Aetna Avenue Your Destination for Small Business Solutions SM PENNSYLVANIA PLAN GUIDE For businesses with 2-50 eligible employees Plans effective December 1, 2008 14.02.970.1-PA (8/09)
PENNSYLVANIA PLAN GUIDE PENNSYLVANIA PLAN GUIDE Health care is a journey AETNA AVENUE IS THE WAY IN THIS GUIDE: 2 Small business commitment 3 Benefits for every stage of life 4 Medical overview 8 Medical plan options 24 Dental overview 26 Dental plan options 32 Life & disability overview 34 Life plan options 35 Life & disability plan options 36 Underwriting guidelines 42 Limitations and exclusions As a small business owner, providing value to your customers and growing your business are your top priorities. Yet, today health care is a business issue for every entrepreneur. Small businesses need health benefits and insurance plans that fit their workplace. Aetna Avenue provides employers with a choice of insurance benefits solutions. We know that choice, ease and reputation are as valuable to employers as they are to employees. Aetna offers a variety of plans for small business from medical plans, to dental, life and disability plans. Health benefits and health insurance, dental benefits/dental insurance, life insurance and disability insurance plans/policies are offered, underwritten or administered by Aetna Health Inc., Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna).
CHOICE For business owners and employees At Aetna, we provide employers a choice of health insurance benefits plans. Within these benefits programs, employers can choose specific plan designs that fit business and employee needs. Employees have access to a wide network of doctors and other providers ensuring that they have a choice in how they receive their health care. Medical plans supporting members on their health care journey Traditional plans Cost-sharing plans Consumer-directed plans Dental, life and disability plans providing valuable protection DMO PPO PPO Max Freedom-of-Choice plan design Consumer-directed plan Preventive Basic term life insurance Packaged life and disability plans EASE Allowing you to focus on your business Employers want to focus on their customers and growing their business not the health insurance benefits program. Aetna makes sure that our plan designs are easy to set-up, administer, use and provide support to ensure your success. Administration making it work for your business Aetna s plan designs automatically process health claim reimbursements, provide a password-protected website to keep track of accounts and are supported by knowledgeable service representatives. Secure and online, Aetna Enroll SM makes managing health benefits easy and eliminates time-consuming, expensive paper-based processes. Ready on day-one making it work for your employees Once employees are members of the Aetna health benefits and health insurance plans, they ll have access to our various tools and resources to help them use the plans effectively from the start. Aetna Navigator our online resource for employers, members and providers Look up rates for providers, facilities and hospitals for common services and treatment Track medical claims online Discount programs for eye, dental and other health care Personal Health Record providing a complete picture of health Temporary ID cards available for members to print as needed REPUTATION In business it s everything Your reputation is important to your business. At Aetna, our reputation is just as important. With 150 years of experience, we value our name, products and services and focus on delivering the right solution for your small business our reputation depends upon it. Our account executives, underwriters and customer service representatives are committed to providing your small business the valuable service it deserves. MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 1
PENNSYLVANIA PLAN GUIDE PENNSYLVANIA PLAN GUIDE AETNA AVENUE S COMMITMENT TO SMALL BUSINESS EMPLOYERS We know that small business owners health insurance benefits needs are often different than a larger employer. Aetna Avenue focuses on employers with 2 50 employees and our insurance benefits programs are designed to work for this size group. We ll work with you to determine the right plans for your business and assist you through implementation. AETNA S MARKET MAP Guiding your small business health care journey Aetna s market map is a resource for brokers and employers to help determine the right insurance benefits plan for their business. The market map asks specific questions related to the business and employee need in order to narrow the field of plan design choices. Basic benefits for your employees Limiting the expense to your business Allowing employees to buy-up and share more of the cost You might be a Basic buyer These plans fit PA POS 5.3 PA POS Cost-Sharing 4.3 PA POS Cost-Sharing 5.3 DO YOU VALUE Employee responsibility Consumerism s ability to make a difference Tools and resources to support consumerism Innovative plan design You might be a Value seeker These plans fit PA POS Cost-Sharing 2.3 PA POS HSA Compatible No-Referral 6.3 PA Health Network Option AHF HRA 1.3 Traditional benefits plans Limiting the financial impact on employees You might be a Traditionalist These plans fit PA POS No-Referral 4.3 PA POS 6.3 2
YOUNG SINGLES Consumer-directed health plans YOUNG FAMILIES Traditional plans ESTABLISHED FAMILIES Cost-sharing plans EMPTY NESTERS Cost-sharing plans Consumer-directed health plans HEALTH INSURANCE BENEFITS FOR EVERY STAGE OF LIFE YOUNG SINGLES Includes singles and couples without children Ready to conquer the world? Thinking big thoughts? Well, one of those thoughts should be about health coverage. Since they re probably on a budget, they might want an affordable policy with lower monthly payments and modest out-of-pocket costs that also provides for quality preventive care, prescription drug coverage and financial protection to help safeguard their assets. YOUNG FAMILIES Includes married couples and single parents with young children and teens Children tend to get sick more than adults which means employees and their pediatricians get to know each other quite well. It also means they re probably looking for health coverage with lower fees for office visits, lower monthly payments and caps on their out-of-pocket expenses. And, of course, they can benefit from quality preventive care for the entire family. ESTABLISHED FAMILIES Includes married couples and single parents with teens and college-aged children As the children get older, the entire family s needs change. Time management is important for active parents and children. Teenagers still need checkups and care for injuries and illness, while parents need to start thinking about their own needs, like plan designs that cover preventive care and screenings and promote a healthy lifestyle. And college brings financial concerns to the forefront, as well as the need for a national network. EMPTY NESTERS Includes men and women age 55 and over with no children at home The kids are leaving home. It s a wistful time, but also an exciting one. What are the plans? Travel? Leisure? Reassessing health coverage needs? These employees are probably looking for a policy that combines financial security with quality coverage for prescriptions, hospital inpatient/outpatient services and emergency care. MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 3
PENNSYLVANIA PLAN GUIDE Pennsylvania provider network* County Adams Allegheny Armstrong Beaver Bedford Berks Blair Bradford Bucks Butler Cambria Cameron Carbon Centre Chester Clarion Clearfield Clinton Columbia Crawford Cumberland Dauphin Delaware Elk Erie Fayette Forest Franklin Fulton Greene Huntingdon Indiana Jefferson Lackawanna Lancaster Lawrence Lebanon Lehigh Luzerne Lycoming McKean Mercer Monroe Montgomery Northampton Northumberland Perry Philadelphia Pike Potter Schuylkill Snyder Somerset Sullivan Susquehanna Venango Warren Washington Wayne Westmoreland Wyoming York POS Health Network Option & PPO Plans *Network subject to change. PPO Plans Only Aetna Avenue MEDICAL OVERVIEW WELLNESS ON US SM Wellness for employees means a healthier business for employers. Employees can get in-network preventive care for $0! Our small business health benefits and insurance plans in Pennsylvania include $0 copay in-network for preventive care. It s one more way for us to help employees get a step closer to better health. See what employees can get for $0: Immunizations + Routine vision exams + Routine physicals + Child wellness visits + Routine mammogram + Routine OB/GYN visits + Plan Name Description PCP Required Aetna POS Aetna POS No-Referral Aetna Health Network Option SM (Aetna HealthFund ) Aetna PPO Aetna Indemnity The Aetna POS plan is a two-tiered product that allows members to access care in one of two ways: 1. PCP Referred, in-network, or; 2. Self-referred, in or out-of-network. Members have lower out of pocket costs when they use the HMO (referred) tier of the plan and follow the PCP referral process. Member cost sharing increases if members decide to self refer in or out-of-network. The Aetna POS No-Referral plan 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. The HealthFund 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 HealthFund 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 deductible is met. If the fund is depleted and the deductible is met, the base medical benefits plan begins meaning the member pays a coinsurance and/or copayment for remaining covered expenses. 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 nonnetwork providers at higher out-of-pocket costs. This 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. + Any benefits limitations for preventive services will still be applied per the plan design. Yes Referrals Required $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay Yes for PCPreferred care. No for selfreferred care. Network QPOS Yes/ Optional No Aetna Choice POS (Open Access) Yes/ Optional No Aetna Health Network Option SM (Aetna HealthFund ) No No Open Choice PPO No No N/A 4
AETNA HIGH DEDUCTIBLE HSA COMPATIBLE POS NO- REFERRAL / PPO PLANS Aetna High Deductible HSA Compatible POS No-Referral and PPO Health Plans are compatible with a Health Savings Account (HSA). HSA-compatible plans provide integrated medical and pharmacy benefits. Preventive care services are from the deductible. 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 assist in covering their future medical and dental expenses. HSA accounts can be funded by the employer or employee and are portable. Fund contributions may be tax-deductible (limits apply). When funds are used to cover qualified out-of-pocket medical and dental expenses, they are not taxed. Note: Employers and employees should consult with their tax advisor to determine eligibility requirements and tax advantages for participation in the HSA plan. SMALL GROUP SITUS Aetna Small Group benefits and rates are based on the group/s headquarter location, subject to applicable small group reform laws. Eligible employees who live or work in CT, DC, DE, MD, NJ, NY, PA, and VA (the situs region) will receive the same rates and benefits as the headquarter location. AETNA SMALL GROUP MULTI-STATE SOLUTION As part of Aetna s commitment to make it easier for small businesses to do business with us, and bring more consistency across benefit offerings to employers with employees in multiple locations, Aetna offers a multi-state solution. PA domiciled employers can offer a PA PPO plan to their employees who live and work outside the situs region. The situs region is comprised of the following eight states CT, DC, DE, MD, NJ, NY, PA, and VA. The rates and benefits will match those offered in Pennsylvania. If the out-ofsitus employee resides in a non-network area, the employee will be enrolled in an indemnity plan. Plan sponsors will need to continue to meet small group underwriting guidelines, and the majority of eligible employees must be in Pennsylvania. In all instances, extraterritorial benefits that may apply on any of the out-of-state employees will be implemented to the extent these are more comprehensive than the domiciled state benefits. These benefits will only apply to the out-of-state employees in the states where required. For dental products, an out-of-state dental plan will be offered to employees who live and work outside the situs region defined above. HEALTH REIMBURSEMENT ARRANGEMENT (HRA) The Aetna HealthFund HRA combines the protection of a deductible-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. 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. Aetna s 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. MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 5
PENNSYLVANIA PLAN GUIDE PENNSYLVANIA PLAN GUIDE COBRA ADMINISTRATION Aetna COBRA administration offers a full range of notification, documentation and record-keeping processes that can assist employers with managing the complex billing and notification processes that are 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 outof-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. 6
HEALTH SAVINGS ACCOUNT (HSA) No set-up or administrative fees The Aetna HealthFund HSA, when coupled with a HSA-compatible high-deductible 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. You own your HSA Contribute tax free HSA ACCOUNT You choose how and when to use your dollars Roll it over each year and let it grow Earns interest, tax free MEMBER S HSA PLAN TODAY Use for qualified expenses with tax-free dollars FUTURE Plan for future and retiree health-related costs HIGH-DEDUCTIBLE HEALTH PLAN Eligible in-network preventive care services may not be subject to the deductible; however, a copay or coinsurance may be charged You pay 100% until deductible is met, then only pay a share of the cost Meet out-of-pocket maximum, then plan pays 100% MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 7
PENNSYLVANIA PLAN GUIDE TRADITIONAL POS PLAN OPTIONS Plan Options PA POS 7.3 + Member Benefits In-Network PCP Coordinated Out-of-Network* Plan Coinsurance N/A Calendar Year Deductible** N/A $2,500 per member $7,500 family Calendar Year Out-of-Pocket Maximum*** (Deductible and prescription drugs, including self-injectables, do not apply toward the Out-of-Pocket Maximum.) $2,500 per member $5,000 family $10,000 per member $30,000 family Lifetime Maximum Benefit Unlimited $1,000,000 Wellness On Us SM Well Baby/Child and Adult Physical Exams (Age and frequency schedules apply. In-network and out-of-network combined.) Routine GYN Exams (Limited to one exam and Pap smear per 365 days. Routine Mammograms (One annual mammogram for females age 40 and over. In-network and out-of-network combined.) Routine Eye Exam (One exam per 24 months. In-network and out-of-network combined.) Glasses and Contact Lens Reimbursement $0 copay 50%, deductible $0 copay 50%, deductible $0 copay $0 copay $100/24 month period. In-network and out-of-network combined. Aetna Vision SM Discount Program Included Not Covered Primary Physician Office Visit $40 copay Specialist Office Visit $50 copay Outpatient Services - Lab $0 copay Outpatient Services - X-ray $50 copay Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services (20 visits per calendar year. In-network and out-of-network combined.) Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per calendar year. Outpatient Speech Therapy (30 visits per calendar year. Durable Medical Equipment ($2,500 Calendar Year Maximum. $150 copay $50 copay $50 copay $50 copay 50% Inpatient Hospital $500 copay per day, per admission Outpatient Surgery $500 copay Emergency Room (Copay if admitted.) $150 copay $150 copay Mental Health Inpatient (Limited to 30 days per calendar year. Substance Abuse Inpatient (In-Network: Detox: Unlimited days per calendar year; Rehab: 30 days per calendar year; 90 days per lifetime. Out-of-Network: Detox: 7 days per admission, 4 admissions per lifetime. In-network and out-of-network combined. Rehab: 30 days per calendar year; 90 days per lifetime. Prescription Drugs $500 copay per day, per admission $500 copay per day, per admission Prescription Drug Deductible N/A N/A Prescription Drugs - Retail: 30-day supply Option 1: $20/$40/$70 Option 2: $15 for Generic Drugs; Brand-name drugs are not covered. Members may access Aetna s negotiated discount for brand-name drugs at participating pharmacies. (Option 2 is not available with the No-Referral plan.) Prescription Drugs - Mail Order: 31-90-day supply Option 1: $40/$80/$140 Option 2: $30 for Generic Drugs; Brand-name drugs are not covered. Members may access Aetna s negotiated discount for brand-name drugs at participating pharmacies. (Option 2 is not available with the No-Referral plan.) Not Covered Not Covered Contraceptives and Diabetic Supplies Included Not Covered 90 Day Transition of Coverage (TOC) for Prior Authorization and Step Therapy Option 1: Included for Prior Authorization and Step Therapy. Option 2: Included for Prior Authorization. Step Therapy Not Applicable. Self-Injectables (Excluding Insulin) Option 1: 90% Option 2: No coverage provided. Members may access Aetna s negotiated discount for formulary and non-formulary drugs at participating pharmacies. Not Covered Not Covered Optional Features No Referral Option: PA POS No-Referral 7.3 (Offered Only with RX Option 1). See page 23 for important plan provisions. 8
TRADITIONAL POS PLAN OPTIONS Plan Options PA POS 1.3 + PA POS 2.3 + Member Benefits In-Network PCP Coordinated Out-of-Network* In-Network PCP Coordinated Out-of-Network* Plan Coinsurance N/A N/A 60% after deductible Calendar Year Deductible** N/A $2,000 per member $6,000 family Calendar Year Out-of-Pocket Maximum*** (Deductible and prescription drugs, including self-injectables, do not apply toward the Out-of-Pocket Maximum.) $2,500 per member $5,000 family $10,000 per member $30,000 family N/A $2,500 per member $5,000 family $1,500 per member $4,500 family $10,000 per member $30,000 family Lifetime Maximum Benefit Unlimited $1,000,000 Unlimited $1,000,000 Wellness On Us SM Well Baby/Child and Adult Physical Exams (Age and frequency schedules apply. In-network and out-of-network combined.) Routine GYN Exams (Limited to one exam and Pap smear per 365 days. Routine Mammograms (One annual mammogram for females age 40 and over. In-network and out-of-network combined.) Routine Eye Exam (One exam per 24 months. In-network and out-of-network combined.) Glasses and Contact Lens Reimbursement $0 copay 50%, deductible $0 copay 60%, deductible $0 copay 50%, deductible $0 copay 60%, deductible $0 copay $0 copay 60% after deductible $0 copay $0 copay 60% after deductible $100/24 month period. In-network and out-of-network combined. $100/24 month period. In-network and out-of-network combined. Aetna Vision SM Discount Program Included Not Covered Included Not Covered Primary Physician Office Visit $30 copay $20 copay 60% after deductible Specialist Office Visit $50 copay $40 copay 60% after deductible Outpatient Services - Lab $0 copay $0 copay 60% after deductible Outpatient Services - X-ray $50 copay $40 copay 60% after deductible Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services (20 visits per calendar year. Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per calendar year. Outpatient Speech Therapy (30 visits per calendar year. Durable Medical Equipment ($2,500 Calendar Year Maximum. Inpatient Hospital $150 copay $150 copay 60% after deductible $50 copay $40 copay 60% after deductible $50 copay $40 copay 60% after deductible $50 copay $40 copay 60% after deductible 50% 50% $300 copay per day, per admission $200 copay per day, per admission 60% after deductible Outpatient Surgery $300 copay $200 copay 60% after deductible Emergency Room (Copay if admitted.) $150 copay $150 copay $150 copay $150 copay Mental Health Inpatient (Limited to 30 days per calendar year. Substance Abuse Inpatient (In-Network: Detox: Unlimited days per calendar year; Rehab: 30 days per calendar year; 90 days per lifetime. Out-of-Network: Detox: 7 days per admission, 4 admissions per lifetime. In-network and out-of-network combined. Rehab: 30 days per calendar year; 90 days per lifetime. Prescription Drugs $300 copay per day, per admission $300 copay per day, per admission $200 copay per day, per admission $200 copay per day, per admission Prescription Drug Deductible N/A N/A N/A N/A Prescription Drugs - Retail: 30-day supply Option 1: $15/$35/$60 Option 2: $20/$40/$70 Prescription Drugs - Mail Order: 31-90-day supply Option 1: $30/$70/$120 Option 2: $40/$80/$140 Not Covered Option 1: $15/$30/$50 Option 2: $20/$40/$70 Not Covered Option 1: $30/$60/$100 Option 2: $40/$80/$140 60% after deductible 60% after deductible Not Covered Not Covered Contraceptives and Diabetic Supplies Included Not Covered Included Not Covered 90 Day Transition of Coverage (TOC) for Prior Authorization Included Not Covered Included Not Covered and Step Therapy Self-Injectables (Excluding Insulin) 90% Not Covered 90% Not Covered Optional Features No Referral Option: PA POS No-Referral 1.3 No Referral Option: PA POS No-Referral 2.3 MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING See page 23 for important plan provisions. 9
PENNSYLVANIA PLAN GUIDE TRADITIONAL POS PLAN OPTIONS Plan Options PA POS 3.3 + PA POS 4.3 + Member Benefits In-Network PCP Coordinated Out-of-Network* In-Network PCP Coordinated Out-of-Network* Plan Coinsurance N/A 70% after deductible N/A 80% after deductible Calendar Year Deductible** N/A $1,000 per member $3,000 family Calendar Year Out-of-Pocket Maximum*** (Deductible and prescription drugs, including self-injectables, do not apply toward the Out-of-Pocket Maximum.) $2,500 per member $5,000 family $5,000 per member $15,000 family N/A $2,500 per member $5,000 family $500 per member $1,500 family $5,000 per member $15,000 family Lifetime Maximum Benefit Unlimited $1,000,000 Unlimited $1,000,000 Wellness On Us SM Well Baby/Child and Adult Physical Exams (Age and frequency schedules apply. In-network and out-of-network combined.) Routine GYN Exams (Limited to one exam and Pap smear per 365 days. Routine Mammograms (One annual mammogram for females age 40 and over. In-network and out-of-network combined.) Routine Eye Exam (One exam per 24 months. In-network and out-of-network combined.) Glasses and Contact Lens Reimbursement $0 copay 70%, deductible $0 copay 80%, deductible $0 copay 70%, deductible $0 copay 80%, deductible $0 copay 70% after deductible $0 copay 80% after deductible $0 copay 70% after deductible $0 copay 80% after deductible $100/24 month period. In-network and out-of-network combined. $100/24 month period. In-network and out-of-network combined. Aetna Vision SM Discount Program Included Not Covered Included Not Covered Primary Physician Office Visit $15 copay 70% after deductible $10 copay 80% after deductible Specialist Office Visit $30 copay 70% after deductible $20 copay 80% after deductible Outpatient Services - Lab $0 copay 70% after deductible $0 copay 80% after deductible Outpatient Services - X-ray $30 copay 70% after deductible $20 copay 80% after deductible Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services (20 visits per calendar year. In-network and out-of-network combined.) Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per calendar year. Outpatient Speech Therapy (30 visits per calendar year. Durable Medical Equipment ($2,500 Calendar Year Maximum. Inpatient Hospital $150 copay 70% after deductible $150 copay 80% after deductible $30 copay 70% after deductible $20 copay 80% after deductible $30 copay 70% after deductible $20 copay 80% after deductible $30 copay 70% after deductible $20 copay 80% after deductible 50% 50% $150 copay per day, per admission 70% after deductible $0 copay per admission 80% after deductible Outpatient Surgery $150 copay 70% after deductible $0 copay 80% after deductible Emergency Room (Copay if admitted.) $150 copay $150 copay $150 copay $150 copay Mental Health Inpatient (Limited to 30 days per calendar year. Substance Abuse Inpatient (In-Network: Detox: Unlimited days per calendar year; Rehab: 30 days per calendar year; 90 days per lifetime. Out-of-Network: Detox: 7 days per admission, 4 admissions per lifetime. In-network and out-of-network combined. Rehab: 30 days per calendar year; 90 days per lifetime. Prescription Drugs $150 copay per day, per admission $150 copay per day, per admission 70% after deductible $0 copay per admission 80% after deductible 70% after deductible $0 copay per admission 80% after deductible Prescription Drug Deductible N/A N/A N/A N/A Prescription Drugs - Retail: 30-day supply Option 1: $10/$25/$50 Option 2: $20/$40/$70 Prescription Drugs - Mail Order: 31-90-day supply Option 1: $20/$50/$100 Option 2: $40/$80/$140 Not Covered Option 1: $5/$20/$40 Option 2: $20/$40/$70 Not Covered Option 1: $10/$40/$80 Option 2: $40/$80/$140 Not Covered Not Covered Contraceptives and Diabetic Supplies Included Not Covered Included Not Covered 90 Day Transition of Coverage (TOC) for Prior Authorization Included Not Covered Included Not Covered and Step Therapy Self-Injectables (Excluding Insulin) 90% Not Covered 90% Not Covered Optional Features No Referral Option: PA POS No-Referral 3.3 No Referral Option: PA POS No-Referral 4.3 See page 23 for important plan provisions. 10
TRADITIONAL POS PLAN OPTIONS Plan Options PA POS 8.3 + Member Benefits In-Network PCP Coordinated Out-of-Network* Plan Coinsurance N/A Calendar Year Deductible** N/A $5,000 per member $15,000 family Calendar Year Out-of-Pocket Maximum*** (Deductible and prescription drugs, including self-injectables, do not apply toward the Out-of-Pocket Maximum.) $5,000 per member $10,000 family Lifetime Maximum Benefit Unlimited $250,000 Wellness On Us SM Well Baby/Child and Adult Physical Exams (Age and frequency schedules apply. In-network and out-of-network combined.) Routine GYN Exams (Limited to one exam and Pap smear per 365 days. Routine Mammograms (One annual mammogram for females age 40 and over. In-network and out-of-network combined.) Routine Eye Exam (One exam per 24 months. In-network and out-of-network combined.) Glasses and Contact Lens Reimbursement $10,000 per member $30,000 family $0 copay 50%, deductible $0 copay 50%, deductible $0 copay $0 copay $100/24 month period. In-network and out-of-network combined. Aetna Vision SM Discount Program Included Not Covered Primary Physician Office Visit $50 copay Specialist Office Visit $75 copay Outpatient Services - Lab $0 copay Outpatient Services - X-ray $75 copay Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services (20 visits per calendar year. Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per calendar year. Outpatient Speech Therapy (30 visits per calendar year. Durable Medical Equipment ($2,500 Calendar Year Maximum. $150 copay $75 copay $75 copay $75 copay 50% Inpatient Hospital $750 copay per day, per admission Outpatient Surgery $750 copay Emergency Room (Copay if admitted.) $150 copay $150 copay Mental Health Inpatient (Limited to 30 days per calendar year. Substance Abuse Inpatient (In-Network: Detox: Unlimited days per calendar year; Rehab: 30 days per calendar year; 90 days per lifetime. Out-of-Network: Detox: 7 days per admission, 4 admissions per lifetime. In-network and out-of-network combined. Rehab: 30 days per calendar year; 90 days per lifetime. Prescription Drugs $750 copay per day, per admission $750 copay per day, per admission Prescription Drug Deductible N/A N/A Prescription Drugs - Retail: 30-day supply Option 1: $20/$40/$70 Option 2: $15 for Generic Drugs; Brand-name drugs are not covered. Members may access Aetna s negotiated discount for brand-name drugs at participating pharmacies. Prescription Drugs - Mail Order: 31-90-day supply Option 1: $40/$80/$140 Option 2: $30 for Generic Drugs; Brand-name drugs are not covered. Members may access Aetna s negotiated discount for brand-name drugs at participating pharmacies. Not Covered Not Covered Contraceptives and Diabetic Supplies Included Not Covered 90 Day Transition of Coverage (TOC) for Prior Authorization and Step Therapy Option 1: Included for Prior Authorization and Step Therapy. Option 2: Included for Prior Authorization. Step Therapy Not Applicable. Self-Injectables (Excluding Insulin) Option 1: 90% Option 2: No coverage provided. Members may access Aetna s negotiated discount for formulary and non-formulary drugs at participating pharmacies. Optional Features Not Applicable Not Covered Not Covered MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING See page 23 for important plan provisions. 11
PENNSYLVANIA PLAN GUIDE TRADITIONAL POS PLAN OPTIONS Plan Options PA POS 5.3 + PA POS 9.3 + Member Benefits In-Network PCP Coordinated Out-of-Network* In-Network PCP Coordinated Out-of-Network* Plan Coinsurance N/A N/A Calendar Year Deductible** N/A $5,000 per member $15,000 family Calendar Year Out-of-Pocket Maximum*** (Deductible and prescription drugs, including self-injectables, do not apply toward the Out-of-Pocket Maximum.) $2,500 per member $5,000 family $10,000 per member $30,000 family N/A $2,500 per member $5,000 family $5,000 per member $15,000 family Lifetime Maximum Benefit Unlimited $250,000 Unlimited $250,000 Wellness On Us SM $10,000 per member $30,000 family Well Baby/Child and Adult Physical Exams (Age and frequency schedules apply. In-network and out-of-network combined.) Routine GYN Exams (Limited to one exam and Pap smear per 365 days. Routine Mammograms (One annual mammogram for females age 40 and over. In-network and out-of-network combined.) Routine Eye Exam (One exam per 24 months. In-network and out-of-network combined.) $0 copay 50%, deductible $0 copay 50%, deductible $0 copay 50%, deductible $0 copay 50%, deductible $0 copay $0 copay $0 copay $0 copay Glasses and Contact Lens Reimbursement $100/24 month period. In-network and out-of-network combined. $100/24 month period. In-network and out-of-network combined. Aetna Vision SM Discount Program Included Not Covered Included Not Covered Primary Physician Office Visit $20 copay $15 copay Specialist Office Visit $40 copay $30 copay Outpatient Services - Lab $0 copay $0 copay Outpatient Services - X-ray $40 copay $30 copay Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services (20 visits per calendar year. Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per calendar year. Outpatient Speech Therapy (30 visits per calendar year. Durable Medical Equipment ($2,500 Calendar Year Maximum. Inpatient Hospital $150 copay $150 copay $40 copay $30 copay $40 copay $30 copay $40 copay $30 copay 50% 50% $300 copay per day, per admission $200 copay per day, per admission Outpatient Surgery $300 copay $200 copay Emergency Room (Copay if admitted.) $150 copay $150 copay $150 copay $150 copay Mental Health Inpatient (Limited to 30 days per calendar year. Substance Abuse Inpatient (In-Network: Detox: Unlimited days per calendar year; Rehab: 30 days per calendar year; 90 days per lifetime. Out-of-Network: Detox: 7 days per admission, 4 admissions per lifetime. In-network and out-of-network combined. Rehab: 30 days per calendar year; 90 days per lifetime. Prescription Drugs $300 copay per day, per admission $300 copay per day, per admission $200 copay per day, per admission $200 copay per day, per admission Prescription Drug Deductible N/A N/A N/A N/A Prescription Drugs - Retail: 30-day supply Option 1: $15/$35/$60 Not Covered Option 1: $15/$30/$50 Not Covered Prescription Drugs - Mail Order: 31-90-day supply Option 1: $30/$70/$120 Not Covered Option 1: $30/$60/$100 Not Covered Contraceptives and Diabetic Supplies Included Not Covered Included Not Covered 90 Day Transition of Coverage (TOC) for Prior Authorization Included Not Covered Included Not Covered and Step Therapy Self-Injectables (Excluding Insulin) 90% Not Covered 90% Not Covered Optional Features No Referral Option: PA POS No-Referral 5.3 No Referral Option: PA POS No-Referral 9.3 See page 23 for important plan provisions. 12
TRADITIONAL POS PLAN OPTIONS Plan Options PA POS 6.3 + Member Benefits In-Network PCP Coordinated Out-of-Network* Plan Coinsurance N/A Calendar Year Deductible** N/A $5,000 per member $15,000 family Calendar Year Out-of-Pocket Maximum*** (Deductible and prescription drugs, including self-injectables, do not apply toward the Out-of-Pocket Maximum.) $2,500 per member $5,000 family Lifetime Maximum Benefit Unlimited $250,000 Wellness On Us SM Well Baby/Child and Adult Physical Exams (Age and frequency schedules apply. In-network and out-of-network combined.) Routine GYN Exams (Limited to one exam and Pap smear per 365 days. Routine Mammograms (One annual mammogram for females age 40 and over. In-network and out-of-network combined.) Routine Eye Exam (One exam per 24 months. In-network and out-of-network combined.) Glasses and Contact Lens Reimbursement $10,000 per member $30,000 family $0 copay 50%, deductible $0 copay 50%, deductible $0 copay $0 copay $100/24 month period. In-network and out-of-network combined. Aetna Vision SM Discount Program Included Not Covered Primary Physician Office Visit $10 copay Specialist Office Visit $20 copay Outpatient Services - Lab $0 copay Outpatient Services - X-ray $20 copay Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services (20 visits per calendar year. Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per calendar year. Outpatient Speech Therapy (30 visits per calendar year. Durable Medical Equipment ($2,500 Calendar Year Maximum. $150 copay $20 copay $20 copay $20 copay 50% Inpatient Hospital $0 copay per admission Outpatient Surgery $0 copay Emergency Room (Copay if admitted.) $150 copay $150 copay Mental Health Inpatient (Limited to 30 days per calendar year. Substance Abuse Inpatient (In-Network: Detox: Unlimited days per calendar year; Rehab: 30 days per calendar year; 90 days per lifetime. Out-of-Network: Detox: 7 days per admission, 4 admissions per lifetime. In-network and out-of-network combined. Rehab: 30 days per calendar year; 90 days per lifetime. Prescription Drugs $0 copay per admission $0 copay per admission Prescription Drug Deductible N/A N/A Prescription Drugs - Retail: 30-day supply Option 1: $10/$25/$50 Not Covered Prescription Drugs - Mail Order: 31-90-day supply Option 1: $20/$50/$100 Not Covered Contraceptives and Diabetic Supplies Included Not Covered 90 Day Transition of Coverage (TOC) for Prior Authorization Included Not Covered and Step Therapy Self-Injectables (Excluding Insulin) 90% Not Covered Optional Features No Referral Option: PA POS No-Referral 6.3 MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING See page 23 for important plan provisions. 13
PENNSYLVANIA PLAN GUIDE POS COST-SHARING PLAN OPTIONS Plan Options PA POS COST-SHARING 1.3 + PA POS COST-SHARING 2.3 + Member Benefits In-Network PCP Coordinated Out-of-Network* In-Network PCP Coordinated Out-of-Network* Plan Coinsurance N/A N/A Calendar Year Deductible** (Deductible applies only to in-network inpatient hospital-type services/outpatient surgery and out-of-network benefits unless state mandated.) Calendar Year Out-of-Pocket Maximum*** (Deductible does apply to the Out-of-Pocket Maximum. Prescription drugs, including self-injectables, do not apply toward the Out-of-Pocket Maximum.) $2,500 per member/$5,000 family ( $5,000 per member/$10,000 family ( $2,000 per member/$4,000 family ( $4,000 per member/$8,000 family ( Lifetime Maximum Benefit Unlimited $250,000 Unlimited $250,000 Wellness On Us SM Well Baby/Child and Adult Physical Exams (Age and frequency schedules apply. In-network and out-of-network combined.) Routine GYN Exams (Limited to one exam and Pap smear per 365 days. Routine Mammograms (One annual mammogram for females age 40 and over. In-network and out-of-network combined.) Routine Eye Exam (One exam per 24 months. In-network and out-of-network combined.) Glasses and Contact Lens Reimbursement $0 copay, deductible 50%, deductible $0 copay, deductible 50%, deductible $0 copay, deductible 50%, deductible $0 copay, deductible 50%, deductible $0 copay, deductible $0 copay, deductible $0 copay, deductible $0 copay, deductible $100/24 month period. In-network and out-of-network combined. $100/24 month period. In-network and out-of-network combined. Aetna Vision SM Discount Program Included Not Covered Included Not Covered Primary Physician Office Visit Specialist Office Visit $40 copay, deductible $50 copay, deductible $30 copay, deductible $50 copay, deductible Outpatient Services - Lab $0 copay, deductible $0 copay, deductible Outpatient Services - X-ray Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services (20 visits per calendar year. Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per calendar year. Outpatient Speech Therapy (30 visits per calendar year. Durable Medical Equipment ($2,500 Calendar Year Maximum. Inpatient Hospital $50 copay, deductible $150 copay, deductible $50 copay, deductible $50 copay, deductible $50 copay, deductible $50 copay, deductible $150 copay, deductible $50 copay, deductible $50 copay, deductible $50 copay, deductible 50%, deductible 50%, deductible $0 copay per admission after deductible $0 copay per admission after deductible Outpatient Surgery $0 copay after deductible $0 copay after deductible Emergency Room (Copay if admitted.) Mental Health Inpatient (Limited to 30 days per calendar year. Substance Abuse Inpatient (In-Network: Detox: Unlimited days per calendar year; Rehab: 30 days per calendar year; 90 days per lifetime. Out-of-Network: Detox: 7 days per admission, 4 admissions per lifetime. In-network and out-of-network combined. Rehab: 30 days per calendar year; 90 days per lifetime. Prescription Drugs $150 copay, deductible $0 copay per admission after deductible $0 copay per admission after deductible $150 copay, deductible $150 copay, deductible $0 copay per admission after deductible $0 copay per admission after deductible Prescription Drug Deductible N/A N/A N/A N/A $150 copay, deductible Prescription Drugs - Retail: 30-day supply $20/$40/$70 Not Covered $20/$40/$70 Not Covered Prescription Drugs - Mail Order: 31-90-day supply $40/$80/$140 Not Covered $40/$80/$140 Not Covered Contraceptives and Diabetic Supplies Included Not Covered Included Not Covered 90 Day Transition of Coverage (TOC) for Prior Authorization Included Not Covered Included Not Covered and Step Therapy Self-Injectables (Excluding Insulin) 90% Not Covered 90% Not Covered Optional Features Not Applicable Not Applicable See page 23 for important plan provisions. 14
POS COST-SHARING PLAN OPTIONS Plan Options PA POS COST-SHARING 3.3 + PA POS COST-SHARING 4.3 + Member Benefits In-Network PCP Coordinated Out-of-Network* In-Network PCP Coordinated Out-of-Network* Plan Coinsurance N/A N/A Calendar Year Deductible** (Deductible applies only to in-network inpatient hospital-type services/outpatient surgery and out-of-network benefits unless state mandated.) Calendar Year Out-of-Pocket Maximum*** (Deductible does apply to the Out-of-Pocket Maximum. Prescription drugs, including self-injectables, do not apply toward the Out-of-Pocket Maximum.) $1,500 per member/$3,000 family ( $2,500 per member/$5,000 family ( $1,000 per member/$2,000 family ( $2,500 per member/$5,000 family ( Lifetime Maximum Benefit Unlimited $250,000 Unlimited $250,000 Wellness On Us SM Well Baby/Child and Adult Physical Exams (Age and frequency schedules apply. In-network and out-of-network combined.) Routine GYN Exams (Limited to one exam and Pap smear per 365 days. Routine Mammograms (One annual mammogram for females age 40 and over. In-network and out-of-network combined.) Routine Eye Exam (One exam per 24 months. In-network and out-of-network combined.) Glasses and Contact Lens Reimbursement $0 copay, deductible 50%, deductible $0 copay, deductible 50%, deductible $0 copay, deductible 50%, deductible $0 copay, deductible 50%, deductible $0 copay, deductible $0 copay, deductible $0 copay, deductible $0 copay, deductible $100/24 month period. In-network and out-of-network combined. $100/24 month period. In-network and out-of-network combined. Aetna Vision SM Discount Program Included Not Covered Included Not Covered Primary Physician Office Visit Specialist Office Visit $30 copay, deductible $50 copay, deductible $20 copay, deductible $40 copay, deductible Outpatient Services - Lab $0 copay, deductible $0 copay, deductible Outpatient Services - X-ray Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services (20 visits per calendar year. Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per calendar year. Outpatient Speech Therapy (30 visits per calendar year. Durable Medical Equipment ($2,500 Calendar Year Maximum. Inpatient Hospital $50 copay, deductible $150 copay, deductible $50 copay, deductible $50 copay, deductible $50 copay, deductible $40 copay, deductible $150 copay, deductible $40 copay, deductible $40 copay, deductible $40 copay, deductible 50%, deductible 50%, deductible $0 copay per admission after deductible $0 copay per admission after deductible Outpatient Surgery $0 copay after deductible $0 copay after deductible Emergency Room (Copay if admitted.) Mental Health Inpatient (Limited to 30 days per calendar year. Substance Abuse Inpatient (In-Network: Detox: Unlimited days per calendar year; Rehab: 30 days per calendar year; 90 days per lifetime. Out-of-Network: Detox: 7 days per admission, 4 admissions per lifetime. In-network and out-of-network combined. Rehab: 30 days per calendar year; 90 days per lifetime. Prescription Drugs $150 copay, deductible $0 copay per admission after deductible $0 copay per admission after deductible $150 copay, deductible $150 copay, deductible $0 copay per admission after deductible $0 copay per admission after deductible Prescription Drug Deductible N/A N/A N/A N/A $150 copay, deductible Prescription Drugs - Retail: 30-day supply $15/$40/$60 Not Covered $15/$40/$60 Not Covered Prescription Drugs - Mail Order: 31-90-day supply $30/$80/$120 Not Covered $30/$80/$120 Not Covered Contraceptives and Diabetic Supplies Included Not Covered Included Not Covered 90 Day Transition of Coverage (TOC) for Prior Authorization Included Not Covered Included Not Covered and Step Therapy Self-Injectables (Excluding Insulin) 90% Not Covered 90% Not Covered Optional Features Not Applicable No Referral Option: PA POS Cost-Sharing No-Referral 4.3 MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING See page 23 for important plan provisions. 15
PENNSYLVANIA PLAN GUIDE POS COST-SHARING PLAN OPTIONS Plan Options PA POS COST-SHARING 5.3 + * Member Benefits In-Network PCP Coordinated Out-of-Network* Plan Coinsurance N/A Calendar Year Deductible** (Deductible applies to in-network inpatient hospital-type services/outpatient surgery and out-ofnetwork benefits unless state mandated.) Calendar Year Out-of-Pocket Maximum*** (Deductible does apply to the Out-of-Pocket Maximum. Prescription drugs, including self-injectables, do not apply toward the Out-Pocket Maximum.) $500 per member/$1,000 family ( $2,500 per member/$5,000 family ( Lifetime Maximum Benefit Unlimited $250,000 Wellness On Us SM Well Baby/Child and Adult Physical Exams (Age and frequency schedules apply. In-network and out-of-network combined.) Routine GYN Exams (Limited to one exam and Pap smear per 365 days. Routine Mammograms (One annual mammogram for females age 40 and over. In-network and out-of-network combined.) Routine Eye Exam (One exam per 24 months. In-network and out-of-network combined.) $0 copay, deductible 50%, deductible $0 copay, deductible 50%, deductible $0 copay, deductible $0 copay, deductible Glasses and Contact Lens Reimbursement $100/24 month period. In-network and out-of-network combined. Aetna Vision SM Discount Program Included Not Covered Primary Physician Office Visit $20 copay, deductible Specialist Office Visit $40 copay, deductible Outpatient Services - Lab $0 copay, deductible Outpatient Services - X-ray $40 copay, deductible Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services (20 visits per calendar year. Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per calendar year. Outpatient Speech Therapy (30 visits per calendar year. Durable Medical Equipment ($2,500 Calendar Year Maximum. Inpatient Hospital $150 copay, deductible $40 copay, deductible $40 copay, deductible $40 copay, deductible 50%, deductible $0 copay per admission after deductible Outpatient Surgery $0 copay after deductible Emergency Room (Copay if admitted.) $150 copay, deductible $150 copay, deductible Mental Health Inpatient (Limited to 30 days per calendar year. Substance Abuse Inpatient (In-Network: Detox: Unlimited days per calendar year; Rehab: 30 days per calendar year; 90 days per lifetime. Out-of-Network: Detox: 7 days per admission, 4 admissions per lifetime. In-network and out-of-network combined. Rehab: 30 days per calendar year; 90 days per lifetime. Prescription Drugs $0 copay per admission after deductible $0 copay per admission after deductible Prescription Drug Deductible N/A N/A Prescription Drugs - Retail: 30-day supply $15/$40/$60 Not Covered Prescription Drugs - Mail Order: 31-90-day supply $30/$80/$120 Not Covered Contraceptives and Diabetic Supplies Included Not Covered 90 Day Transition of Coverage (TOC) for Prior Authorization Included Not Covered and Step Therapy Self-Injectables (Excluding Insulin) 90% Not Covered Optional Features No Referral Option: PA POS Cost-Sharing No-Referral 5.3 See page 23 for important plan provisions. 16
CONSUMER DIRECTED POS HSA COMPATIBLE PLAN OPTIONS Plan Options Member Benefits In-Network PA POS HSA COMPATIBLE NO-REFERRAL 5.3 +, Out-of-Network* In-Network PA POS HSA COMPATIBLE NO-REFERRAL 6.3 +, Out-of-Network* Plan Coinsurance N/A 60% after deductible N/A 70% after deductible Plan Year Deductible** (All covered prescription drug and medical expenses, except preventive services, apply to the deductible.) Plan Year Out-of-Pocket Maximum*** (All amounts paid as deductible, copayment and coinsurance for covered services and supplies apply toward the Out-of-Pocket Maximum.) $2,500 Individual/$5,000 Family ( $5,000 Individual/$10,000 Family ( $1,500 Individual/$3,000 Family ( $3,000 Individual/$6,000 Family ( Lifetime Maximum Benefit Unlimited $1,000,000 Unlimited $1,000,000 Wellness On Us SM Well Baby/Child and Adult Physical Exams (Age and frequency schedules apply. In-network and out-of-network combined.) Routine GYN Exams (Limited to one exam and Pap smear per 365 days. Routine Mammograms (One mammogram per plan year for females age 40 and over. In-network and out-of-network combined.) Routine Eye Exam (One exam per 24 months. In-network and out-of-network combined.) Glasses and Contact Lens Reimbursement $0 copay, deductible 100%, deductible $0 copay, deductible 100%, deductible $0 copay, deductible 100%, deductible $0 copay, deductible 100%, deductible $0 copay, deductible 100%, deductible $0 copay, deductible 100%, deductible $0 copay, deductible 100%, deductible $0 copay, deductible 100%, deductible $100/24 month period. In-network and out-of-network combined. $100/24 month period. In-network and out-of-network combined. Aetna Vision SM Discount Program Included Not Covered Included Not Covered Primary Physician Office Visit $30 copay after deductible 60% after deductible $20 copay after deductible 70% after deductible Specialist Office Visit $50 copay after deductible 60% after deductible $40 copay after deductible 70% after deductible Outpatient Services - Lab $50 copay after deductible 60% after deductible $40 copay after deductible 70% after deductible Outpatient Services - X-ray $50 copay after deductible 60% after deductible $40 copay after deductible 70% after deductible Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services (20 visits per plan year. In-network and out-of-network combined.) Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per plan year. Outpatient Speech Therapy (30 visits per plan year. In-network and out-of-network combined.) Durable Medical Equipment ($2,500 Plan Year Maximum. Inpatient Hospital $150 copay after deductible 60% after deductible $150 copay after deductible 70% after deductible $50 copay after deductible 60% after deductible $40 copay after deductible 70% after deductible $50 copay after deductible 60% after deductible $40 copay after deductible 70% after deductible $50 copay after deductible 60% after deductible $40 copay after deductible 70% after deductible $500 copay per day, per admission, after deductible 60% after deductible $300 copay per day, per admission, after deductible 70% after deductible Outpatient Surgery $500 copay after deductible 60% after deductible $300 copay after deductible 70% after deductible Emergency Room (Copay if admitted.) $150 copay after deductible $150 copay after deductible $150 copay after deductible $150 copay after deductible Mental Health Inpatient (Limited to 30 days per plan year. Substance Abuse Inpatient (In-Network: Detox: Unlimited days per plan year; Rehab: 30 days per plan year; 90 days per lifetime. Out-of-Network: Detox: 7 days per admission, 4 admissions per lifetime. In-network and out-of-network combined. Rehab: 30 days per plan year; 90 days per lifetime. Prescription Drugs Prescription Drug Deductible $500 copay per day, per admission, after deductible $500 copay per day, per admission, after deductible Integrated with Medical Deductible 60% after deductible $300 copay per day, per admission, after deductible 60% after deductible $300 copay per day, per admission, after deductible N/A Integrated with Medical Deductible 70% after deductible 70% after deductible Prescription Drugs - Retail: 30-day supply $15/$40/$60 after deductible Not Covered $15/$40/$60 after deductible Not Covered Prescription Drugs - Mail Order: 31-90-day supply $30/$80/$120 after deductible Not Covered $30/$80/$120 after deductible N/A Not Covered Contraceptives and Diabetic Supplies Included Not Covered Included Not Covered 90 Day Transition of Coverage (TOC) for Prior Authorization Included Not Covered Included Not Covered Self-Injectables (Excluding Insulin) 90% after deductible Not Covered 90% after deductible Not Covered MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING See page 23 for important plan provisions. 17