency room 20% after 20% after Urgent Care 20% after 50% after 20% after 50% after Inpatient Hospital Facility 20% after 50% after 20% after 50% after Rehabilitation services (PT/OT/ST) (30 visits per plan year, PT/OT combined, and 30 visits per plan year, ST. Participating and Non-Participating combined.) 20% after 50% after 20% after 50% after Refer to pages 25 26 for important plan provisions. 20
Traditional Open POS Plus Plans Plan Name VA IH Open POS Plus 3000 80/50* Member Benefits Participating Providers Non-Participating Providers 1 Plan Year Deductible 2 Plan Year Out-of-Pocket Limit $3,000 Individual/ $6,000 Family $6,000 Individual/ $12,000 Family $5,000 Individual/ $10,000 Family $10,000 Individual/ $20,000 Family Deductible and Out-of-Pocket Limit Embedded Embedded Accumulation 3 Not Included In Out-of-Pocket Limit Primary Care Physician Office Visit Specialist Office Visit Walk-In Clinic Visit Chiropractic Services (20 visits per plan year. Participating and Non-Participating combined.) Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply. Participating and Non-Participating combined.) Non-covered expenses, balance-billed charges and failure to precertify penalties $30 copay, waived $50 copay, waived $30 copay, waived 50% after 50% after 50% after 25% after 25% after $0 copay, waived Well-child exams and immunizations: 0%, waived. Other preventive care: 50% after, except waived for routine gyn exam Diagnostic Testing: Lab 20% after 50% after Diagnostic Testing: X-ray 20% after 50% after Imaging (MRA/MRS, MRI, PET and CAT scans) 20% after 50% after Prescription Drug Deductible Not applicable Not applicable Prescription Drugs (Up to 30-day supply) 4 : Preferred generic drugs/preferred brand drugs/ Non-preferred generic and brand drugs. Two-times the 30-day supply cost-sharing for up to 90-day supply. Aetna Specialty CareRx SM Drugs 4 (Up to 30-day supply for self-injectable, infused and oral specialty drugs, excludes insulin) $10/$35/$60 $10/$35/$60 + 30% $200 copay Not covered Outpatient Surgery 20% after 50% after Emergency room 20% after Urgent Care 20% after 50% after Inpatient Hospital Facility 20% after 50% after Rehabilitation services (PT/OT/ST) (30 visits per plan year, PT/OT combined, and 30 visits per plan year, ST. Participating and Non-Participating combined.) 20% after 50% after Refer to pages 25 26 for important plan provisions. 21
Consumer-Directed PPO HSA-Compatible Plans Plan Name VA IH PPO 1500 HSA* VA IH PPO 2500 HSA* Member Benefits Participating Providers Non-Participating Participating Providers Non-Participating Providers 1 Providers 1 Plan Year Deductible 2 Plan Year Out-of-Pocket Limit $1,500 Individual/ $3,000 Family $3,000 Individual/ $6,000 Family $3,000 Individual/ $6,000 Family $6,000 Individual/ $12,000 Family $2,500 Individual/ $5,000 Family $5,000 Individual/ $10,000 Family $5,000 Individual/ $10,000 Family $10,000 Individual/ $20,000 Family Deductible and Out-of-Pocket Limit Non-embedded Non-embedded Non-embedded Non-embedded Accumulation 3 Not Included In Out-of-Pocket Limit Primary Care Physician Office Visit Specialist Office Visit Walk-In Clinic Visit Chiropractic Services (20 visits per plan year. Participating and Non-Participating combined.) Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply. Participating and Non-Participating combined.) Diagnostic Testing: Lab Diagnostic Testing: X-ray Imaging (MRA/MRS, MRI, PET and CAT scans) Prescription Drug Deductible Prescription Drugs (Up to 30-day supply) 4 : Preferred generic drugs/preferred brand drugs/ Non-preferred generic and brand drugs. Two-times the 30-day supply cost-sharing for up to 90-day supply. Aetna Specialty CareRx SM Drugs 4 (Up to 30-day supply for self-injectable, infused and oral specialty drugs, excludes insulin) Outpatient Surgery Non-covered expenses, balance-billed charges and failure to precertify penalties $20 copay after $40 copay after $20 copay after 30% after $30 copay after 30% after $50 copay after 30% after $30 copay after Non-covered expenses, balance-billed charges and failure to precertify penalties 30% after 30% after 30% after 25% after 25% after 25% after 25% after $0 copay, waived $40 copay after $40 copay after $200 copay after Integrated with medical $10/$35/$60 after $200 copay after $300 copay after Well-child exams and immunizations: 0%, waived. Other preventive care: 30% after, except waived for routine gyn exam $0 copay, waived 30% after $50 copay after 30% after $50 copay after 30% after $200 copay after Integrated with medical $10/$35/$60 + 30% after Not covered Integrated with medical $10/$35/$60 after $200 copay after 30% after $200 copay after Well-child exams and immunizations: 0%, waived. Other preventive care: 30% after, except waived for routine gyn exam 30% after 30% after 30% after Integrated with medical $10/$35/$60 + 30% after Not covered 30% after Emergency room (Copay is waived if admitted.) $200 copay after $200 copay after Urgent Care Inpatient Hospital Facility Rehabilitation services (PT/OT/ST) (30 visits per plan year, PT/OT combined, and 30 visits per plan year, ST. Participating and Non-Participating combined.) $75 copay after $500 copay per admission after $40 copay after 30% after $75 copay after 30% after $300 copay per day, 5 day copay max per admission, after 30% after $50 copay after 30% after 30% after 30% after Refer to pages 25 26 for important plan provisions. 22
Consumer-Directed PPO HSA-Compatible Plans Plan Name VA IH PPO 5000 90/50 HSA* Member Benefits Participating Providers Non-Participating Providers 1 Plan Year Deductible 2 Plan Year Out-of-Pocket Limit $5,000 Individual/ $10,000 Family $6,000 Individual/ $12,000 Family $5,000 Individual/ $10,000 Family $10,000 Individual/ $20,000 Family Deductible and Out-of-Pocket Limit Non-embedded Non-embedded Accumulation 3 Not Included In Out-of-Pocket Limit Non-covered expenses, balance-billed charges and failure to precertify penalties Primary Care Physician Office Visit 10% after 50% after Specialist Office Visit 10% after 50% after Walk-In Clinic Visit 10% after 50% after Chiropractic Services (20 visits per plan year. Participating and Non-Participating combined.) Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply. Participating and Non-Participating combined.) 10% after 25% after 0%, waived Well-child exams and immunizations: 0%, waived. Other preventive care: 50% after, except waived for routine gyn exam Diagnostic Testing: Lab 10% after 50% after Diagnostic Testing: X-ray 10% after 50% after Imaging (MRA/MRS, MRI, PET and CAT scans) 10% after 50% after Prescription Drug Deductible Prescription Drugs (Up to 30-day supply) 4 : Preferred generic drugs/preferred brand drugs/ Non-preferred generic and brand drugs. Two-times the 30-day supply cost-sharing for up to 90-day supply. Aetna Specialty CareRx SM Drugs 4 (Up to 30-day supply for self-injectable, infused and oral specialty drugs, excludes insulin) Integrated with medical $10/$35/$60 after $200 copay after Integrated with medical $10/$35/$60 + 30% after Not covered Outpatient Surgery 10% after 50% after Emergency room 10% after Urgent Care 10% after 50% after Inpatient Hospital Facility 10% after 50% after Rehabilitation services (PT/OT/ST) (30 visits per plan year, PT/OT combined, and 30 visits per plan year, ST. Participating and Non-Participating combined.) 10% after 50% after Refer to pages 25 26 for important plan provisions. 23
Traditional Indemnity Plan Plan Name Member Benefits Plan Year Deductible 2 Plan Year Out-of-Pocket Limit Deductible and Out-of-Pocket Limit Accumulation 3 Not Included In Out-of-Pocket Limit Primary Care Physician Office Visit Specialist Office Visit Walk-In Clinic Visit Chiropractic Services (20 visits per plan year) Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) Diagnostic Testing: Lab Diagnostic Testing: X-ray Imaging (MRA/MRS, MRI, PET and CAT scans) Prescription Drug Deductible Prescription Drugs (Up to 30-day supply) 4 : Preferred generic drugs/preferred brand drugs/ Non-preferred generic and brand drugs. Two-times the 30-day supply cost-sharing for up to 90-day supply. Aetna Specialty CareRx SM Drugs 4 (Up to 30-day supply for self-injectable, infused and oral specialty drugs, excludes insulin) Outpatient Surgery Emergency Room Urgent Care Inpatient Hospital Facility Rehabilitation services (PT/OT/ST) (30 visits per plan year, PT/OT combined, and 30 visits per plan year, ST) VA IH Indemnity 500 70%* Non-Participating Providers 1 $500 Individual/ $1,000 Family $4,000 Individual/ $8,000 Family Embedded Non-covered expenses, balance-billed charges and failure to precertify penalties 30% after 30% after 30% after 25% after 0%, waived 30% after 30% after 30% after Not applicable $10/$35/$60 $200 copay 30% after 30% after 30% after 30% after 30% after Refer to pages 25 26 for important plan provisions. 24