Top Echelon Contracting 2015 Health Insurance Benefit Summary

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1 Top Echelon Contracting 2015 Health Insurance Benefit Summary Top Echelon Contracting offers employees health insurance through Aetna ( one of the largest and most nationally recognized health care companies in the United States) and Key Benefit Administrators (KBA). Employees working an average of 30 hours or more per week will have the opportunity to participate in one of the six (6) plans described below. KBA MVP Plan 0/0 Employee Only $ $ Employee and Spouse $ $ Employee and Child(ren) $ $ Family $ $ KBA MVP Preferred Plus 0/0 Employee Only $ $ Employee and Spouse $ $ Employee and Child(ren) $ $ Family $ $ /10000 (Base Plan) Employee Only $ $ Employee and Spouse $ $ Employee and Child(ren) $ $ Family $1, $ /6000 Employee Only $ $ Employee and Spouse $ $ Employee and Child(ren) $ $ Family $1, $ /4000 Employee Only $ $ Employee and Spouse $1, $ Employee and Child(ren) $ $ Family $1, $ /1500 Employee Only $ $ Employee and Spouse $1, $ Employee and Child(ren) $1, $ Family $1, $ Disclaimer: This is a comparison of plans only. Actual benefit coverage can be found in the Summary Plan Description or by calling Aetna s or KBA s Customer Service number on the back of your ID card. Benefits are subject to P:\ACD\HR\BENEFITS\Medical\Aetna\Medical Summary New Hire doc Revised 1/1/15

2 If you elect health insurance coverage, the employee premium for the health insurance will be deducted from your pay on a pre-tax basis unless you direct otherwise. Your monthly premium will be divided equally into four payments and will be deducted from your pay for the first four pay dates of a month. In the months that have five pay dates, you will not have a deduction for medical insurance for the fifth pay date. Your payroll deductions for the health insurance will begin the first pay of the month in which your coverage becomes effective. The above "Employee Monthly Premium" reflects an employer contribution of up to of the "Employee Only" single coverage for the Base plan. If you do not turn in a timesheet, no deductions can be made for that week and the deduction will be added to the next pay. For example, if your monthly premium is $198.08, you would have a $49.52 pre-tax deduction from each pay for the first four pay periods. If you do not turn in a timesheet one week, $99.04 will be deducted from your next pay. For more information about our complete benefit package please visit our Web site at: If you have any questions, please feel free to contact: HR at or HR@TopEchelonContracting.com Finding a PPO Health Care Provider is Easy Aetna Plans: Go to the Aetna Web site ( and click on FIND A DOCTOR on the left side just below the picture. On the next page select Search a public directory just above Aetna member Login on the top of the page. Next, select A plan offered by my employer. Enter your search criteria and then Select a plan. You should select: Aetna Open Access Plans - Managed Choice KBA Plans: To locate providers visit the Multiplan Web site ( then follow these four easy steps to identify your providers of choice. Step 1: Select Search for a Doctor or Facility and then select MultiPlan Limited Benefit Plan logo. Step 2: Choose a Provider Type: Doctor or Facility. Step 3: Select Location, Type or Name of Doctor. Step 4: Results. Providers matching your search criteria will be displayed on the page(s) that follow. Disclaimer: This is a comparison of plans only. Actual benefit coverage can be found in the Summary Plan Description or by calling Aetna s or KBA s Customer Service number on the back of your ID card. Benefits are subject to P:\ACD\HR\BENEFITS\Medical\Aetna\Medical Summary New Hire doc Revised 1/1/15

3 2015 Top Echelon Contracting Comparison /Breakdown of Aetna & KBA Healthcare Plan Options Schedule of Benefits KBA MVP Plan 0/0 KBA MVP Plan Preferred Plus 0/0 5000/10000 (Base Plan) 3000/ / /1500 Deductible (Network) $0/$0 $0/$0 $5,000 Single $10,000 Family $3,000 Single $6,000 Family $2,000/$4,000 $500/$1,500 Coinsurance (Network) 100% 100% 90% : 80% : 20% 80% : 20% 80% : 20% Out of Pocket Max (Network) $1,850/$12,700 $1,850/$12,700 $5,950 Single $11,900 Family $5,000 Single $10,000 Family $4,000/$8,000 $3,000/$6,000 Deductible (Non-Network) $500/$1,000 $500/$1,000 $10,000 Single $20,000 Family $6,000 Single $12,000 Family $4,000/$8,000 $1,000/$3,000 Coinsurance (Non-Network) 40% 40% 70% : 30% 60% : 40% : : Out of Pocket Max (Non- Network) N/A N/A Office Visit (Network) $15/Visit $15/Visit Specialist Visit (Network) $25/Visit $25/Visit Allergy Injections (Network) N/A N/A Allergy Testing (Network) N/A N/A $20,000 Single $40,000 Family $10,000 Single $20,000 Family $8,000/$16,000 $5,000/$10,000 20% $30/Visit $30/Visit 20% $50/Visit $50/Visit 20% $5 $5 20% 20% 20% Preventative Services (Network) Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Emergency Room Visit (Network) $400/Visit $400/Visit 20% $200/Visit + 20% $200/Visit + 20% Urgent Care Services (Network) $15/Visit $15/Visit 20% $75/Visit $75/Visit

4 2015 Top Echelon Contracting Comparison /Breakdown of Aetna & KBA Healthcare Plan Options Schedule of Benefits E-Visit Walk-in Clinics Inpatient Services (Network) Outpatient Services (Network) KBA MVP Plan 0/0 KBA MVP Plan Preferred Plus 0/0 5000/10000 (Base Plan) N/A N/A N/A N/A N/A N/A $1,000 p/day, 150 day benefit period $500 daily benefit, max 2 days per benefit period. 3000/ / / % $30/visit $30/visit 20% $30/visit $30/visit 20% 20% 20% 20% 20% 20% Lifetime Maximum (Network) Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited Retail Pharmacy (Network) 30 Day Supply Includes Diabetic Test Strip Home Delivery (Network) 90 Day Supply Preferred: $25 $75 Preferred: $62.50 $ Preferred: $25 $75 Preferred: $62.50 $ % Preferred: $40 CareRx: 25% non-formulary drugs Preferred: $100 CareRx: 25% non-formulary drugs Preferred: $40 CareRx: 25% non-formulary drugs Preferred: $100 CareRx: 25% For formulary and nonformulary drugs

5 KBA Minimum Value Plan (MVP) & MVP Preferred Plus Benefit Summary MVP MVP Preferred Plus MVP Covered Benefits Network Non-network Network Non-network Deductible $0/$0 $500/$1,000 $0/$0 $500/$1,000 Coinsurance 100% 40% 100% 40% Out of Pocket Maximum $1,850/$12,700 N/A $1,850/$12,700 N/A MVP Covered Benefits Network Non-network Network Non-network PPO Network Multiplan Multiplan Emergency Room Services $400 Copay Ded/Coin $400 Copay Ded/Coin Primary Care Visit to Treat an Injury or Illness (exc. Well Baby, Preventative and X-Rays $15 Copay Ded/Coin $15 Copay Ded/Coin Specialist Visit $25 Copay Ded/Coin $25 Copay Ded/Coin Imaging (CT, PET Scans, MRIs $400 Copay Ded/Coin $400 Copay Ded/Coin Laboratory Outpatient and Professional Services $50 Copay Ded/Coin $50 Copay Ded/Coin X-rays and Diagnostic Imaging $50 Copay Ded/Coin $50 Copay Ded/Coin Preventative Care/Screening/Immunization (MEC) 100% Covered Ded/Coin 100% Covered Ded/Coin Chronic Disease Management Benefit 100% Covered Ded/Coin 100% Covered Ded/Coin Prescription Drugs Generics $15 Copay Ded/Coin $15 Copay Ded/Coin Preferred Brand Name Drugs $25 Copay Ded/Coin $25 Copay Ded/Coin Non-Preferred Brand Name Drugs $75 Copay Ded/Coin $75 Copay Ded/Coin Fully Insured Limited Medical Indemnity Benefits Inpatient Hospital Daily Indemnity Benefit $1,000 p/day, 150 day benefit period Inpatient Hospital Admission Daily Indemnity Benefit NO Coverage for MVP Plan Only $2,000 p/day, max of 1 admission per benefit period Inpatient Surgery & Anesthesia Daily Indemnity Benefit $1,000 Daily benefit, max of 2 days per benefit period. Includes a 20% Daily Anesthesia Benefit. Outpatient Surgery & Anesthesia Daily Indemnity Benefit $500 daily benefit, max of 2 days per benefit period. Includes a 20% Daily Anesthesia Benefit. Intensive Care Daily Indemnity Benefit $1,000 daily benefit, max of 30 days per benefit period. Critical Illness Benefit $10,000 Benefit Life AD&D* $10,000 Benefit $10,000 Benefit * The Life AD&D benefit is included with all MVP offerings except for groups domiciled in CA, CT, NY and HI. Mental and Nervous and Substance Abuse are covered the same as any other illness. * Minimum Cost Includes the following services: COBRA, HIPAA and Claims Administration; AHDI Population Management; Distribution Fee; PPO Network Access Fee; Stop Loss Insurance Fee.