Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Texas 2 100 Plan guide Like creating a painting, the key to creating the right health plan is unlocking the right combination of cost and coverage Plans effective July 1, 2014 For businesses with 2 100 employees www.aetna.com 64.10.302.1-TX E (6/14)
64.43.302.1-TX E (6/14) Unlocking the right health plan Every company has its own particular needs, driven in part by the health of its employees, by its commitment to health and wellness and, of course, by its financial resources. We believe creating the right health plan means unlocking the right combination of these four options to meet a company s specific needs: Benefits, Network, Cost sharing, Funding. Experience matters Unlocking the right combination isn t a matter of chance. It s a matter of working with an experienced and knowledgeable guide. A guide like Aetna. We take the time to listen and learn about your needs, share knowledge and provide tools to help achieve the right balance of cost and coverage. Our approach makes all the difference in the value you get from your plan, and in the satisfaction of your employees. Today s health care environment demands a new set of solutions to meet new challenges. Together, we can unlock those solutions to create a healthy future for your company and your employees. Health/dental benefits plans, health/dental insurance plans, life insurance and disability insurance plans/policies are offered, underwritten or administered by Aetna Health Inc., Aetna Dental Inc. Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). Each insurer has sole financial responsibility for its own products.
Unlock the right combination We want to make unlocking the right benefits as easy as possible. So we ve organized information in this easy-to-understand guide. 64.44.302.1-TX E (6/14) M D L&D Health care reform 4 Plans, tools and extras 7 8 Network options, cost sharing and premiums 9 Health and wellness programs 10 Medical Plans Overview 11 HNOnly Plans 16 EPO Plans 17 OAMC Plans 18 OAMC HSA Plans 30 AWH EPO HSA and Savings Plus OAMC HSA Plans 34 PPO and Indemnity Plans 35 AWH EPO Plans 36 Savings Plus OAMC Plans 41 Dental Plans Overview 54 Aetna Standard Dental Plans 2 9 56 Aetna Voluntary Dental Plans 3 9 58 Aetna Standard and Voluntary Dental Plans 10 100 60 Life and Disability Plans Overview 64 Term Life Plan Options 67 Packaged Life and Disability Plan Options 67 Limitations and exclusions 68 New business checklist 70 3
Changes to your plan due to health care reform Signed into law in March 2010, the Affordable Care Act is the most life-changing law since the passing of Medicare in the 1960s. The Affordable Care Act will shape new rules and guidance through 2014 and beyond. We are committed to following the new health care law and to helping you understand its impact. We have outlined below key changes that may impact your health care benefits: Essential health benefits package* As of January 1, 2014, Aetna plans must offer standard coverage known as essential health benefits. This includes all plans inside and outside of the health insurance exchanges. Aetna plans provide your employees with essential health benefits, and limit cost sharing. Here are the broad categories of essential benefits that will be included in your employees coverage: Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance abuse services Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric dental Pediatric vision Out-of-pocket (OOP) maximum mandate Beginning in 2014, all cost sharing must apply toward the OOP maximum, including in-network medical, behavioral health and pharmacy cost-sharing. This does not include premiums, balance billing amounts of non-network providers or spending for noncovered services. The out-of-pocket maximum must include: Copays Deductibles Coinsurance Fees These fees are included in your premium: Health Insurer Fee Annual fee to offset premium subsidies and tax credit related expenses Transitional Reinsurance Program Contribution Helps finance the cost of high-risk individuals in the individual market Patient-Centered Outcomes Research Fee (also known as the Comparative Effectiveness Fee) Fee to fund clinical outcomes effectiveness research Guaranteed issue Guaranteed issue of health insurance coverage applies to individual, small group and large group markets. Guaranteed Issue is available for: Group Health Plans/Insurance Coverage (insured only) Individual Health Insurance Coverage (including medical conversion) Pharmacy (insured only) Behavioral Health (insured only)** Please note that guaranteed issue is not available for: Self-funded plans Standalone/separate dental or vision Hospital Indemnity/Fixed Indemnity Medicare and Medicare Supplement Medicaid Retiree-only plans Grandfathered plans Association/MEWA plans Rating rule changes The rate review regulations are changing and we are making sure they stay affordable. We are working to protect you from rate increases without decreasing competition, reducing consumer choice of providers, or causing problems. Waiting period Plans may not have any waiting periods longer than 90 days. The maximum 90-day waiting period applies to fully insured and self-funded plans. We will update our policies and will work with employers that have waiting periods exceeding 90 days. This will go into effect for all groups on January 1, 2014. 4 *For 2 to 50 only. **Note: No standalone insured behavioral health.
Pediatric dental/vision (2 to 50) Pediatric dental and vision mandates are a separate essential health benefit category and are included with your medical benefits. We will cover those services in 2014 according to the benchmark plan coverage. Pediatric Dental PPO OAMC Plans Savings Plus OAMC Plans (Different Ded/OOP) OAMC Plans Savings Plus OAMC Plans (Same Ded/OOP) In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Dental Checkup (aka preventive/diagnostic) 0%; 0%; 0%; 0%; 0%; 0%; Dental Basic 30% after 30% after 30% after 30% after 0% after 0% after Dental Major after after after after 0% after 0% after Dental Ortho after after after after 0% after 0% after OAMC Plans HSA Plans Savings Plus OAMC HSA Plans Indemnity HNOnly (HMO) (Different Ded/OOP) HNOnly (HMO) (No Ded) In-Network Out-of-Network No Network In-Network In-Network Dental Checkup (aka preventive/diagnostic) 0% after 0% after 0%; 0% 0% Dental Basic 30%; 30% after 30% after 30% after 30% Dental Major ; after after after Dental Ortho ; after after after EPO Plans AWH EPO Plans (Different Ded/OOP) EPO Plans AWH EPO Plans (Same Ded/OOP) AWH EPO HSA Plans In-Network In-Network In-Network Dental Checkup (aka preventive/diagnostic) 0%; 0%; 0% after Dental Basic 30% after 0% after 30% after Dental Major after 0% after after Dental Ortho after 0% after after These plans do not cover all vision or dental expenses and have exclusions and limitations. Members should refer to their plan documents to determine which services are covered and to what extent. 5
Pediatric Vision Traditional PPO plans OAMC Plans OAMC HSA Plans Pediatric Vision In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Vision exam (one exam per 12 months) $0; after ** $0; 30% or after ** $0; 30%, or after ** Preferred eyeglass frames, prescription lenses or prescription contact lenses* $0; after $0; 30% or after ** $0 after 30%, or after ** Non-Preferred eyeglass frames, prescription lenses or prescription contact lenses* after after after 30% or after ** after 30%, or after ** Savings Plus OAMC Plans Savings Plus OAMC HSA Plans Indemnity plan HNOnly Plans Pediatric Vision Designated/ Non-Designated Out-of-Network Designated/ Non-Designated Out-of-Network No Network In-Network Vision exam (one exam per 12 months) $0; after $0; after 0%; $0; Preferred eyeglass frames, prescription lenses or prescription contact lenses* $0; after $0; after after 0%; $0; Non-Preferred eyeglass frames, prescription lenses or prescription contact lenses* after after after after 0%; after EPO Plans AWH EPO Plans AWH EPO HSA Plans Pediatric Vision Designated/ Non-Designated Designated/ Non-Designated Designated/ Non-Designated Vision exam (one exam per 12 months) $0; 0%; 0%; Preferred eyeglass frames, prescription lenses or prescription contact lenses* $0; $0; $0 after Non-Preferred eyeglass frames, prescription lenses or prescription contact lenses* after after after 6 *This plan will cover the following: -- One set of eyeglass frames and lenses or contacts per 12 months. -- Important notes: This plan will cover either one pair of prescription lenses for eyeglass frames or prescription contact lenses, but not both, per 12 months. Coverage does not include the office visit for the fitting of prescription contact lenses. **Coinsurance level varies depending on the out-of-network coinsurance on the medical plan. These plans do not cover all vision or dental expenses and have exclusions and limitations. Members should refer to their plan documents to determine which services are covered and to what extent.
Unlocking the right plan for your business Our product portfolio includes a range of coverage and cost combinations. You ll find choices for different budgets and benefits strategies. And you ll see that we re more than medical. You can round out your benefits offering with dental as well as life and disability offerings. Take a look at what s available. Medical plans Open Access Managed Choice Aetna Whole Health SM Savings Plus EPO Health Network Only (HNOnly) PPO Indemnity HSA compatible plans Plan levels You can choose up to three levels of health plans. These levels are named using metals bronze, silver, and gold. But the levels differ in how much the health plan pays. Each level includes the same essential health benefits. Health plan levels Average amount the plan pays for covered services Premium cost for employees Bronze 60% Lowest Silver 70% Lower Gold 80% Higher Tools to help your employees stay healthy, informed and productive With Aetna health plans, your employees get online tools and helpful resources that let them make the most of their benefits. Our most popular tools include: Secure member website. Your employees get self-service tools, plus health plan and health information through their Aetna Navigator website. Think of it as the key that unlocks the full value of their health benefits package. Encourage them to sign up at www.aetna.com. Member Payment Estimator. With an Aetna health plan, your employees can compare and estimate costs* for office visits, tests, surgeries and more. This means they can save money** and avoid surprises. This online tool factors in their, coinsurance and copays, plus contracted rates. They can see how much they have to pay and how much the plan will pay. They can log in to their Aetna Navigator member website to use the tool. Online provider directory. Finding doctors, specialists, hospitals and more in the Aetna network is easy with our DocFind directory. It s available at www.aetna.com and the Aetna Navigator member website. My Life Values. Your employees get 24/7 online services and support for managing their everyday personal and work matters. You ll soon be seeing many changes in health insurance, thanks to health care reform. Many of them affect your business. And some of them might be confusing. Visit the health care reform section on www.aetna.com for more information. Or talk with your broker. * Estimated costs not available in all markets. The tool gives members an estimate of what they would owe for a particular service based on their plan at that very point in time. Actual costs may differ from the estimate if, for example, claims for other services are processed after members get their estimate but before the claim for this service is submitted. Or, if the doctor or facility performs a different service at the time of the member s visit. ** In 2011, members who used Member Payment Estimator before receiving care saved an average of $170 out of pocket on 34 common procedures, according to the Member Payment Estimator Study, Aetna Informatics and Product Development, August 2012. 7
Dental plans DMO Participating Dental Network (PDN) PDN Max Freedom-of-Choice plan design Dual option Voluntary Dental plan extras There s extra value built into our dental portfolio: Dental-medical integration. Our program encourages preventive dental care among employees who have diabetes or heart disease, or who are pregnant. This can lead to more of your employees taking steps to stay healthy. Dental discounts. Aetna ValuePass SM, a MasterCard prepaid card, is a flexible way to give employees access to our nationwide network of dental services at discounted rates. It guarantees savings that range from 15 to 50 percent off the average retail cost of dental services.* Offer it alongside your current dental plan, as a voluntary plan with no employer contribution, or as a replacement for your current dental benefit, through defined contribution. Life and disability plans** Term life insurance Packaged life and disability Life and disability plan extras Aetna Life Essentials SM. Through our program, your employees get access to expert advice on legal and financial matters at no added cost. Plus, they get discounts on health products and services, like fitness and vision care.*** Funeral planning and concierge service. Through our partnership with Everest, we offer our life members pre-planning and at-need services. Aetna Return to Work Solutions SM program. Our return to work solutions provide customers with the support and resources they need to help get valued employees back to work safely and as soon as possible. * Savings are based on average retail charges in the geographic area and Aetna s negotiated rates. Actual retail charges and discounts provided by Aetna ValuePass participating providers will vary. **For groups 51 to 100, please consult your sales representative for a plan design to meet your group needs. ***These services are discount programs, not insurance. 8 The Aetna ValuePass SM program (the program ) is NOT insurance. The program provides cardholders with access to discounted fees pursuant to schedules negotiated by Aetna Life Insurance Company ( Aetna ), 151 Farmington Avenue, Hartford, CT 06156, 1-888-215-6578, with dental providers (the Aetna ValuePass participating providers ) in the Aetna Dental Access network. Aetna is the discount medical plan organization. Your card may be used at any dental provider, but you will only receive discounted fees at Aetna ValuePass participating providers. The range of discounts provided under the program will vary depending on the type of Aetna ValuePass participating provider and type of services received. The card provides payments directly to the providers accepting payments using the funds on your card. In order to receive a discount, you must use the card to pay for services or products furnished by the Aetna ValuePass participating providers. www.aetnavaluepass.com.
Together, we ll unlock the right combination of benefits, network, cost sharing and funding options for you and your employees. About our benefits Choose from numerous, integrated benefits options that can lead to improved employee engagement and health, while helping you manage your costs. This includes medical, pharmacy, dental, life, disability and vision. Plus, online tools that help employees use their benefits wisely and get help when they need it. About our network We have many full-network and tiered-network options to lower employer costs while still providing employees with access to quality care. Our doctor networks prioritize quality and efficiency to improve the health care experience and make it easy for individuals to get the care they need. About our cost sharing Some of our cost sharing arrangements encourage employees to become more involved in their own health care and become better health care consumers. Employees with these plans receive more preventive care, have lower overall costs and use online tools more frequently. About our funding options We can show you how a combined network, cost sharing and benefits approach can help you manage your premium to meet your budget. We also offer a range of funding options from traditional fully insured to enhanced self-insured solutions that provide different levels of cost, plan control and information access. Network options for healthy outcomes and lower costs Our network solutions help lower your costs while providing employees with access to trusted doctors and hospitals. Your employees can still get care within the broad Aetna network. But they pay less out of pocket when they use doctors and hospitals in our special networks. The more they use health care providers in these networks, the more likely you are to see lower medical costs. We make it easier for your employees, too. They get online tools for estimating costs and finding the right doctors and hospitals. Cost sharing and premiums for every budget Your focus is on lower costs. Increasingly, that means greater levels of employee cost sharing. With us in your corner, you can map out a strategy based on your employee base and price point. And you can choose from the full spectrum of health plan types: Our fully insured portfolio, traditionally a mainstay for small businesses, provides plans with a range of robust coverage options. Emerging self-funded options for small businesses may help you manage costs while offering the needed administrative support. Our consumer-directed health plans have long offered fully featured coverage, along with lower premiums and higher s. Our research has found that members with Aetna HealthFund plans have lower overall health care costs, receive more preventive care and use online tools more frequently than members with traditional plans. 9
We can help you unlock What s Your Healthy? SM Unlock health and wellness Having a happier, healthier workforce is important to you. So is cost management. We ve found that helping your employees get more involved in managing their health and well-being is a great way to meet these goals. Talk to your broker or Aetna representative to learn more about our programs. Wellness on us Wellness for employees means a healthier business for employers. As always, our business health benefits and insurance plans offer $0 copays for in-network eye exams and $0 copay for in-network preventive care. It s one more way to help employees get a step closer to better health. Preventive care benefits with no copay: Immunizations Routine physicals Child wellness visits Routine mammogram Routine OB/GYN visits No-cost health incentive credit (51 to 100 employees) Members can earn $50 in just a few simple steps. Members earn a $50 credit towards 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 employee s spouse is covered under the plan, he or she is also eligible for the same incentive credit. So a family could save 0 in out-of-pocket expenses each year. Incentive rewards will be credited towards the and coinsurance amounts. This program is included at no additional cost on all plans except the HSA compatible plans. Women s preventive health benefits These services are generally covered at no cost share, when provided in network: Well-woman visits (annually and now including prenatal visits) Screening for gestational diabetes Human papillomavirus (HPV) DNA testing Counseling for sexually transmitted infections Counseling and screening for human immunodeficiency virus (HIV) Screening and counseling for interpersonal and domestic violence Breastfeeding support, supplies and counseling Generic formulary contraceptives, certain brand formulary contraceptives are covered without member copayment; certain religious organizations or religious employers may be exempt from offering contraceptive services We make things easy for you Health plan management and administration is our specialty, which makes it easier for you to manage health insurance benefits with: eenrollment. Handle enrollments, terminations and other changes online, with less paperwork and greater efficiency. ebilling. Save time and simplify reconciliation and payment, anytime, anywhere, with our secure system. It lets you get, view and pay all your medical and dental bills online. Wellness programs can make health and fitness part of everyday living Women s health and preventive health reminders Simple Steps To A Healthier Life program Informed Health Line* Healthy Lifestyle Coaching 24-hour nurse line Aetna discount programs Personal Health Record 10 * While only your doctor can diagnose, prescribe or give medical advice, the Informed Health Line nurses can provide information on more than 5,000 health topics. Contact your doctor first with any questions or concerns regarding your health care needs.
Aetna Medical Overview Medical coverage can be a deal-breaker in recruiting and keeping talented employees. Our medical plan portfolio was designed with the needs of businesses like yours in mind. You ll find flexible options, from traditional indemnity to consumer-directed plans. You can choose the plan design and benefits level that fits your budget and achieve the right combination of cost and coverage for your business. M 11
M 12 Aetna High-Deductible HSA-Compatible, Aetna Open Access Managed Choice, Aetna Savings Plus and Aetna Whole Health plans Aetna High-Deductible HSA-Compatible, Aetna Open Access Managed Choice, Aetna Savings Plus and Aetna Whole Health plans are compatible with a health savings account (HSA). HSA-compatible plans provide integrated medical and pharmacy benefits. Preventive care services are exempt from the. HSAs 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. It is completely at the discretion of the employer or employee whether or not to establish an HSA. Note: Employers and employees should consult with their tax advisor to determine eligibility requirements and tax advantages for participation in the HSA plan. Health Savings Account (HSA) No set-up or administrative fees Our HealthFund HSA, when coupled with a HSA-compatible high- health benefits and health insurance plan, is a tax-advantaged savings account. Once enrolled, account contributions can be made by the employee and/or employer. The HSA can be used to pay for qualified expenses tax free. Member s HSA Plan Members own their HSA Contribute tax free Members choose how and when to use their 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 Members pay 100 percent until is met, then only pay a share of the cost Meet out-of-pocket maximum, then plan pays 100 percent Health Reimbursement Arrangement (HRA) Our HealthFund 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 Our 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. First-year POP fees are with the purchase of medical with five or more enrolled employees. 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. Choose Generics Generic medications normally cost 85 percent less than the brand versions. Generic medications must meet the same quality standards as the brand name drugs. With generics, the member gets the same quality for less money. Here s how Choose Generics works If a member is currently taking a brand name medication and a generic is available, they will need to use the generic version at the next refill or pay the cost difference between the two drugs.
For new prescriptions, if the prescribed drug is available in a generic form, the member will automatically receive the generic drug. If the prescriber writes dispense as written, or the member requests the brand name drug when a generic is available, the member will pay the difference in cost plus the applicable copay. Step Therapy Step therapy promotes the appropriate use of equally effective but lower-cost medications first. For any given condition, there are many therapy choices. We help members navigate their choices and find the most effective option, by starting with prerequisite medications. Trying one or more prerequisite medications is required before a step-therapy medication will be covered. Prerequisite medications are FDA-approved and treat the same condition as the corresponding step-therapy medications. Members can talk to their doctors about switching Members currently taking a step-therapy medication should ask their doctor for an equivalent medication that does not require step therapy. The doctor can ask for exception if it is medically necessary to use a medication on the step-therapy list This process takes place within 72-hours of the request, or within 2-hours of an expedited request. If approved, both the prescriber and the member are notified. If the request isn t approved, and the member does not try an alternative option, he or she can still get the medication. The member will just pay the full price of the medication. To request an exception, the doctor should contact the Aetna Pharmacy Precertification Unit Fax: 1-877-269-9916 Phone: Call toll-free at 1-855-240-0535 E-mail: Send an e-mail through our provider website at https://navinet.navimedix.com/main.asp While working with a prescriber is the preferred way to request an exception, the member may wish to make the request. To do so, they may call the Aetna Pharmacy Precertification Unit at the phone number above or visit www.aetna.com and log in to their secure Aetna Navigator member website, and click Contact Us. Administrative Fees Fee description Premium-Only Plan (POP) Fee Initial set-up* $190 Renewal fees $125 Health Reimbursement Arrangement (HRA) and Flexible Spending Account (FSA)** Initial set-up 2 25 Employees $360 $235 26 50 Employees $460 $285 51 100 Employees $560 $335 Monthly fees*** Additional set-up fee for stacked plans (those electing an Aetna HRA and FSA simultaneously) Participation fee for stacked participants $5.45 per participant $150.45 per participant Renewal fee Minimum fees 0 25 Employees $25 per month minimum 26 100 Employees $50 per month minimum COBRA Services Annual fee 20 50 Employees $165 51 100 Employees $230 Per employee per month 20 50 Employees $0.95 51 100 Employees $1.05 Initial notice fee $3.00 per notice (includes notices at time of implementation and during ongoing administration) Minimum fees 20 50 Employees $25 per month minimum 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 M * Nondiscrimination testing provided annually after open enrollment for POP and FSA only. Additional off-cycle testing available at employer request for 0 fee. Nondiscrimination testing only available for FSA and POP products. **Aetna FSA pricing is inclusive for POP. Debit cards are available for FSA only. Contact Aetna for further information. *** For HRA, if the employer opts out of Streamline, the fee is increased $1.50 per participant. 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. Aetna HRAs are subject to employer-defined use and forfeiture rules. 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. 13
M Texas Provider Network* OAMC/Preferred Provider Benefits Plan (PPO) Network Anderson Crosby Hidalgo McLennan Shelby Andrews Crockett Hockley McMullen Sherman Angelina Culberson Houston Menard Smith Archer Dallam Howard Midland Starr Armstrong Dawson Hudspeth Milam Stephens Bailey De Witt Hutchinson Mills Sterling Bandera Deaf Smith Irion Mitchell Stonewall Baylor Dickens Jack Montague Sutton Blanco Dimmit Jackson Moore Swisher Borden Donley Jasper Morris Taylor Bosque Eastland Jim Hogg Motley Terrell Bowie Ector Jeff Davis Nacogdoches Terry Brazos Edwards Jones Newton Throckmorton Brewster Falls Karnes Nolan Titus Briscoe Fayette Kenedy Ochiltree Tom Green Brooks Fisher Kent Oldham Trinity Brown Floyd Kerr Panola Tyler Burleson Foard Kimble Parmer Upshur Burnet Franklin Kinney Pecos Upton Calhoun Freestone Knox Polk Uvalde Callahan Frio La Salle Presidio Val Verde Cameron Gaines Lamar Potter Victoria Camp Garza Lamb Randall Ward Carson Gillespie Lavaca Reagan Washington Cass Glasscock Lee Real Webb Castro Goliad Leon Red River Wheeler Cherokee Gonzales Limestone Reeves Wichita Childress Gray Lipscomb Refugio Wilbarger Clay Gregg Llano Roberts Willacy Cochran Hale Loving Robertson Winkler Coke Hall Lubbock Runnels Wise Coleman Hamilton Lynn Rusk Wood Collingsworth Hansford Madison Sabine Yoakum Comanche Hardeman Marion San Augustine Young Concho Harrison Martin San Saba Zapata Coryell Hartley Mason Schleicher Zavala Cottle Haskell Maverick Scurry Crane Hemphill McCullough Shackelford 14 *Network subject to change. All counties listed in the HMO/HNOnly are also included in the OAMC network.
Texas Provider Network* M HMO/HNOnly 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. 15
M HNOnly Plans (2 50) (51 100) Silver HNOnly HNOnly Silver HNOnly 2000 80% HNOnly 2000 80% Silver HNOnly 3000 80% HNOnly 3000 80% Networks Available Health Network Only Health Network Only Health Network Only Member Benefits Participating Providers Participating Providers Participating Providers Calendar Year Deductible1 Calendar Year Out-of-Pocket Limit2 $0 Individual/ $0 Family $2,000 Individual/ $4,000 Family $6,000 Individual/ $12,000 Family $3,000 Individual/ $6,000 Family $5,500 Individual/ $11,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded Embedded Embedded Not Included In Out-of-Pocket Limit2 A Primary Care Physician Office Visit $30 copay; $30 copay; Specialist Office Visit $60 copay; $60 copay; Walk-In Clinics $30 copay; $30 copay; Chiropractic 20% after 20% after Preventive Care/Screenings/Immunizations $0 copay $0 copay; $0 copay; Diagnostic Testing: Lab $20 copay; $15 copay; Diagnostic Testing: X-ray $60 copay; $40 copay; Imaging (CT/PET scans MRIs) 20% after 20% after Prescription Drug Deductible N/A Integrated with Medical Retail Prescription Drugs (up to 30 day supply) Preferred Generic/Preferred Brand/ Non-Preferred Generic, Brand & Specialty Mail Order: three-times retail copay, up to 90-day supply Aetna Specialty CareRx SM Includes Preferred self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin) (Deductible for preferred generics) up to $500 (Deductible for preferred generics) up to $500 up to $300 up to $300 Outpatient Surgery OP Hospital Department 20% after 20% after Emergency Room $350 copay; (Copay if admitted) $350 copay; (Copay if admitted) Urgent Care 0 copay; $125 copay; Inpatient Hospital Facility 20% after 20% after 16 Refer to pages 51 53 for footnotes.
EPO Plans M (2 50) (51 100) Gold EPO 3000 100% EPO 3000 100% Silver EPO 2000 70% EPO 2000 70% Bronze EPO 3750 EPO 3750 Networks Available Elect Choice (Open Access) Elect Choice (Open Access) Elect Choice (Open Access) Member Benefits Participating Providers Participating Providers Participating Providers Calendar Year Deductible1 Calendar Year Out-of-Pocket Limit2 $3,000 Individual/ $6,000 Family $3,000 Individual/ $6,000 Family $2,000 Individual/ $4,000 Family $3,750 Individual/ $7,500 Family Deductible & Out-of-Pocket Limit Accumulation Embedded Embedded Embedded Not Included In Out-of-Pocket Limit2 A Primary Care Physician Office Visit $30 copay; $30 copay; $50 copay; Specialist Office Visit $60 copay; $60 copay; after Walk-In Clinics $30 copay; $30 copay after $50 copay; Chiropractic and Rehabilitation Services (PT/OT/ST) (35 visits combined) 0% after $60 copay; after Preventive Care/Screenings/Immunizations $0 copay; $0 copay; $0 copay; Diagnostic Testing: Lab $30 copay; $15 copay; after Diagnostic Testing: X-ray $60 copay; $30 copay; after Imaging (CT/PET scans MRIs) 0% after 30% after after Prescription Drug Deductible N/A Integrated with Medical Integrated with Medical Retail Prescription Drugs (up to 30 day supply) Preferred Generic /Preferred Brand/ Non-Preferred Generic, Brand & Specialty Mail Order: three-times retail copay, up to 90-day supply Aetna Specialty CareRx SM Includes Preferred self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin) $50 up to $500 (Deductible for preferred generics) $50 up to $500 up to $500 30% up to $300 30% up to $300 30% up to $300 Outpatient Surgery OP Hospital Department 0% after 30% after after Emergency Room $350 copay; (Copay if admitted) 30% after after Urgent Care 0 copay; $125 copay; after Inpatient Hospital Facility 0% after 30% after after Refer to pages 51 53 for footnotes. 17
M OAMC Plans (2 50) (51 100) Gold OAMC 500 80/50 OAMC 500 80/50 Silver OAMC 500 50/50 OAMC 500 50/50 Networks Available Managed Choice POS (Open Access) Managed Choice POS (Open Access) Member Benefits Participating Providers Non-Participating Providers4 Calendar Year Deductible1 Calendar Year Out-of-Pocket Limit2 $500 Individual/ $1,000 Family $3,500 Individual/ $7,000 Family $1,000 Individual/ $2,000 Family $7,000 Individual/ $14,000 Family Participating Providers $500 Individual/ $1,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded Embedded Not Included In Out-of-Pocket Limit2 A Primary Care Physician Office Visit Specialist Office Visit Walk-In Clinics Chiropractic (PT/OT/ST) and Rehabilitation Services (35 visits per calendar year) Preventive Care/Screenings/Immunizations Diagnostic Testing: Lab Diagnostic Testing: X-ray $25 copay; $50 copay; $25 copay; after $35 copay; Non-Participating Providers4 $2,000 Individual/ $4,000 Family $12,700 Individual/ $25,400 Family after after $70 copay after after after $35 copay; after 20% after after after after $0 copay; $25 copay; $50 copay; after $0 copay; after $35 copay; after after after $70 copay after after Imaging (CT/PET scans MRIs) 20% after after after after Prescription Drug Deductible N/A N/A N/A N/A Retail Prescription Drugs (up to 30 day supply) Preferred Generic /Preferred Brand/ Non-Preferred Generic, Brand & Specialty Mail Order: three-times retail copay, up to 90-day supply Aetna Specialty CareRx SM Includes Preferred self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin) $50 up to $500 + 30% $50 + 30% up to $500 30% up to $300 30% 30% up to $300 30% + 30% Outpatient Surgery OP Hospital Department 20% after after after after Emergency Room Urgent Care $250 copay plus 20% coinsurance; (Copay if admitted) $75 copay; after $125 copay; after after Inpatient Hospital Facility 20% after after after after 18 Refer to pages 51 53 for footnotes.
OAMC Plans M (2 50) (51 100) Gold OAMC 1000 80/50 OAMC 1000 80/50 Gold OAMC 1000 80/50 EX OAMC 1000 80/50 EX Networks Available Managed Choice POS (Open Access) Managed Choice POS (Open Access) Member Benefits Participating Providers Non-Participating Providers4 Calendar Year Deductible1 Calendar Year Out-of-Pocket Limit2 $1,000 Individual/ $2,000 Family $3,500 Individual/ $7,000 Family $2,000 Individual/ $4,000 Family $7,000 Individual/ $14,000 Family Participating Providers $1,000 Individual/ $2,000 Family $3,500 Individual/ $7,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded Embedded Not Included In Out-of-Pocket Limit2 A Primary Care Physician Office Visit Specialist Office Visit Walk-In Clinics Chiropractic (PT/OT/ST) and Rehabilitation Services (35 visits per calendar year) Preventive Care/Screenings/Immunizations Diagnostic Testing: Lab Diagnostic Testing: X-ray $25 copay; $50 copay; $25 copay; after $25 copay; after $50 copay; after $25 copay; Non-Participating Providers4 $2,000 Individual/ $4,000 Family $7,000 Individual/ $14,000 Family after after after 20% after after 20% after after $0 copay; $20 copay; $50 copay; after $0 copay; after $20 copay; after $50 copay; after after after Imaging (CT/PET scans MRIs) 20% after after 20% after after Prescription Drug Deductible N/A N/A N/A N/A Retail Prescription Drugs (up to 30 day supply)5 Preferred Generic /Preferred Brand/ Non-Preferred Generic, Brand & Specialty Mail Order: three-times retail copay, up to 90-day supply Aetna Specialty CareRx SM Includes Preferred self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin) $50 up to $500 + 30% $50 + 30% $50 $75 30% up to $300 30% 30% up to $300 30% + 30% $50 + 30% $75 + 30% Outpatient Surgery OP Hospital Department 20% after after 20% after after Emergency Room Urgent Care $250 copay plus 20% coinsurance; (Copay if admitted) $75 copay; after $75 copay; $250 copay plus 20% coinsurance; (Copay if admitted) after Inpatient Hospital Facility 20% after after 20% after after Refer to pages 51 53 for footnotes. 19
M OAMC Plans (2 50) (51 100) Silver OAMC 1000 60/50 OAMC 1000 60/50 Silver OAMC 1000 60/50 EX OAMC 1000 60/50 EX Networks Available Managed Choice POS (Open Access) Managed Choice POS (Open Access) Member Benefits Participating Providers Non-Participating Providers4 Calendar Year Deductible1 Calendar Year Out-of-Pocket Limit2 $1,000 Individual/ $2,000 Family $2,000 Individual/ $4,000 Family $12,700 Individual/ $25,400 Family Participating Providers $1,000 Individual/ $2,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded Embedded Not Included In Out-of-Pocket Limit2 A Primary Care Physician Office Visit $35 copay; after $35 copay; Specialist Office Visit $70 copay after after $70 copay Walk-In Clinics Chiropractic (PT/OT/ST) and Rehabilitation Services (35 visits per calendar year) Preventive Care/Screenings/Immunizations Diagnostic Testing: Lab $35 copay; after $35 copay; Non-Participating Providers4 $2,000 Individual/ $4,000 Family $12,700 Individual/ $25,400 Family after after after 40% after after 40% after after $0 copay; $35 copay; after $0 copay; after $35 copay; Diagnostic Testing: X-ray 40% after after $70 copay; after after after Imaging (CT/PET scans MRIs) 40% after after 40% after after Prescription Drug Deductible Integrated with medical Integrated with medical N/A N/A Retail Prescription Drugs (up to 30 day supply)5 Preferred Generic /Preferred Brand/ Non-Preferred Generic, Brand & Specialty Mail Order: three-times retail copay, up to 90-day supply Aetna Specialty CareRx SM Includes Preferred self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin) (Deductible for preferred generics) up to $500 + 30% $45 $75 30% up to $300 30% 30% up to $300 30% + 30% $45 + 30% $75 + 30% Outpatient Surgery OP Hospital Department 40% after after 40% after after Emergency Room 40% after 40% after Urgent Care 0 copay; after 0 copay; after Inpatient Hospital Facility 40% after after 40% after after 20 Refer to pages 51 53 for footnotes.
OAMC Plans M (2 50) (51 100) Gold OAMC 1500 80/50 OAMC 1500 80/50 Silver OAMC 1500 70/50 OAMC 1500 70/50 Networks Available Managed Choice POS (Open Access) Managed Choice POS (Open Access) Member Benefits Participating Providers Non-Participating Providers4 Calendar Year Deductible1 Calendar Year Out-of-Pocket Limit2 $1,500 Individual/ $3,000 Family $3,500 Individual/ $7,000 Family $3,000 Individual/ $6,000 Family $7,000 Individual/ $14,000 Family Participating Providers $1,500 Individual/ $3,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded Embedded Not Included In Out-of-Pocket Limit2 A Primary Care Physician Office Visit Specialist Office Visit Walk-In Clinics Chiropractic (PT/OT/ST) and Rehabilitation Services (35 visits per calendar year) Preventive Care/Screenings/Immunizations Diagnostic Testing: Lab Diagnostic Testing: X-ray $25 copay; $50 copay; $25 copay; after $35 copay; after $70 copay; after $35 copay; Non-Participating Providers4 $3,000 Individual/ $6,000 Family $12,700 Individual/ $25,400 Family after after after 20% after after 30% after after $0 copay; $15 copay; $50 copay; after $0 copay; after $35 copay; after $70 copay; after after after Imaging (CT/PET scans MRIs) 20% after after 30% after after Prescription Drug Deductible N/A N/A Integrated with medical Integrated with medical Retail Prescription Drugs (up to 30 day supply) Preferred Generic /Preferred Brand/ Non-Preferred Generic, Brand & Specialty Mail Order: three-times retail copay, up to 90-day supply Aetna Specialty CareRx SM Includes Preferred self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin) $50 up to $500 + 30% $50 + 30% (Deductible for preferred generics) $50 up to $500 30% up to $300 30% 30% up to $300 30% + 30% $50 + 30% Outpatient Surgery OP Hospital Department 20% after after 30% after 50 % after Emergency Room Urgent Care $75 copay; $250 copay; (Copay if admitted) after 0 copay; 30% after after Inpatient Hospital Facility 20% after after 30% after after Refer to pages 51 53 for footnotes. 21
M OAMC Plans (2 50) (51 100) Silver OAMC 1500 70/50 EX OAMC 1500 70/50 EX Silver OAMC 1500 70/50 Basic OAMC 1500 70/50 Basic Networks Available Managed Choice POS (Open Access) Managed Choice POS (Open Access) Member Benefits Participating Providers Non-Participating Providers4 Calendar Year Deductible1 Calendar Year Out-of-Pocket Limit2 $1,500 Individual/ $3,000 Family $3,000 Individual/ $6,000 Family $12,700 Individual/ $25,400 Family Participating Providers $1,500 Individual/ $3,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded Embedded Not Included In Out-of-Pocket Limit2 A Primary Care Physician Office Visit Specialist Office Visit Walk-In Clinics Chiropractic (PT/OT/ST) and Rehabilitation Services (35 visits per calendar year) Preventive Care/Screenings/Immunizations Diagnostic Testing: Lab Diagnostic Testing: X-ray $30 copay; $60 copay; $30 copay; after $40 copay; * after $40 copay; * after $40 copay; * Non-Participating Providers4 $3,000 Individual/ $6,000 Family $12,700 Individual/ $25,400 Family after after after 30% after after 30% after after $0 copay; $30 copay; $60 copay; after $0 copay; after after 30% after after after 30% after after Imaging (CT/PET scans MRIs) 30% after after 30% after after Prescription Drug Deductible N/A N/A N/A N/A Retail Prescription Drugs (up to 30 day supply)5 Preferred Generic /Preferred Brand/ Non-Preferred Generic, Brand & Specialty Mail Order: three-times retail copay, up to 90-day supply Aetna Specialty CareRx SM Includes Preferred self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin) $45 $75 + 30% $45 + 30% $75 + 30% up to $500 30% up to $300 30% 30% up to $300 30% + 30% Outpatient Surgery OP Hospital Department 30% after 50 % after 30% after after Emergency Room 30% after 30% after Urgent Care 0 copay; after 0 copay; after Inpatient Hospital Facility 30% after after 30% after after 22 Refer to pages 51 53 for footnotes.
OAMC Plans M (2 50) (51 100) Gold OAMC 2000 100/70 OAMC 2000 100/70 Gold OAMC 2000 100/70 EX OAMC 2000 100/70 EX Networks Available Managed Choice POS (Open Access) Managed Choice POS (Open Access) Member Benefits Participating Providers Non-Participating Providers4 Calendar Year Deductible1 Calendar Year Out-of-Pocket Limit2 $2,000 Individual/ $4,000 Family $2,500 Individual/ $5,000 Family $4,000 Individual/ $8,000 Family $5,000 Individual/,000 Family Participating Providers $2,000 Individual/ $4,000 Family $2,500 Individual/ $5,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded Embedded Not Included In Out-of-Pocket Limit2 A Primary Care Physician Office Visit Specialist Office Visit Walk-In Clinics Chiropractic (PT/OT/ST) and Rehabilitation Services (35 visits per calendar year) Preventive Care/Screenings/Immunizations Diagnostic Testing: Lab Diagnostic Testing: X-ray $30 copay; $50 copay; $30 copay; 30% after $30 copay; 30% after $50 copay; 30% after $30 copay; Non-Participating Providers4 $4,000 Individual/ $8,000 Family $5,000 Individual/,000 Family 30% after 30% after 30% after 0% after 30% after 0% after 30% after $0 copay; $30 copay; $50 copay; 30% after $0 copay; 30% after $30 copay; 30% after $50 copay; 30% after 30% after 30% after Imaging (CT/PET scans MRIs) 0% after 30% after 0% after 30% after Prescription Drug Deductible N/A N/A N/A N/A Retail Prescription Drugs (up to 30 day supply)5 Preferred Generic /Preferred Brand/ Non-Preferred Generic, Brand & Specialty Mail Order: three-times retail copay, up to 90-day supply Aetna Specialty CareRx SM Includes Preferred self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin) $50 up to $500 + 30% $50 + 30% $50 $75 30% up to $300 30% 30% up to $300 30% + 30% $50 + 30% $75 + 30% Outpatient Surgery OP Hospital Department 0% after 30% after 0% after 30% after Emergency Room Urgent Care $75 copay; $250 copay; (Copay if admitted) 30% after $75 copay; $250 copay; (Copay if admitted) 30% after Inpatient Hospital Facility 0% after 30% after 0% after 30% after Refer to pages 51 53 for footnotes. 23
M OAMC Plans (2 50) (51 100) Silver OAMC 2000 70/50 OAMC 2000 70/50 Silver OAMC 2000 70/50 EX OAMC 2000 70/50 EX Networks Available Managed Choice POS (Open Access) Managed Choice POS (Open Access) Member Benefits Participating Providers Non-Participating Providers4 Calendar Year Deductible1 Calendar Year Out-of-Pocket Limit2 $2,000 Individual/ $4,000 Family $4,000 Individual/ $8,000 Family $12,700 Individual/ $25,400 Family Participating Providers $2,000 Individual/ $4,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded Embedded Not Included In Out-of-Pocket Limit2 A Primary Care Physician Office Visit Specialist Office Visit Walk-In Clinics Chiropractic (PT/OT/ST) and Rehabilitation Services (35 visits per calendar year) Preventive Care/Screenings/Immunizations Diagnostic Testing: Lab Diagnostic Testing: X-ray $30 copay; $60 copay; $30 copay; after $30 copay; after $60 copay; after $30 copay; Non-Participating Providers4 $4,000 Individual/ $8,000 Family $12,700 Individual/ $25,400 Family after after after 30% after after 30% after after $0 copay; $30 copay; $30 copay; after $0 copay; after $30 copay; after $60 copay; after after after Imaging (CT/PET scans MRIs) 30% after after 30% after after Prescription Drug Deductible Integrated with Medical Integrated with Medical N/A N/A Retail Prescription Drugs (up to 30 day supply)5 Preferred Generic /Preferred Brand/ Non-Preferred Generic, Brand & Specialty Mail Order: three-times retail copay, up to 90-day supply Aetna Specialty CareRx SM Includes Preferred self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin) (Deductible for preferred generics) up to $500 + 30% $45 $75 up to $300 30% up to $300 30% + 30% $45 + 30% $75 + 30% Outpatient Surgery OP Hospital Department 30% after after 30% after after Emergency Room 30% after 30% after Urgent Care $125 copay; after $125 copay; after Inpatient Hospital Facility 30% after after 30% after after 24 Refer to pages 51 53 for footnotes.