Baptist Health System and HealthTexas Medical Group Network San Antonio, TX Medical plans at-a-glance for businesses with 2 100 employees Aetna Whole Health SM EPO Plans TX Gold AWH EPO 500 80/60 (2 50) TX AWH EPO 500 80/60 (51 100) TX Gold AWH EPO 750 80/60 (2 50) TX AWH EPO 750 80/60 (51 100) Networks available Elect Choice (Open Access) Elect Choice (Open Access) Member Benefits Designated Non-Designated Calendar Year Out-of-Pocket Limit2, 2 A 90.03.186.1-TX (3/14) $500 Individual/ $1,000 Family $3,000 Individual/ $6,000 Family $1,500 Individual/ $3,000 Family Designated $750 Individual/ $1,500 Family $3,500 Individual/ $7,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded Embedded Primary Care Physician Office Visit Specialist Office Visit Walk-In Clinics Diagnostic Testing: Lab Diagnostic Testing: X-ray $15 copay; deductible $25 copay; deductible $70 copay; deductible Non-Designated $1,500 Individual/ $3,000 Family $20 copay; deductible $20 copay; deductible 0%; deductible copay; deductible $20 copay; deductible $70 copay; deductible 0%; deductible Imaging (CT/PET scans MRIs) 20% after deductible 20% after deductible Prescription Drug Deductible $50 30% up to $300 30% up to $300 Outpatient Surgery OP Hospital Department 20% after deductible 20% after deductible Emergency Room 20% after deductible 20% after deductible Urgent Care Inpatient Hospital Facility 20% after deductible 20% after deductible
Aetna Whole Health SM EPO Plans TX Silver AWH EPO 1000 80/60 (2 50) TX AWH EPO 1000 80/60 (51 100) TX Silver AWH EPO 1500 80/60 (2 50) TX AWH EPO 1500 80/60 (51 100) Networks available Elect Choice (Open Access) Elect Choice (Open Access) Member Benefits Designated Non-Designated Calendar Year Out-of-Pocket Limit2, 2 A $1,000 Individual/ $2,000 Family $2,000 Individual/ $4,000 Family Designated $1,500 Individual/ $3,000 Family $5,500 Individual/ $11,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded Embedded Primary Care Physician Office Visit Specialist Office Visit Walk-In Clinics Diagnostic Testing: Lab Diagnostic Testing: X-ray Non-Designated $3,000 Individual/ $6,000 Family 0%; deductible 0%; deductible Imaging (CT/PET scans MRIs) 20% after deductible 20% after deductible Prescription Drug Deductible 30% up to $300 30% up to $300 Outpatient Surgery OP Hospital Department 20% after deductible 20% after deductible Emergency Room 20% after deductible 20% after deductible Urgent Care Inpatient Hospital Facility 20% after deductible 20% after deductible Health insurance plans are underwritten and/or administered by Aetna Life Insurance Company (Aetna). 2
Aetna Whole Health SM EPO Plans TX Silver AWH EPO 3000 100/50 (2 50) TX AWH EPO 3000 100/50 (51 100) TX Silver AWH EPO 3000 70/50 (2 50) TX AWH EPO 3000 70/50 (51 100) Networks available Elect Choice (Open Access) Elect Choice (Open Access) Member Benefits Designated Non-Designated Calendar Year Out-of-Pocket Limit2, 2 A $3,000 Individual/ $6,000 Family Designated $3,000 Individual/ $6,000 Family $5,500 Individual/ $11,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded Embedded Primary Care Physician Office Visit Specialist Office Visit Walk-In Clinics Diagnostic Testing: Lab Diagnostic Testing: X-ray Non-Designated 0%; deductible after deductible after deductible Imaging (CT/PET scans MRIs) 0% after deductible after deductible 30% after deductible after deductible Prescription Drug Deductible 30% up to $300 30% up to $300 Outpatient Surgery OP Hospital Department 0% after deductible after deductible 30% after deductible after deductible Emergency Room 0% after deductible 30% after deductible Urgent Care Inpatient Hospital Facility 0% after deductible after deductible 30% after deductible after deductible 30% after deductible after deductible 3
Aetna Whole Health SM EPO Plans TX Silver AWH EPO 5000 100/50 (2 50) TX AWH EPO 5000 100/50 (51 100) TX Bronze AWH EPO 6000 100/70 (2 50) TX AWH EPO 6000 100/70 (51 100) Networks available Elect Choice (Open Access) Elect Choice (Open Access) Member Benefits Designated Non-Designated Calendar Year Out-of-Pocket Limit2, 2 A $5,500 Individual/ $11,000 Family Designated Deductible & Out-of-Pocket Limit Accumulation Embedded Embedded Primary Care Physician Office Visit Specialist Office Visit Walk-In Clinics Diagnostic Testing: Lab Diagnostic Testing: X-ray $25 copay; deductible $25 copay; deductible $25 copay; deductible Non-Designated 30% after deductible 30% after deductible 30% after deductible Imaging (CT/PET scans MRIs) 0% after deductible after deductible 0% after deductible 30% after deductible Prescription Drug Deductible Integrated with Medical (Deductible for preferred generics) 30% up to $300 30% up to $300 Outpatient Surgery OP Hospital Department 0% after deductible after deductible 0% after deductible 30% after deductible Emergency Room 0% after deductible 0% after deductible Urgent Care Inpatient Hospital Facility 0% after deductible after deductible 0% after deductible 30% after deductible 30% after deductible 4
Aetna Whole Health SM EPO HSA Plans TX Bronze AWH EPO 5000 100/70 HSA (2 50) TX AWH EPO 5000 100/70 HSA (51 100) Networks Available Elect Choice (Open Access) Member Benefits Designated Non-Designated Calendar Year Out-of-Pocket Limit2 Deductible & Out-of-Pocket Limit Accumulation Embedded Primary Care Physician Office Visit 0% after deductible 30% after deductible Specialist Office Visit 0% after deductible 30% after deductible Walk-In Clinics 0% after deductible Diagnostic Testing: Lab 0% after deductible 30% after deductible Diagnostic Testing: X-ray 0% after deductible 30% after deductible Imaging (CT/PET scans MRIs) 0% after deductible 30% after deductible Prescription Drug Deductible Integrated with Medical 30% up to $300 Outpatient Surgery OP Hospital Department 0% after deductible 30% after deductible Emergency Room 0% after deductible Urgent Care 0% after deductible 30% after deductible Inpatient Hospital Facility 0% after deductible 30% after deductible 0% after deductible 30% after deductible 5
Footnotes This is a partial description of plans and benefits available; for more information, refer to Aetna s Producer World website at www.aetna.com for specific plan design benefit descriptions or you can also contact your licensed agent or Aetna sales representative. AWH EPO 1Deductible applies to all services unless otherwise noted. 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. 2Once the family out-of-pocket limit is met, all family members will be considered as having met their out-of-pocket limit for the remainder of the calendar year. No one family member may contribute more than the individual out-of-pocket limit amount to the family out-of-pocket limit. Deductible applies to the out-of-pocket limit. 2 A The family maximum out-of-pocket does not include pharmacy expenses for the TX AWH EPO 500 80/60, TX AWH EPO 750 80/60, TX AWH EPO 1000 80/60, TX AWH EPO 1500 80/60, TX AWH EPO 3000 100/50 and TX AWH EPO 5000 100/50 plans for 51+ employees. 3 Choose Generics If the member or the physician requests brand when generic is available, the member pays the applicable copay plus the difference between the generic price and the brand price. Mail order delivery of 90-day supply at 3X retail copay. Precertification and step therapy apply. AWH EPO HSA 1Deductible applies to all services unless otherwise noted. 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. Once the family deductible is met, all family members will be considered as having met their deductible for the remainder of the calendar year. 2Once the family out-of-pocket limit is met, all family members will be considered as having met their out-of-pocket limit for the remainder of the calendar year. No one family member may contribute more than the individual out-of-pocket limit amount to the family out-of-pocket limit. Once the family out-of-pocket limit is met, all family members will be considered as having met their out-of-pocket limit for the remainder of the calendar year. 3Choose Generics If the member or the physician requests brand when generic is available, the member pays the applicable copay plus the difference between the generic price and the brand price. Mail order delivery of 90-day supply at 3X retail copay. Precertification and step therapy apply. 6
This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Rates and benefits may vary by location. Health insurance plans contain exclusions and limitations. are independent contractors and not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features are subject to change. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to www.aetna.com. www.aetna.com 2014 Aetna Inc. 90.03.186.1-TX (3/14)