Brochure for aetna

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Brochure for aetna

  1. 1. Take charge of your health. We’re here to help. AetnA AdvAntAge plAns for individuAls, fAmilies And the self-employed in texAs AA.02.311.1-TX (4/10) G
  2. 2. it’s easy to establish a health savings Account… Aetna Advantage Simply enroll in an Aetna HSA Compatible High Deductible Health Plan and you will automatically have an HSA opened plan choices through Bank of America. You will also receive a debit card and a welcome package with additional information to get you started. If you do not wish to set up an HSA, you can opt out by calling Bank of America – or the account will be Our health insurance plans are designed to automatically canceled after 90 days if the debit card is not offer you quality coverage at an excellent activated or if you do not enroll online. value. Coverage can include prescription drugs, doctor visits, hospitalization and preventive Why choose an Aetna HealthFund HSA? care services. n No set-up fees Generally speaking, the lower your “premiums,” or n No monthly administration fee monthly payments, the higher your “deductible,” which is n No withdrawal forms required the amount you pay out of pocket before the plan begins n Convenient access to HSA funds via debit card or online paying for expenses. n Track HSA activity online You’ll pay less by using “in-network” doctors, hospitals, pharmacies and other health care providers who Is your doctor in the Aetna network? participate in Aetna’s nationwide network than by using Which local physicians, hospitals, pharmacies and eyewear “out-of-network” doctors. providers participate in the nationwide Aetna Advantage Visit www.planforyourhealth.com for an in-depth list Plan network? Visit www.aetna.com/docfind/custom/ of terms in this brochure and what they mean. advplans. Or call 1-800-694-3258 and ask for a directory of providers. About HSAs Get more from your Aetna plan Many of our high-deductible plans are Health Savings Account (HSA) Compatible, offering you lower premiums Cover just your children and tax advantaged savings. An HSA is a personal Aetna Advantage Plans are also available for children only, account that lets you pay for qualified medical expenses which means you can enroll your child even if no other with tax advantaged funds. You or an eligible family family member enrolls. Coverage includes immunizations, member make contributions to your HSA tax-free, and well-child visits, emergency room and dental preventive those dollars earn interest tax-free. Then, when you make services (if a dental plan is selected). withdrawals from your account to pay for qualified health care expenses, they’re tax-free, too. Note: when an HSA Compatible plan is selected for child only enrollment, an HSA account is not available for the child. Add dental pdn max With the Aetna Advantage Dental PDN Max insurance plan, you can obtain services from either a participating or non-participating dentist. Participating dentists have agreed to provide services at a negotiated rate for both covered Aetna Advantage Plans for Individuals, Families and the services, as well as non-covered services such as cosmetic Self-Employed are underwritten by Aetna Life Insurance tooth whitening and orthodontic care, so you generally Company (Aetna) directly and/or through an out-of-state pay less out-of-pocket. You also have the flexibility to visit a blanket trust. In some states, individuals may qualify as a business group of one and may be eligible for guaranteed dentist who does not participate in Aetna’s network, though issue, small group health plans. These plans are medically you will not have access to negotiated fees. Dental coverage underwritten and you may be declined coverage in accordance is offered only if medical coverage is obtained. with your health condition. 1
  3. 3. Plan Details 4) Managed Choice Open Access and Preferred Provider Benefits Plans (PPO) Value plan options 1) Affordability — a balance of lower monthly First Dollar Managed Choice Open premiums and quality coverage…where you Access and Preferred Provider Benefits want to cap the amount you’ll spend on total Plans (PPO) plan options medical expenses each year robust coverage and lower out-of-pocket featuring: expenses with no deductibles when you n Lower monthly premiums (that’s the “Value” part) choose a network provider n No deductible for generic prescription drugs featuring: 5) n Lower copay for in-network provider visits Preventive and Hospital Care n No deductible for generic prescription drugs plan options Affordability is one of your top priorities and 2) Managed Choice Open Access and Preferred Provider Benefits Plans (PPO) plan options you use only basic health care services…and want to keep your monthly premiums lower featuring: robust coverage and lower monthly payments n Health insurance coverage with lower monthly balanced with a deductible…where you don’t premiums and varying deductible levels want to pay a lot for frequent doctor visits featuring: n Health insurance coverage with lower monthly premiums and varying deductible levels 6) Managed Choice Open Access and Preferred Provider Benefits Plans (PPO) with Limited Rx robust medical coverage with limited 3) Managed Choice Open Access and Preferred Provider Benefits Plans (PPO) High Deductible plan options pharmacy benefits…with lower costs for smart consumers featuring: lower premium costs…and an hsA-compatible n Health insurance coverage with lower monthly plan that offers tax advantaged savings premiums featuring: n 0% coinsurance in network after your deductible is met n Lower monthly premiums, higher annual deductibles (at least $3,000 for individuals and $6,000 for families) n Can be paired with a tax-advantaged Health Savings Account (HSA) 2 3
  4. 4. Ae t nA’ s t e x As plus ... these benefits Are r At i ngs Ar e As * inCluded with most of your rates will depend on the area in our plAns. which your county is located. for more information or a quote on what your n Coverage for office visits to your primary care rate would be, call your broker. physician and specialists n No claim forms to fill out when you visit Area 1 Counties+ a network provider Blanco Bosque De Witt Dimmit Jim Hogg Jones Lavaca Llano (except Milam Mills Washington Webb Brazos Edwards Karnes Horseshoe Real Zapata n No referrals required to see a specialist* Brooks Frio Kenedy Bay) Refugio Zavala Brown Gillespie Kerr Madison Robertson n No waiting period for routine physical exams Burleson Coleman Goliad Gonzales Kimble Kinney Mason Maverick San Saba Taylor Comanche Hamilton La Salle McMullen Uvalde n 100% annual routine GYN exam coverage — no waiting period, no dollar maximum and Area 2 Counties+ no copay or deductible when you visit a Ector Jasper Lubbock Midland Wichita (Brookeland) McLennan Tom Green network provider n Coverage for prescription drugs* Area 3 Counties+ Aransas Castro Gray Jackson Ochiltree Sherman n Coverage for routine physicals including lab work Armstrong Childress Hall Jim Wells Oldham Starr Bee Collingsworth Hansford Kleberg Parmer Swisher and X-rays Briscoe Dallam Hartley Lipscomb Potter Victoria Calhoun Deaf Smith Hemphill Live Oak Randall Wheeler n 100% coverage for in-network childhood Cameron Carson Donley Duval Hidalgo Hutchinson Moore Nueces Roberts San Patricio Willacy immunizations Area 4 Counties+ Anderson Cottle Hale Knox Polk Sutton * These benefits are not applicable to Preventive and Hospital Care plans Andrews Crane Hardeman Lamb Presidio Terrell Angelina Crockett Haskell Leon Reagan Terry Archer Crosby Henderson Limestone Reeves Throckmorton Bailey Culberson (except Loving Runnels Trinity Baylor Dawson Mabank) Lynn Rusk Upton Borden Dickens Hockley Martin Sabine Val Verde Bowie Eastland Houston McCulloch San Augustine Ward Brewster Falls Howard Menard Schleicher Wilbarger Callahan Fisher Hudspeth Mitchell Scurry Winkler Cass Floyd Irion Motley Shackelford Yoakum Clay Foard Jack Nacogdoches Shelby Young Cochran Gaines Jeff Davis Nolan Stephens Coke Garza Kent Panola Sterling Concho Glasscock King Pecos Stonewall Area 5 Counties+ Aexcel specialist network** Camp Ellis Harrison Johnson Palo Pinto Tarrant Cherokee Erath Henderson Kaufman Parker Titus Collin Fannin (Mabank) Lamar Rains Upshur Cooke Franklin Hill Marion Red River Van Zandt Dallas Freestone Hood Montague Rockwall Wise Delta Grayson Hopkins Morris Smith Wood Denton Gregg Hunt Navarro Somervell Area 6 Counties++ Aexcel specialist network** Austin Fort Bend Harris Liberty Orange Waller Brazoria Galveston Jasper (except Matagorda San Jacinto Wharton Chambers Grimes Brookeland) Montgomery Tyler Colorado Hardin Jefferson Newton Walker Area 7 Counties+ Aexcel specialist network** Atascosa Bexar Guadalupe Medina Bandera Comal Kendall Wilson Area 8 Counties++ Aexcel specialist network** Bastrop Caldwell Hays Llano (Horseshoe Travis Bell Coryell Lampasas Bay) Williamson Burnet Fayette Lee Area 9 Counties++ El Paso * All products not available in all counties. Please refer to the county in which you reside for the available product. ** The Aetna Performance Network® features Aexcel-designated specialists who have demonstrated cost-effectiveness in the delivery of care and met certain clinical performance measures. The Aexcel designation applies to select specialists in 12 specialty areas: Cardiology, Cardiothoracic Surgery, Gastroenterology, General Surgery, Obstetrics and Gynecology, Orthopedics, Otolaryngology/ENT, Neurology, Neurosurgery, Plastic Surgery, Urology, and Vascular Surgery. Aetna members in the designated counties must choose Aexcel designated specialists or they will incur out-of- network charges. There is no additional cost when members use Aexcel specialists. You’ll find them by looking for the star next to the doctors’ names at www.aetna.com/docfind/custom/ advplans or in your printed directory. + Areas 1-5, and Area 7 are Preferred Provider Benefits Plans. 4 ++ Area 6, and Area 8-9 are Managed Choice Open Access Plans. 5
  5. 5. 1) 2) first dollar managed Choice managed Choice open Access open Access and preferred and preferred provider benefits provider benefits plans (ppo) 30 plans (ppo) 2500 member benefits in-network out-of-network+ member benefits in-network out-of-network+ Deductible Deductible Individual $0 $5,000 Individual $2,500 $5,000 Family $0 $10,000 Family $5,000 $10,000 Coinsurance 30% up to 50% after Coinsurance 20% after 50% after (Member’s responsibility) out-of-pocket max. deductible up to (Member’s responsibility) deductible up to deductible up to out-of-pocket max. out-of-pocket max. out-of-pocket max. $0 once out-of-pocket max. is satisfied $0 once out-of-pocket max. is satisfied Coinsurance Maximum Coinsurance Maximum Individual $7,500 $7,500 Individual $2,500 $5,000 Family $15,000 $15,000 Family $5,000 $10,000 Out-of-Pocket Maximum Out-of-Pocket Maximum Individual $7,500 $12,500 Individual $5,000 $10,000 Family $15,000 $25,000 Family $10,000 $20,000 Includes deductible Includes deductible Lifetime Maximum* per insured $5,000,000 Lifetime Maximum* per insured $5,000,000 Non-Specialist Office Visit $30 copay 30% Non-Specialist Office Visit $30 copay 30% Unlimited visits after deductible Unlimited visits deductible waived after deductible General Physician, Family Practitioner, General Physician, Family Practitioner, Pediatrician or Internist Pediatrician or Internist Specialist Visit $40 copay 30% Specialist Visit $40 copay 30% Unlimited visits after deductible Unlimited visits deductible waived after deductible Hospital Admission 30% 50% Hospital Admission 20% 50% after deductible after deductible after deductible Outpatient Surgery 30% 50% Outpatient Surgery 20% 50% after deductible after deductible after deductible Urgent Care Facility $50 copay 50% Urgent Care Facility $50 copay 50% after deductible deductible waived after deductible Emergency Room $100 copay** (waived if admitted) Emergency Room $100 copay** (waived if admitted) 30% coinsurance 20% coinsurance after deductible Annual Routine Gyn Exam $0 copay 30% Annual Routine Gyn Exam $0 copay 30% No waiting period, after deductible No waiting period, deductible waived after deductible no calendar year max. no calendar year max. Annual Pap/Mammogram Annual Pap/Mammogram Maternity Not covered Maternity Not covered (except for pregnancy complications) (except for pregnancy complications) Preventive Health — $30 copay 30% Preventive Health — $30 copay 30% Routine Physical after deductible Routine Physical deductible waived after deductible Aetna will pay up to $200 per exam* Includes lab work and X-rays Aetna will pay up to $200 per exam* Includes lab work and X-rays No waiting period No waiting period Lab/X-Ray 30% 50% Lab/X-Ray 20% 50% after deductible after deductible after deductible Skilled Nursing — in lieu of hospital 30% 50% Skilled Nursing — in lieu of hospital 20% 50% 30 days per calendar year* after deductible 30 days per calendar year* after deductible after deductible Physical/Occupational Therapy 30% 50% Physical/Occupational Therapy 20% 50% and Chiropractic Care after deductible and Chiropractic Care after deductible after deductible 24 visits per calendar year* 24 visits per calendar year* Aetna will pay a max. of $25 per visit* Aetna will pay a max. of $25 per visit* Home Health Care — 30% 50% Home Health Care — 20% 50% in lieu of hospital after deductible in lieu of hospital after deductible after deductible 30 visits per calendar year* 30 visits per calendar year* Durable Medical Equipment 30% 50% Durable Medical Equipment 20% 50% Aetna will pay up to $2000 per after deductible Aetna will pay up to $2000 per after deductible after deductible calendar year* calendar year* phArmACy phArmACy Pharmacy Deductible $500 $500 Pharmacy Deductible $500 $500 per individual per individual Does not apply to generic Does not apply to generic Generic $15 copay $15 copay plus 30% Generic $15 copay $15 copay plus 30% Oral Contraceptives Included deductible waived deductible waived Oral Contraceptives Included deductible waived deductible waived Preferred Brand $40 copay $40 copay plus 30% Preferred Brand $35 copay $35 copay plus 30% Oral Contraceptives Included after deductible after deductible Oral Contraceptives Included after deductible after deductible Non-Preferred Brand $60 copay $60 copay plus 30% Non-Preferred Brand $50 copay $50 copay plus 30% Oral Contraceptives Included after deductible after deductible Oral Contraceptives Included after deductible after deductible Self-Injectible Drugs 20% Not covered Self-Injectible Drugs 20% Not covered after deductible after deductible Calendar Year Maximum Unlimited Unlimited Calendar Year Maximum $5,000 $5,000 per individual* per individual* + Payment for out-of-network facility covered expenses is determined based * Maximum applies to combined in and out-of-network benefits. on Aetna’s Market Fee Schedule. Payment for out-of-network non-facility ** Copay is billed separately and not due at time of service. Copay does covered expenses is determined based on the negotiated charge that would not count towards coinsurance or out-of-pocket maximum. apply if such services were received from a Network Provider. 6 7
  6. 6. managed Choice open Access managed Choice open Access and preferred provider benefits and preferred provider benefits plans (ppo) 3500 plans (ppo) 5000 member benefits in-network out-of-network+ member benefits in-network out-of-network+ Deductible Deductible Individual $3,500 $7,000 Individual $5,000 $10,000 Family $7,000 $14,000 Family $10,000 $20,000 Coinsurance 20% after 50% after Coinsurance 20% after 50% after (Member’s responsibility) deductible up to deductible up to (Member’s responsibility) deductible up to deductible up to out-of-pocket max. out-of-pocket max. out-of-pocket max. out-of-pocket max. $0 once out-of-pocket max. is satisfied $0 once out-of-pocket max. is satisfied Coinsurance Maximum Coinsurance Maximum Individual $6,500 $5,500 Individual $5,000 $2,500 Family $13,000 $11,000 Family $10,000 $5,000 Out-of-Pocket Maximum Out-of-Pocket Maximum Individual $10,000 $12,500 Individual $10,000 $12,500 Family $20,000 $25,000 Family $20,000 $25,000 Includes deductible Includes deductible Lifetime Maximum* per insured $5,000,000 Lifetime Maximum* per insured $5,000,000 Non-Specialist Office Visit $35 copay 30% Non-Specialist Office Visit $40 copay 30% Unlimited visits deductible waived after deductible Unlimited visits deductible waived after deductible General Physician, Family General Physician, Family Practitioner, Practitioner, Pediatrician or Internist Pediatrician or Internist Specialist Visit $45 copay 30% Specialist Visit $50 copay 30% Unlimited visits deductible waived after deductible Unlimited visits deductible waived after deductible Hospital Admission 20% 50% Hospital Admission 20% 50% after deductible after deductible after deductible after deductible Outpatient Surgery 20% 50% Outpatient Surgery 20% 50% after deductible after deductible after deductible after deductible Urgent Care Facility $50 copay 50% Urgent Care Facility $50 copay 50% deductible waived after deductible deductible waived after deductible Emergency Room $100 copay** (waived if admitted) Emergency Room $100 copay** (waived if admitted) 20% coinsurance after deductible 20% coinsurance after deductible Annual Routine Gyn Exam $0 copay 30% Annual Routine Gyn Exam $0 copay 30% No waiting period, deductible waived after deductible No waiting period, deductible waived after deductible no calendar year max. no calendar year max. Annual Pap/Mammogram Annual Pap/Mammogram Maternity Not covered Maternity Not covered (except for pregnancy complications) (except for pregnancy complications) Preventive Health — $35 copay 30% Preventive Health — $40 copay 30% Routine Physical deductible waived after deductible Routine Physical deductible waived after deductible Aetna will pay up to $200 per exam* Aetna will pay up to $200 per exam* Includes lab work and X-rays No waiting period Includes lab work and X-rays No waiting period Lab/X-Ray 20% 50% Lab/X-Ray 20% 50% after deductible after deductible after deductible after deductible Skilled Nursing — in lieu of hospital 20% 50% Skilled Nursing — in lieu of hospital 20% 50% 30 days per calendar year* after deductible after deductible 30 days per calendar year* after deductible after deductible Physical/Occupational Therapy 20% 50% Physical/Occupational Therapy 20% 50% and Chiropractic Care after deductible after deductible and Chiropractic Care after deductible after deductible 24 visits per calendar year* 24 visits per calendar year* Aetna will pay a max. of $25 per visit* Aetna will pay a max. of $25 per visit* Home Health Care — 20% 50% Home Health Care — 20% 50% in lieu of hospital after deductible after deductible in lieu of hospital after deductible after deductible 30 visits per calendar year* 30 visits per calendar year* Durable Medical Equipment 20% 50% Durable Medical Equipment 20% 50% Aetna will pay up to $2000 per after deductible after deductible Aetna will pay up to $2000 per after deductible after deductible calendar year* calendar year* phArmACy phArmACy Pharmacy Deductible $500 $500 Pharmacy Deductible $500 $500 per individual per individual Does not apply to generic Does not apply to generic Generic $15 copay $15 copay plus 30% Generic $15 copay $15 copay plus 30% Oral Contraceptives Included deductible waived deductible waived Oral Contraceptives Included deductible waived deductible waived Preferred Brand $35 copay $35 copay plus 30% Preferred Brand $35 copay $35 copay plus 30% Oral Contraceptives Included after deductible after deductible Oral Contraceptives Included after deductible after deductible Non-Preferred Brand $50 copay $50 copay plus 30% Non-Preferred Brand $50 copay $50 copay plus 30% Oral Contraceptives Included after deductible deductible waived Oral Contraceptives Included after deductible after deductible Self-Injectible Drugs 20% Not covered Self-Injectible Drugs 20% Not covered after deductible after deductible Calendar Year Maximum $5,000 $5,000 Calendar Year Maximum $5,000 $5,000 per individual* per individual* + Payment for out-of-network facility covered expenses is determined based on * Maximum applies to combined in and out-of-network benefits. Aetna’s Market Fee Schedule. Payment for out-of-network non-facility covered ** Copay is billed separately and not due at time of service. Copay does expenses is determined based on the negotiated charge that would apply if such not count towards coinsurance or out-of-pocket maximum. services were received from a Network Provider. 8 9
  7. 7. managed Choice open Access 3) managed Choice open Access and preferred provider benefits and preferred provider benefits plans (ppo) high deductible plans (ppo) 7500 3000 (hsA Compatible) member benefits in-network out-of-network+ member benefits in-network out-of-network+ Deductible Deductible Individual $7,500 $10,000 Individual $3,000 $6,000 Family $15,000 $20,000 Family $6,000 $12,000 Coinsurance 20% after 50% after Coinsurance 0% after 50% after (Member’s responsibility) deductible up to deductible up to (Member’s responsibility) deductible up to deductible up to out-of-pocket max. out-of-pocket max. out-of-pocket max. out-of-pocket max. $0 once out-of-pocket max. is satisfied $0 once out-of-pocket max. is satisfied Coinsurance Maximum Coinsurance Maximum Individual $2,500 $2,500 Individual $0 $6,500 Family $5,000 $5,000 Family $0 $13,000 Out-of-Pocket Maximum Out-of-Pocket Maximum Individual $10,000 $12,500 Individual $3,000 $12,500 Family $20,000 $25,000 Family $6,000 $25,000 Includes deductible Includes deductible Lifetime Maximum* per insured $5,000,000 Lifetime Maximum* per insured $5,000,000 Non-Specialist Office Visit $45 copay 30% Non-Specialist Office Visit 0% 30% Unlimited visits deductible waived after deductible Unlimited visits after deductible after deductible General Physician, Family Practitioner, General Physician, Family Practitioner, Pediatrician or Internist Pediatrician or Internist Specialist Visit $50 copay 30% Specialist Visit 0% 30% Unlimited visits deductible waived after deductible Unlimited visits after deductible after deductible Hospital Admission 20% 50% Hospital Admission 0% 50% after deductible after deductible after deductible after deductible Outpatient Surgery 20% 50% Outpatient Surgery 0% 50% after deductible after deductible after deductible after deductible Urgent Care Facility $50 copay 50% Urgent Care Facility 0% 50% deductible waived after deductible after deductible after deductible Emergency Room $100 copay** (waived if admitted) Emergency Room $0 copay after deductible 20% coinsurance after deductible Annual Routine Gyn Exam $0 copay 30% Annual Routine Gyn Exam $0 copay 30% No waiting period, deductible waived after deductible No waiting period, deductible waived after deductible no calendar year max. no calendar year max. Annual Pap/Mammogram Annual Pap/Mammogram Maternity Not covered Maternity Not covered (except for pregnancy complications) Except for pregnancy complications Preventive Health — $20 copay 30% Preventive Health — $45 copay 30% Routine Physical deductible waived after deductible Routine Physical deductible waived after deductible Aetna will pay up to $200 per exam* Aetna will pay up to $200 per exam* No waiting period Includes lab work and X-rays Includes lab work and X-rays No waiting period Lab/X-Ray 0% 50% Lab/X-Ray 20% 50% after deductible after deductible after deductible after deductible Skilled Nursing — in lieu of hospital 0% 50% Skilled Nursing — in lieu of hospital 20% 50% 30 days per calendar year* after deductible after deductible 30 days per calendar year* after deductible after deductible Physical/Occupational Therapy 0% 50% Physical/Occupational Therapy 20% 50% and Chiropractic Care after deductible after deductible and Chiropractic Care after deductible after deductible 24 visits per calendar year* 24 visits per calendar year* Aetna will pay a max. of $25 per visit* Aetna will pay a max. of $25 per visit* Home Health Care — 20% 50% Home Health Care — 0% 50% in lieu of hospital after deductible after deductible in lieu of hospital after deductible after deductible 30 visits per calendar year* 30 visits per calendar year* Durable Medical Equipment 20% 50% Durable Medical Equipment 0% 50% Aetna will pay up to $2000 per after deductible after deductible Aetna will pay up to $2000 per after deductible after deductible calendar year* calendar year* phArmACy phArmACy Pharmacy Deductible $500 $500 Pharmacy Deductible Integrated Medical/Rx Deductible per individual per individual Does not apply to generic Generic 0% after Medical/ 30% after Medical/ Generic $15 copay $15 copay plus 30% Oral Contraceptives Included Rx deductible Rx deductible Oral Contraceptives Included deductible waived deductible waived Preferred Brand 0% after Medical/ 30% after Medical/ Preferred Brand $35 copay $35 copay plus 30% Oral Contraceptives Included Rx deductible Rx deductible Oral Contraceptives Included after deductible after deductible Non-Preferred Brand $50 copay $50 copay plus 30% Non-Preferred Brand 0% after Medical/ 30% after Medical/ Oral Contraceptives Included after deductible after deductible Oral Contraceptives Included Rx deductible Rx deductible Self-Injectible Drugs 20% Not covered Self-Injectible Drugs 0% after Medical/ Not covered after deductible Rx deductible Calendar Year Maximum $5,000 $5,000 Calendar Year Maximum $5,000 $5,000 per individual* per individual* + Payment for out-of-network facility covered expenses is determined based on * Maximum applies to combined in and out-of-network benefits. Aetna’s Market Fee Schedule. Payment for out-of-network non-facility covered ** Copay is billed separately and not due at time of service. Copay does expenses is determined based on the negotiated charge that would apply if such not count towards coinsurance or out-of-pocket maximum. services were received from a Network Provider. 10 11
  8. 8. managed Choice open Access 4) and preferred provider benefits managed Choice open Access plans (ppo) high deductible and preferred provider benefits 5000 (hsA Compatible) plans (ppo) value 1500 member benefits in-network out-of-network+ member benefits in-network out-of-network+ Deductible Deductible Individual $5,000 $10,000 Individual $1,500 $3,000 Family $10,000 $20,000 Family $3,000 $6,000 Coinsurance 30% after 50% after Coinsurance 0% after 50% after (Member’s responsibility) deductible up to deductible up to (Member’s responsibility) deductible up to deductible up to out-of-pocket max. out-of-pocket max. out-of-pocket max. out-of-pocket max. $0 once out-of-pocket max. is satisfied $0 once out-of-pocket max. is satisfied Coinsurance Maximum Coinsurance Maximum Individual $1,500 $7,000 Individual $0 $2,500 Family $3,000 $14,000 Family $0 $5,000 Out-of-Pocket Maximum Out-of-Pocket Maximum Individual $3,000 $10,000 Individual $5,000 $12,500 Family $6,000 $20,000 Family $10,000 $25,000 Includes deductible Includes deductible Lifetime Maximum* per insured $5,000,000 Lifetime Maximum* per insured $5,000,000 Non-Specialist Office Visit Visits 1-2 $30 copay, 30% Unlimited visits ded. waived; Visit 3+ after deductible Non-Specialist Office Visit 0% 30% General Physician, Family Practitioner, 30% after deductible. Unlimited visits after deductible after deductible Pediatrician or Internist Spec. and non- spec General Physician, Family Practitioner, share visit max Pediatrician or Internist Specialist Visit Visits 1-2 $30 copay, 30% Specialist Visit 0% 30% Unlimited visits ded. waived; Visit 3+ after deductible Unlimited visits after deductible after deductible 30% after deductible. Spec. and non- spec Hospital Admission 0% 50% share visit max after deductible after deductible Hospital Admission 30% 50% Outpatient Surgery 0% 50% after deductible after deductible after deductible after deductible Outpatient Surgery 30% 50% Urgent Care Facility 0% 50% after deductible after deductible after deductible after deductible Urgent Care Facility $50 copay 50% Emergency Room $0 copay after deductible deductible waived after deductible Annual Routine Gyn Exam $0 copay 30% Emergency Room $100 copay** (waived if admitted) No waiting period, deductible waived after deductible 30% coinsurance after deductible no calendar year max. Annual Routine Gyn Exam $0 copay 30% Annual Pap/Mammogram No waiting period, deductible waived after deductible no calendar year max. Maternity Not covered Annual Pap/Mammogram (except for pregnancy complications) Maternity Not covered Preventive Health — $25 copay 30% (except for pregnancy complications) Routine Physical deductible waived after deductible Preventive Health — $50 copay 30% Aetna will pay up to $200 per exam* Includes lab work and X-rays Routine Physical deductible waived after deductible No waiting period Aetna will pay up to $200 per exam* Lab/X-Ray 0% 50% No waiting period Includes lab work and X-rays after deductible after deductible Lab/X-Ray 30% 50% Skilled Nursing — in lieu of hospital 0% 50% after deductible after deductible 30 days per calendar year* after deductible after deductible Skilled Nursing — in lieu of hospital 30% 50% Physical/Occupational Therapy 0% 50% 30 days per calendar year* after deductible after deductible and Chiropractic Care after deductible after deductible Physical/Occupational Therapy 30% 50% 24 visits per calendar year* Aetna will pay a max. of $25 per visit* and Chiropractic Care after deductible after deductible 24 visits per calendar year* Aetna will pay a max. of $25 per visit* Home Health Care — 0% 50% in lieu of hospital after deductible after deductible Home Health Care — 30% 50% 30 visits per calendar year* in lieu of hospital after deductible after deductible 30 visits per calendar year* Durable Medical Equipment 0% 50% Durable Medical Equipment 30% 50% Aetna will pay up to $2000 per after deductible after deductible Aetna will pay up to $2000 per after deductible after deductible calendar year* calendar year* phArmACy phArmACy Pharmacy Deductible Integrated Medical/Rx Deductible Pharmacy Deductible $500 $500 per individual per individual Does not apply to generic Generic 0% after Medical/ 30% after Medical/ Generic $20 copay $20 copay plus 30% Oral Contraceptives Included Rx deductible Rx deductible Oral Contraceptives Included deductible waived deductible waived Preferred Brand 0% after Medical/ 30% after Medical/ Preferred Brand $40 copay $40 copay plus 30% Oral Contraceptives Included Rx deductible Rx deductible Oral Contraceptives Included after deductible after deductible Non-Preferred Brand Not covered Not covered Non-Preferred Brand 0% after Medical/ 30% after Medical/ Oral Contraceptives Included Aetna Discount Oral Contraceptives Included Rx deductible Rx deductible Applies Self-Injectible Drugs 0% after Medical/ Not covered Self-Injectible Drugs Not covered Not covered Rx deductible Aetna Discount Applies Calendar Year Maximum $5,000 $5,000 Calendar Year Maximum $5,000 $5,000 per individual* per individual* + Payment for out-of-network facility covered expenses is determined based on * Maximum applies to combined in and out-of-network benefits. Aetna’s Market Fee Schedule. Payment for out-of-network non-facility covered ** Copay is billed separately and not due at time of service. Copay does expenses is determined based on the negotiated charge that would apply if such not count towards coinsurance or out-of-pocket maximum. services were received from a Network Provider. 12 13
  9. 9. managed Choice open Access managed Choice open Access and preferred provider benefits and preferred provider benefits plans (ppo) value 2500 plans (ppo) value 5000 member benefits in-network out-of-network+ member benefits in-network out-of-network+ Deductible Deductible Individual $2,500 $5,000 Individual $5,000 $10,000 Family $5,000 $10,000 Family $10,000 $20,000 Coinsurance 30% after 50% after Coinsurance 30% after 50% after (Member’s responsibility) deductible up to deductible up to (Member’s responsibility) deductible up to deductible up to out-of-pocket max. out-of-pocket max. out-of-pocket max. out-of-pocket max. $0 once out-of-pocket max. is satisfied $0 once out-of-pocket max. is satisfied Coinsurance Maximum Coinsurance Maximum Individual $2,500 $5,000 Individual $5,000 $2,500 Family $5,000 $10,000 Family $10,000 $5,000 Out-of-Pocket Maximum Out-of-Pocket Maximum Individual $5,000 $10,000 Individual $10,000 $12,500 Family $10,000 $20,000 Family $20,000 $25,000 Includes deductible Lifetime Maximum* per insured $5,000,000 Includes deductible Non-Specialist Office Visit Visits 1-2 $30 copay, 30% Lifetime Maximum* per insured $5,000,000 Unlimited visits ded. waived; Visit 3+ after deductible Non-Specialist Office Visit Visits 1-2 $30 copay, 30% General Physician, Family Practitioner, 30% after deductible. Unlimited visits ded. waived; Visit 3+ after deductible Pediatrician or Internist Spec. and non- spec General Physician, Family 30% after deductible. share visit max Spec. and non- spec Practitioner, Pediatrician or Internist Specialist Visit Visits 1-2 $30 copay, 30% share visit max Unlimited visits ded. waived; Visit 3+ after deductible Specialist Visit Visits 1-2 $30 copay, 30% 30% after deductible. Unlimited visits ded. waived; Visit 3+ after deductible Spec. and non- spec 30% after deductible. share visit max Spec. and non- spec Hospital Admission 30% 50% share visit max after deductible after deductible Hospital Admission 30% 50% Outpatient Surgery 30% 50% after deductible after deductible after deductible after deductible Outpatient Surgery 30% 50% Urgent Care Facility $50 copay 50% after deductible after deductible deductible waived after deductible Urgent Care Facility $50 copay 50% Emergency Room $100 copay** (waived if admitted) deductible waived after deductible 30% coinsurance after deductible Emergency Room $100 copay** (waived if admitted) Annual Routine Gyn Exam $0 copay 30% 30% after deductible No waiting period, deductible waived after deductible Annual Routine Gyn Exam $0 copay 30% no calendar year max. No waiting period, deductible waived after deductible Annual Pap/Mammogram no calendar year max. Maternity Not covered Annual Pap/Mammogram (except for pregnancy complications) Maternity Not covered Preventive Health — $50 copay 30% (except for pregnancy complications) Routine Physical deductible waived after deductible Preventive Health — $50 copay 30% Aetna will pay up to $200 per exam* Routine Physical deductible waived after deductible No waiting period Includes lab work and X-rays Aetna will pay up to $200 per exam* Includes lab work and X-rays Lab/X-Ray 30% 50% No waiting period after deductible after deductible Lab/X-Ray 30% 50% Skilled Nursing — in lieu of hospital 30% 50% after deductible after deductible 30 days per calendar year* after deductible after deductible Skilled Nursing — in lieu of hospital 30% 50% Physical/Occupational Therapy 30% 50% 30 days per calendar year* after deductible after deductible and Chiropractic Care after deductible after deductible Physical/Occupational Therapy 30% 50% 24 visits per calendar year* Aetna will pay a max. of $25 per visit* and Chiropractic Care after deductible after deductible 24 visits per calendar year* Aetna will pay a max. of $25 per visit* Home Health Care — 30% 50% in lieu of hospital after deductible after deductible Home Health Care — 30% 50% 30 visits per calendar year* in lieu of hospital after deductible after deductible 30 visits per calendar year* Durable Medical Equipment 30% 50% Durable Medical Equipment 30% 50% Aetna will pay up to $2000 per after deductible after deductible Aetna will pay up to $2000 per after deductible after deductible calendar year* calendar year* phArmACy phArmACy Pharmacy Deductible $500 $500 Pharmacy Deductible $500 $500 per individual Does not apply to generic per individual Does not apply to generic Generic $20 copay $20 copay plus 30% Generic $20 copay $20 copay plus 30% Oral Contraceptives Included deductible waived deductible waived Oral Contraceptives Included deductible waived deductible waived Preferred Brand $40 copay $40 copay plus 30% Preferred Brand $40 copay $40 copay plus 30% Oral Contraceptives Included after deductible after deductible Oral Contraceptives Included after deductible after deductible Non-Preferred Brand Not covered Not covered Non-Preferred Brand Not covered Not covered Oral Contraceptives Included Aetna Discount Oral Contraceptives Included Aetna Discount Applies Applies Self-Injectible Drugs Not covered Not covered Self-Injectible Drugs Not covered Not covered Aetna Discount Aetna Discount Applies Applies Calendar Year Maximum $5,000 $5,000 Calendar Year Maximum $5,000 $5,000 per individual* per individual* + Payment for out-of-network facility covered expenses is determined based on * Maximum applies to combined in and out-of-network benefits. Aetna’s Market Fee Schedule. Payment for out-of-network non-facility covered ** Copay is billed separately and not due at time of service. Copay does expenses is determined based on the negotiated charge that would apply if such not count towards coinsurance or out-of-pocket maximum. services were received from a Network Provider. 14 15
  10. 10. 5) preventive and hospital Care 1250*** preventive and hospital Care 3000 (hsA Compatible) member benefits in-network out-of-network+ member benefits in-network out-of-network+ Deductible Deductible Individual $1,250 $2,500 Individual $3,000 $6,000 Family $2,500 $5,000 Family $6,000 $12,000 Coinsurance 20% after 50% after Coinsurance 20% after 50% after (Member’s responsibility) deductible up to deductible up to (Member’s responsibility) deductible up to deductible up to out-of-pocket max. out-of-pocket max. out-of-pocket max. out-of-pocket max. $0 once out-of-pocket max. is satisfied $0 once out-of-pocket max. is satisfied Coinsurance Maximum Coinsurance Maximum Individual $3,000 $7,500 Individual $2,000 $4,000 Family $6,000 $15,000 Family $4,000 $8,000 Out-of-Pocket Maximum Out-of-Pocket Maximum Individual $4,250 $10,000 Individual $5,000 $10,000 Family $8,500 $20,000 Family $10,000 $20,000 Includes deductible Includes deductible Lifetime Maximum* per insured $1,000,000 Lifetime Maximum* per insured $1,000,000 Non-Specialist Office Visit Not covered Not covered Non-Specialist Office Visit Not covered Not covered Unlimited visits Unlimited visits General Physician, Family Practitioner, General Physician, Family Pediatrician or Internist Practitioner, Pediatrician or Internist Specialist Visit Not covered Not covered Specialist Visit Not covered Not covered Unlimited visits Unlimited visits Hospital Admission 20% 50% Hospital Admission 20% 50% after deductible after deductible after deductible after deductible Outpatient Surgery 20% 50% Outpatient Surgery 20% 50% after deductible after deductible after deductible after deductible Urgent Care Facility Not covered Not covered Urgent Care Facility Not covered Not covered Emergency Room $100 copay** (waived if admitted); Emergency Room $100 copay** (waived if admitted); 20% coinsurance after deductible 20% coinsurance after deductible Annual Routine Gyn Exam $0 copay 50% Annual Routine Gyn Exam $0 copay 50% No waiting period, deductible waived after deductible No waiting period, deductible waived after deductible no calendar year max. no calendar year max. Annual Pap/Mammogram Annual Pap/Mammogram Maternity Not covered Maternity Not covered (except for pregnancy complications) (except for pregnancy complications) Preventive Health — $25 copay 50% Preventive Health — $35 copay 50% Routine Physical deductible waived after deductible Routine Physical deductible waived after deductible Aetna will pay up to $200 per exam* Aetna will pay up to $200 per exam* Includes lab work and X-rays Includes lab work and X-rays No waiting period No waiting period Lab/X-Ray Not covered Not covered Lab/X-Ray Not covered Not covered Skilled Nursing — in lieu of hospital 20% 50% Skilled Nursing — in lieu of hospital 20% 50% 30 days per calendar year* after deductible after deductible 30 days per calendar year* after deductible after deductible Physical/Occupational Therapy Not covered Not covered Physical/Occupational Therapy Not covered Not covered and Chiropractic Care and Chiropractic Care 24 visits per calendar year* 24 visits per calendar year* Home Health Care — 20% 50% Home Health Care — 20% 50% in lieu of hospital after deductible after deductible in lieu of hospital after deductible after deductible 30 visits per calendar year* 30 visits per calendar year* Durable Medical Equipment Not covered Durable Medical Equipment Not covered Aetna will pay up to $2000 per (except coverage for Aetna will pay up to $2000 per (except coverage for calendar year* Diabetic Equipment and Supplies) calendar year* Diabetic Equipment and Supplies) phArmACy phArmACy Pharmacy Deductible Not Applicable Not Applicable Pharmacy Deductible Not Applicable Not Applicable per individual per individual Generic Not covered Not covered Generic $15 copay $15 copay plus 50% Oral Contraceptives Included Aetna Discount Oral Contraceptives Included Applies Preferred Brand Not covered Not covered Preferred Brand Not covered Not covered Oral Contraceptives Included Aetna Discount Oral Contraceptives Included Aetna Discount Applies Applies Non-Preferred Brand Not covered Not covered Non-Preferred Brand Not covered Not covered Oral Contraceptives Included Aetna Discount Oral Contraceptives Included Aetna Discount Applies Applies Self-Injectible Drugs Not covered Not covered Self-Injectible Drugs Not covered Not covered Aetna Discount Aetna Discount Applies Applies Calendar Year Maximum $5,000 $5,000 Calendar Year Maximum Not Applicable Not Applicable per individual* per individual* * Maximum applies to combined in and out-of-network benefits. + Payment for out-of-network facility covered expenses is determined based on ** Copay is billed separately and not due at time of service. Copay does Aetna’s Market Fee Schedule. Payment for out-of-network non-facility covered not count towards coinsurance or out-of-pocket maximum. expenses is determined based on the negotiated charge that would apply if such *** Brokers: please see broker information about commissions for this plan. services were received from a Network Provider. 16 17

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