This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.princeton.edu/hr/benefits/spd or by calling 609-258-3302. Important Questions What is the overall deductible? Answers For each Calendar Year In-network: Individual $0 / Family $0 Why this Matters: See the chart starting on page 2 for your costs for services this plan covers. Are there other deductibles for specific services? Is there an out-of-pocket limit on my expenses? What is not included in the out-of-pocket limit? No. None This plan has no out-of-pocket limit. You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. There s no limit on how much you could pay during a coverage period for your share of the cost of covered services. Not applicable because there s no out-of-pocket limit on your expenses. Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn't cover? No. Yes. For a list of in-network providers, see www.aetna.com or call 1-888-982-3862. Yes. Yes. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. This plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan s permission before you see the specialist. Some of the services this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded services. If you aren t clear about any of the terms used in this form, see the Glossary at www.princeton.edu/hr/benefits/sbc. Page 1 of 8
Copayments are fixed dollar amounts (for example, $20) you pay for covered health care, usually when you receive the service. The amount the plan pays for covered services is based on the allowed amount. Since there is no out-of-network coverage, the allowed amount for an out-of-network provider is $0. Therefore, you are responsible for the total of all out-of-network provider charges. This plan may encourage you to use in-network providers by not providing coverage for out-of-network providers. Common Medical Event Services You May Need Primary care visit to treat an injury or illness Your Cost If You Use an In-Network Provider $20 copay Your Cost If You Use an Out-Of- Network Provider Limitations & Exceptions Applies to selected Primary Care Physician only. If you visit a health care provider s office or clinic Specialist visit Other practitioner office visit A referral is required to see a specialist. Chiropractic visits limited to 20 per year, Nutrition visits limited to 12 per year. Preventive care/screening/ immunization Age and frequency schedules may apply. If you have a test Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) If you aren t clear about any of the terms used in this form, see the Glossary at www.princeton.edu/hr/benefits/sbc. Page 2 of 8
Common Medical Event If you need drugs to treat your illness or condition (Prescription coverage is provided by Express Scripts.) More information about prescription drug coverage is available at www.express- Scripts.com Services You May Need Generic drugs Single-Source Brand drugs Multi Source drugs Specialty drugs Your Cost If You Use an In-Network Provider $5 copay (retail) $10 copay (mail order) (retail) $50 copay (mail order) $40 copay (retail) $80 copay (mail order) Costs are the same as the categories above Your Cost If You Use an Out-Of- Network Provider $5 copay (retail) $10 copay (mail order) (retail) $50 copay (mail order) $40 copay (retail) $80 copay (mail order) Costs are the same as the categories above Limitations & Exceptions Covers up to a 30-day supply (retail); 31-90 day supply (mail order). If a maintenance medication is purchased at a retail pharmacy for more than 3 months, subsequent refills will cost twice the retail copayment rate. Some prescriptions may require Prior Authorization, Step Therapy and Quantity Duration Programs Most Specialty drugs must be purchased through Express Scripts Specialty Pharmacy, Accredo. If you have outpatient surgery If you need immediate medical attention Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room services Emergency medical transportation Urgent care $60 copay $60 copay per visit. for non-emergency use. If you have a hospital stay Facility fee (e.g., hospital room) Physician/surgeon fee If you aren t clear about any of the terms used in this form, see the Glossary at www.princeton.edu/hr/benefits/sbc. Page 3 of 8
Your Cost If You Your Cost If You Common Medical Services You May Need Use an In-Network Use an Out-Of- Event Provider Network Provider Limitations & Exceptions Mental/Behavioral health outpatient services If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services Prenatal and postnatal care One time copay of $25 If you are pregnant Delivery and all inpatient services If you aren t clear about any of the terms used in this form, see the Glossary at www.princeton.edu/hr/benefits/sbc. Page 4 of 8
Home health care Coverage limited to 60 visits per calendar year. If you need help recovering or have other special health needs Rehabilitation services Habilitation services Skilled nursing care Limited to 50 visits per calendar year each for Speech, Occupational and Physical Therapies and a separate 50 visits per calendar year for pulmonary and cardiac rehab. Age and visit limits may apply 60 days per calendar year maximum. If you need dental or eye care Durable medical equipment Hospice service Eye exam Glasses Dental check-up Covered Excluded Services & Other Covered Services: Single purchase of a type of equipment is covered including repair. Replacements allowed once every three years. Coverage limited to 180 days lifetime maximum. 1 eye exam per calendar year Pediatric Glasses Reimbursement - 100% once per calendar year. Adult Reimbursement - Up to $70 per 24 months under the HMO; covered under Aetna or MetLife Dental Plans if elected. Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.) Acupuncture (except in lieu of anesthesia) Long-term care Cosmetic surgery Private-duty nursing Routine foot care Weight loss programs Dental care Non-emergency care when traveling outside the U.S. Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.) Hearing aids - limited to $1,500 every 36 months Chiropractic care (limited to 20 visits per Infertility treatment - Diagnosis & treatment of maximum year) underlying medical condition covered with no lifetime maximum. Other infertility treatment limited to $20,000 lifetime maximum. Artificial insemination and ovulation induction limited to 6 attempts per lifetime. Advanced Reproductive Technology limited to 3 attempts for lifetime. If you aren t clear about any of the terms used in this form, see the Glossary at www.princeton.edu/hr/benefits/sbc. Page 5 of 8
Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at 1-888-982-3862. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov. Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: Aetna at 1-888-982-3862, the Department of Labor s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Additionally, a consumer assistance program can help you file an appeal. Contact information is at http://www.aetna.com/individuals-families-healthinsurance/member-guidelines/complaints-grievances-appeals.html Language Access Services: Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-888-982-3862. Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-888-982-3862. 如果需要中文的帮助, 请拨打这个号码 1-888-982-3862. Para obtener asistencia en Español, llame al 1-888-982-3862. Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage". This plan does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (acturial value). This health coverage does meet the minimum value standard for the benefits it provides. To see examples of how this plan might cover costs for a sample medical situation, see the next page. If you aren t clear about any of the terms used in this form, see the Glossary at www.princeton.edu/hr/benefits/sbc. Page 6 of 8
Coverage Examples About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. HMO Coverage Period: 01/01/2014-12/31/2014 Coverage for: Individual + Family Plan Type: HMO Having a baby (normal delivery) Amount owed to provide $ 7,540 Plan pays: $ 7,485 Patient pays: $ 55 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $ 5,400 Plan pays: $ 4,985 Patient pays: $ 415 Sample care costs: Sample care costs: Hospital charges (mother) $ 2,700 Prescriptions $ 2,900 Routine obstetric care $ 2,100 Medical Equipment and Supplies $ 1,300 Hospital charges (baby) $ 900 Office Visits and Procedures $ 700 Anesthesia $ 900 Laboratory tests $ 300 Laboratory tests $ 500 Vaccines, other preventive $ 100 Prescriptions $ 200 $ 100 Radiology $ 200 Total $ 5,400 Vaccines, other preventive Total $ 40 $ 7,540 Patient pays: Patient pays: Deductibles $ - Deductibles $ 0 **Copays $ 415 Copays* $ 55 Coinsurance $ - Coinsurance $ 0 Limits or Exclusions $ - Limits or exclusions Total $ 415 Total $ 55 *Assumes a for maternity care and 3 Mail Order copays for generic prescriptions **Assumes 4 Physician Specialist copays, 3 Nutritionist copays, 4 Mail Order generic prescriptions and 4 Mail Order Single Source Brand prescriptions If you aren t clear about any of the terms used in this form, see the Glossary at www.princeton.edu/hr/benefits/sbc. Page 7 of 8
Coverage Examples HMO Coverage Period: 01/01/2014-12/31/2014 Coverage for: Individual + Family Plan Type: HMO Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient's condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box for each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. If you aren t clear about any of the terms used in this form, see the Glossary at www.princeton.edu/hr/benefits/sbc. Page 8 of 8