Aetna Pharmacy Management Custom RX PLAN FEATURES Deductible (per calendar year) $250 Deductible Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Member Coinsurance 15% Applies to all expenses unless otherwise stated. Payment Limit (per calendar year) $5,000 Includes deductible. Certain other member cost sharing elements may not apply towards the Payment Limit. Lifetime Maximum Primary Care Physician Selection Referral Requirements Unlimited except for where otherwise indicated Not Applicable None PREVENTIVE CARE Routine Physical Exams/Immunizations Covered 100% (One annual exam/pneumonia, Flu, Hepatitis B) Routine Gynecological Care Exams Covered 100% One Routine GYN visit and pap smear every 365 days Routine Mammograms Covered 100% One baseline mammogram for members 35-39; and one annual mammogram for members age 40 and over Routine Digital Rectal Exams / Prostate Specific Covered 100% Antigen Test For males age 40 and over. Colorectal Cancer Screening Covered 100% For all members 50 and over. Bone Density Testing Covered 100% Routine Eye Exam Covered 100% One annual exam. 11/03/2008 1
Routine Hearing Screening Covered 100% One (1) annual exam Hearing Aid Reimbursement $500 every 36 months PHYSICIAN SERVICES Primary Care Physician Visits (Office hours) 15% (After Office Hours) 15% Specialist Office Visits 15% Allergy Testing/Treatment 15% For initial testing by a specialist; with or without physician encounter DIAGNOSTIC PROCEDURES Diagnostic Laboratory and X-Ray 15% EMERGENCY MEDICAL CARE Urgent Care Provider $35 copay Emergency Room; Worldwide (waived if $50 copay admitted) Ambulance 15% HOSPITAL CARE Inpatient Coverage 15% The member cost sharing applies to covered benefits incurred during a member's inpatient stay. Outpatient Surgery 15% The member cost sharing applies to covered benefits incurred during a member's outpatient visit. MENTAL HEALTH SERVICES Inpatient Mental Illness 15% (Combined with Inpatient Substance Abuse) 190 Lifetime days The member cost sharing applies to covered benefits incurred during a member's inpatient stay. Outpatient Mental Illness 15% The member cost sharing applies to covered benefits incurred during a member's outpatient visit. ALCOHOL/DRUG ABUSE SERVICES Inpatient Substance Abuse (Detox and Rehab) 15% (Combined with Inpatient Mental Health) 190 Lifetime days The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. 11/03/2008 2
Outpatient Substance Abuse (Detox and Rehab) 15% The member cost sharing applies to covered benefits incurred during a member's outpatient visit. OTHER SERVICES Skilled Nursing Facility 0% per day - days 1-20; 15% per day - days 21-100 (100 days per Medicare benefit period) The member cost sharing applies to covered benefits incurred during a member's inpatient stay. Home Health Care Covered 100% Hospice Care Covered by Medicare at a Medicare certified hospice Outpatient Short-Term Therapy (speech, physical, 15% cardiac and occupational) Chiropractic Care 15% For manual manipulation of the spine to the extent covered by Medicare Durable Medical Equipment/Prosthetic Devices 15% Podiatry 15% Limited to Medicare covered benefits only Diabetic Supplies Covered 100% Includes test strips, lancets and glucometer Outpatient Complex Radiology 15% Outpatient Dialysis 15% Vision Eyewear Allowance Coaching Lens discounts where available Included 11/03/2008 3
PRESCRIPTION DRUG BENEFITS Prescription drug calendar year Deductible TROOP Member cost sharing once Out of Pocket provision is reached* Retail Copayments Up to a 30-day supply at indicated copay Mail Order through Aetna Rx Home Delivery - Copayments None $4,350 0% $10 for Generic $20 for Preferred Brand $40 for Non-Preferred Brand $20 for Generic $40 for Preferred Brand $80 for Non-Preferred Brand Up to a three month (90-day) supply available via our preferred vendor, Aetna Rx Home Delivery. Requirements: Precertification Step-Therapy Formulary Mandatory Generic (MG) Prescription Options and Exclusions Anti-Obesity Drugs/Appetite Suppressants Contraceptives (covered whether or not medically necessary) Cosmetic Drugs Diabetic Supplies Restriction Yes Yes Open Yes All Contraceptives Covered Covers needles and syringes without purchase of insulin (separate copay applies to each purchase) 11/03/2008 4
Fertility Drugs, Oral and Injectable Performance Enhancement/Lifestyle Drugs Smoking Cessation Aids Imitrex Quantity Limit and Kit Logic Included Maximum 48 kits per year with one copay per kit. * This is a richer benefit than CMS PDP. After $4,350 out of pocket max, CMS PDP member cost sharing is the Greater of 5% or $2.40 generic/$6.00 all other covered medications. Disclaimers 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. 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 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 provided by Aetna Life Insurance Company. MA Only Please refer to the plan documents (Evidence of Coverage) for a complete listing of benefits, exclusions and limitations. The following is a partial listing of exclusions and limitations under the Aetna Medicare Open Plan: 11/03/2008 5
Services that are not medically necessary or covered under the Original Medicare Program unless otherwise noted Plastic or cosmetic surgery unless medically necessary Custodial care Experimental procedures or treatments beyond Original Medicare limits Routine foot care that is not medically necessary Outpatient Prescription Drugs except those covered under Medicare Part B This material is for informational purposes only. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Aetna does not provide care or guarantee access to health services. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Discount Programs provide access to discounted prices and are not insured benefits. While this material is believed to be accurate as of the print date, it is subject to change. Benefits coverage is provided by Aetna Life Insurance Company, a Medicare Advantage organization, with a Medicare contract and benefits, limitations, service areas and premiums subject to change on January 1 of each year. You must be entitled to Medicare Part A and continue to pay your Part B premium and Part A, if applicable. A Medicare Advantage Private Fee-for-Service plan works differently than a Medicare supplement plan. Your doctor or hospital must agree to accept the plan s terms and conditions prior to providing healthcare services to you, with the exception of emergencies. If your doctor or hospital does not agree to accept our payment terms and conditions, they may not provide healthcare services to you, except in emergencies. Providers can find the plan s terms and conditions on our website at: www.aetna.com 11/03/2008 6