PLAN FEATURES Deductible (per calendar year) $500 Individual $500 Individual $1,500 Family $1,500 Family All covered expenses, including prescription drugs, accumulate toward both the preferred and non-preferred Deductible. Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Members with an Employee + 1 or Family Deductible do not have an Individual Deductible to satisfy. Once Family Deductible is met, all family members will be considered as having met the Deductible for the remainder of the calendar year. There is no Individual Deductible to satisfy within the Family Deductible. Member Coinsurance Applies to all expenses unless otherwise stated. Payment Limit (per calendar year) 10% $2,350 Individual 30% $6,250 Individual $7,050 Family $18,750 Family All covered expenses, including prescription drugs, accumulate toward both the preferred and non-preferred Payment Limit. Certain member cost sharing elements may not apply toward the Payment Limit. Pharmacy expenses apply towards the Payment Limit. Only those preferred and non preferred out-of-pocket expenses resulting from the application of coinsurance percentage, deductibles, medical and pharmacy copays (except any penalty amounts) may be used to satisfy the Payment Limit. Members with an Employee + 1 or Family Coinsurance Limit do not have an Individual Payment Limit to satisfy. Once Family Payment Limit is met, all family members will be considered as having met the Payment Limit for the remainder of the calendar year. There is no Individual Payment Limit to satisfy within the Family Payment Limit. Lifetime Maximum Unlimited except where otherwise Unlimited except where otherwise indicated indicated Primary Care Physician Selection Optional Not applicable Certification Requirements - Certification for certain types of Non-Preferred care must be obtained to avoid a reduction in benefits paid for that care. Certification for Hospital Admissions, Treatment Facility Admissions, Convalescent Facility Admissions, Home Health Care, Hospice Care and Private Duty Nursing is required - there will be a $500 penalty for failing to obtain precertification. Referral Requirement PREVENTIVE CARE Routine Adult Physical Exams/ Immunizations 1 exam per 12 months for members age 22 and older. Routine Well Child Exams/Immunizations 7 exams in the first 12 months of life, 3 exams in the second 12 months of life, 3 exams in the third 12 months of life, 1 exam per year thereafter to age 22. Routine Gynecological Care Exams Includes routine tests and related lab fees, limited to 1 exam per calendar year. Routine Mammograms Women's Health Includes: Screening for gestational diabetes, HPV (Human Papillomavirus) DNA testing, counseling for sexually transmitted infections, counseling and screening for Human Immunodeficiency Virus, screening and counseling for interpersonal and domestic violence, breastfeeding support, supplies, and counseling. Contraceptive methods, sterilization procedures, patient education and counseling. Limitations may apply. Routine Digital Rectal Exam / Prostatespecific Antigen Test Colorectal Cancer Screening For all members age 50 and over. Routine Eye Exams 1 routine exam per 12 months. Routine Hearing Screening None None Page 1
PHYSICIAN SERVICES Office Visits to PCP $20 office visit copay; deductible waived Includes services of an internist, general physician, family practitioner or pediatrician. Specialist Office Visits $30 office visit copay; deductible waived Pre-Natal Maternity Hearing Exams - Audiometric Exam 1 routine exam per 12 months. Allergy Testing Allergy Injections $20 office visit copay; deductible waived $20 office visit copay; deductible waived, if billed as an office visit. Otherwise, paid at 100%. DIAGNOSTIC PROCEDURES Diagnostic Laboratory and X-ray MRI, CT scan, PET scan & nuclear cardiac scan If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the applicable physician's office visit member cost sharing. EMERGENCY MEDICAL CARE Urgent Care Provider (benefit availability may vary by location) Emergency Room $30 copay; deductible waived $100 copay; waived if admitted; 10%; deductible waived Same as preferred care. Ambulance HOSPITAL CARE Inpatient Coverage deductible Includes transgender surgery. Inpatient Maternity Coverage (includes delivery and postpartum care) $30 copay; deductible waived for Physician Services; 10%; after deductible for Facility services for Physician Services; 30% after $500 per confinement copay; after deductible for Facility services Outpatient Surgery, Services & Supplies Outpatient Hospital Expenses (excluding surgery) The member cost sharing applies to all Covered Benefits incurred during a member's outpatient visit. MENTAL HEALTH SERVICES Inpatient deductible Outpatient $30 copay; deductible waived The member cost sharing applies to all covered benefits incurred during a member's outpatient visit. ALCOHOL/DRUG ABUSE SERVICES Inpatient deductible Outpatient $30 copay; deductible waived The member cost sharing applies to all Covered Benefits incurred during a member's outpatient visit. Page 2
OTHER SERVICES Convalescent Facility Limited to 120 days per calendar year. The member cost sharing applies to all covered benefits incurring during a member's inpatient stay. Home Health Care Covered 100%;after deductible Limited to 100 visits per calendar year. Includes Private Duty Nursing. Each visit by a nurse or therapist is one visit. Each visit up to 4 hours by a home health care aide is one visit. Home Infusion Therapy Hospice Care - Inpatient Covered 100%, deductible waived Covered 100%, deductible waived Hospice Care - Outpatient Outpatient Speech Therapy Covers all conditions. $30 copay; deductible waived Outpatient Physical and Occupational Therapy $30 copay; deductible waived Include coverage for physical and occupational therapy for children with autism and pervasive developmental disorders. Applied Behavioral Analysis $30 copay; deductible waived Not Covered Covered same as any other Outpatient Mental Health benefit. Pre-certification and in-network providers required. Autism Behavioral Therapy Refer to MBH Outpatient Mental Not Covered Health Combined with outpatient mental health visits Autism Physical Therapy Autism Occupational Therapy Autism Speech Therapy Spinal Manipulation Therapy (Chiropractic) Limited to 20 visits per calendar year. Acupuncture Limited to 12 visits per calendar year. $30 copay; deductible waived Durable Medical Equipment Therapeutic shoes and inserts covered for members with diabetes. Unlimited calendar year maximum. Hearing Aids Limited to $5,000 per calendar year. Bariatric Surgery Not Covered Coverage provided at an Institute of Quality (IOQ), includes Travel and Lodging benefit Gender Reassignment Surgery Includes transgender surgery coverage. Unlimited lifetime limit for gender reassignment surgery if deemed medically necessary and when all of the criteria requirements are met as outlined in the Aetna Clinical Policy Bulletin: Gender Reassignment Surgery (Number 0615). Diabetic Supplies $30 copay; deductible waived Page 3
Contraceptive drugs and devices not obtainable at a pharmacy (includes coverage for contraceptive visits) Generic FDA-approved Women's Contraceptives Transplants Mouth, Jaws and Teeth (oral surgery procedures that are medical in nature) 10%; after deductible. Preferred coverage is provided at an IOE contracted facility only. $30 office visit copay; deductible waived if billed as an office visit otherwise 10% 30% (payable as any other covered expense) after deductible Not Covered deductible after deductible. Non- Preferred coverage is provided at a Non-IOE facility. Same as preferred care Out of Area Dependents Coverage provided at 10%; all non-preferred benefits and limitations apply. FAMILY PLANNING Infertility Treatment $30 copay if billed as an office visit otherwise, 10% Diagnosis and treatment of the underlying medical condition. Comprehensive Infertility Services 50% after deductible Not Covered Coverage includes Artificial Insemination and Ovulation Induction Combined Comprehensive Infertility Services and Advanced Reproductive Technology (ART) $7,000 lifetime maximum for Medical and $3,000 lifetime maximum for Pharmacy, applies to all procedures covered by any Aetna plan except where prohibited by law. Maximum applies to all procedures covered by any Aetna plan except where prohibited by law. For information and approval contact: National Infertility Unit #1-800-575-5999. Advanced Reproductive Technology (ART) 50% after deductible Not Covered ART coverage includes: In vitro fertilization (IVF), zygote intra-fallopian transfer (ZIFT), gamete intrafallopian transfer (GIFT), cryopreserved embryo transfers, intracytoplasmic sperm injection (ICSI) or ovum microsurgery. Also includes, Egg Retrieval for preservation of fertility to delay child bearing. Vasectomy Tubal Ligation PHARMACY Pharmacy Plan Type Aetna Premier Plus Open Formulary The full cost of the drug is applied to the deductible before benefits are considered for payment under the pharmacy plan Generic Drugs 10% after combined medical/rx plan Combined Comprehensive Infertility Services and Advanced Reproductive Technology (ART) $7,000 lifetime maximum for Medical and $3,000 lifetime maximum for Pharmacy, applies to all procedures covered by any Aetna plan except where prohibited by law. Maximums applies to all procedures covered by any Aetna plan except where prohibited by law. For information and approval contact: National Infertility Unit #1-800-575-5999. 50% of submitted cost after combined medical/rx plan deductible for all 10% after combined medical/rx plan drugs up to a 90 day supply Not Applicable Page 4
Preferred Brand-Name Drugs VMware, Inc. 25% after combined medical/rx plan 50% of submitted cost after combined medical/rx plan deductible for all Non-Preferred Brand-Name Drugs 25% after combined medical/rx plan drugs up to a 90 day supply 40% after combined medical/rx plan Not Applicable 50% of submitted cost after combined medical/rx plan deductible for all Pharmacy Day Supply and Requirements Premier Plus Specialty 40% after combined medical/rx plan drugs up to a 90 day supply Not Applicable Up to a 30 day supply Percentage copays will not be doubled Up to a 31-90 day supply from Aetna Rx Home Delivery. Up to a 30 day supply from Aetna Specialty Pharmacy Network. First prescription fill at any retail or specialty pharmacy. Subsequent fills must be through our preferred Aetna Specialty Pharmacy network. Preventive Medications - Deductible is waived for certain preventive medications. A full list of these drugs is available on Aetna Navigator. Plan Includes: Performance Enhancing Medication (6 tablets per month), Contraceptive drugs and devices obtainable from a pharmacy, Oral fertility drugs (subject to infertility maximum), Diabetic supplies. Premier Plus Pre-certification for Specialty Drugs Precert for growth hormones included. Formulary Generic FDA-approved Women's Contraceptives and certain over-thecounter preventive medications covered 100% in network. GENERAL PROVISIONS Dependents Eligibility Spouse, domestic partner and children from birth to age 26 This plan does not cover all health care expenses and includes exclusions and limitations. Members should refer to their plan documents to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, your plan documents may contain exceptions to this list based on state mandates or the plan design or rider(s) purchased by your employer. All medical or hospital services not specifically covered in, or which are limited or excluded in the plan documents; Charges related to any eye surgery mainly to correct refractive errors; Cosmetic surgery, including breast reduction; Custodial care; Dental care and X-rays; Donor egg retrieval; Experimental and investigational procedures; Hearing aids; Immunizations for travel or work; unless specifically listed as covered in your plan documents. Nonmedically necessary services or supplies; Orthotics; Over-the-counter medications and supplies; Reversal of sterilization; Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies, or counseling; and special duty nursing. Weight control services including surgical procedures, medical treatments, weight control/loss programs, dietary regimens and supplements, appetite suppressants and other medications; food or food supplements, exercise programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or treat obesity, including Morbid Obesity, or for the purpose of weight reduction, regardless of the existence of comorbid conditions. Page 5
This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee results or outcomes. Consult the plan documents (i.e. Group Insurance Certificate and/or Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitation relating to the plan. With the exception of Aetna Rx Home Delivery, all preferred providers and vendors are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change without notice. Some benefits are subject to limitations or visit maximums. Certain services require precertification, or prior approval of coverage. Failure to precertify for these services may lead to substantially reduced benefits or denial of coverage. Some of the benefits requiring precertification may include, but are not limited to, inpatient hospital, inpatient mental health, inpatient skilled nursing, outpatient surgery, substance abuse (detoxification, inpatient and outpatient rehabilitation). When the Member s preferred provider is coordinating care, the preferred provider will obtain the precertification. When the member utilizes a non-preferred provider, Member must obtain the precertification. Precertification requirements may vary. Depending on the plan selected, new prescription drugs not yet reviewed by our medication review committee are either available under plans with an open formulary or excluded from coverage unless a medical exception is obtained under plans that use a closed formulary. They may also be subject to precertification or step-therapy. Non-prescription drugs and drugs in the Limitations and Exclusions section of the plan documents (received after open enrollment) are not covered, and medical exceptions are not available for them. While this information is believed to be accurate as of the print date, it is subject to change. Plans are administered by Aetna Life Insurance Company. Page 6