Wisconsin plan guide. Creating the right health benefits package starts with you and your employees

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1 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Wisconsin plan guide Creating the right health benefits package starts with you and your employees Plans effective January 1, 2015 For businesses with employees WI B (9/14)

2 WI B (9/14) Choosing the right health plan Every company has its own particular needs, driven in part by the health of its employees, by its commitment to health and wellness and, of course, by its financial resources. We believe creating the right health insurance plan means combining these four options to meet a company s specific needs: benefits, network, cost sharing, funding. Experience matters We take the time to listen and learn about your needs. Our experience allows us to share knowledge and provide tools to help achieve the right balance of cost and coverage. Our approach makes all the difference in the value you get from your plan, and in the satisfaction of your employees. Today s health care environment demands a new set of solutions to meet new challenges. Together, we can create a healthy future for your company and your employees. Health insurance, dental insurance, life insurance and disability insurance plans/policies are offered, underwritten or administered by Aetna Life Insurance Company (Aetna).

3 We want to make choosing the right benefits as easy as possible. So we ve organized information in this easy-to-understand guide WI B (9/14) M D V L&D Health care reform 4 Plans, tools and extras 6 7 Network options, cost sharing and premiums 8 Health and wellness programs 9 Medical plans overview 10 Medical plan options 11 PPO plans 21 Aurora PPO plans 28 Indemnity plan 35 Dental plans overview 37 Aetna dental plans Aetna voluntary dental plans Aetna dental plans Vision plans overview 49 Aetna Vision Preferred 51 Life and disability plans overview 54 Life 57 Short Term Disability 58 Long Term Disability 59 Packaged Life and Disability 60 Limitations and exclusions 61 New business checklist 64 3

4 Information about your plan due to health care reform Signed into law in March 2010, the Affordable Care Act is the most life-changing law since the passing of Medicare in the 1960s. We are committed to following the new health care law and to helping you understand its impact. We have outlined below key changes that may impact your health care benefits. Essential health benefits package Aetna plans must offer standard coverage known as essential health benefits. This includes all plans inside and outside of the health insurance exchanges. These benefits provide your employees with essential health benefits, and limit cost sharing. Here are the broad categories of essential benefits that will be included in your employees coverage: Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance abuse services Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric dental Pediatric vision Out-of-pocket (OOP) maximum mandate All cost sharing must apply toward the OOP maximum*, including in-network medical, behavioral health and pharmacy cost sharing. This does not include premiums, bills from non-network doctors for amounts above the plan s recognized charge, or spending for non-covered services. The out-of-pocket maximum must include: Copays Deductibles Coinsurance Fees These fees are included in your premium: Health Insurer Fee Annual fee to offset premium subsidies and tax credit related expenses Transitional Reinsurance Program Contribution Helps finance the cost of high-risk individuals in the individual market Patient-Centered Outcomes Research Fee (also known as the Comparative Effectiveness Fee) Fee to fund clinical outcomes effectiveness research Guaranteed issue Guaranteed issue of health insurance coverage applies to individual, small group and large group markets. Guaranteed issue is available for: Group health plans/insurance coverage (insured only) Individual health insurance coverage (including medical conversion) Pharmacy (insured only) Behavioral health (insured only)** Please note that guaranteed issue is not available for: Self-funded plans Standalone/separate dental or vision Hospital indemnity/fixed indemnity Medicare and Medicare Supplement Medicaid Retiree-only plans Grandfathered plans Association/MEWA plans Rating rule changes The rate review regulations are changing and we are making sure they stay affordable. We are working to protect you from rate increases without decreasing competition, reducing consumer choice of providers, or causing problems. Waiting period Plans may not have any waiting periods longer than 90 days. The benefit waiting period for future employees may be the 1 st or 15 th or the month following 0 days, 30 days or 60 days. The maximum 90-day waiting period applies to fully insured and self-funded plans. Refer to Underwriting Guidelines for details. *Prescription drugs may have a separate out-of-pocket maximum. **No standalone insured behavioral health. 4

5 Pediatric dental/vision Pediatric dental and vision mandates are a separate essential health benefit category and are included with your medical benefits. We will cover those services in 2015 according to the benchmark plan coverage. Pediatric dental* Plan name AWH PPO plans/ppo plans PPO HSA plans Indemnity In network Out of network In network Out of network Out of network Dental checkup (a/k/a preventive/diagnostic) (2 exams per calendar year, up to age 19) 0%; 30% after 0% after 30% after 0%; Dental basic 30% after 50% after 30% after 50% after 30% after Dental major 50% after 50% after 50% after 50% after 50% after Dental orthodontics 50% after 50% after 50% after 50% after 50% after Pediatric vision* Plan name AWH PPO plans/ppo plans PPO HSA plans Indemnity In network Out of network In network Out of network Out of network Vision exam (one exam per 12 months) Eyeglass frames, prescription lenses or prescription contact lenses (one set of frames and one set of contact lenses or eyeglass lenses per year) 0%; 0%; 0%; 0%; 0% after 0%; *For groups 2-50 only. These plans do not cover all vision and dental expenses and have exclusions and limitations. Members should refer to their plan documents to determine which services are covered and to what extent. 5

6 Choosing the right plan for your business Our product portfolio includes a range of coverage and cost combinations. You ll find choices for different budgets and benefits strategies. And you ll see that we re more than medical. You can round out your benefits offering with dental as well as life and disability plans. Take a look at what s available. Medical plans PPO plans Indemnity plans Plan levels You can choose up to four levels of health plans. These levels are named using metals bronze, silver, gold and platinum. Each level includes the same essential health benefits. But the levels differ in how much the health plan pays. Health plan levels Average amount the plan pays for covered services Premium cost for employees Bronze 60% Lowest Silver 70% Lower Gold 80% Higher Platinum 90% Highest You ll soon see many changes in health insurance, thanks to health care reform. Many of them affect your business. And some of them might be confusing. Visit the health care reform section on for more information. Or talk with your broker. Tools to help your employees stay healthy, informed and productive With Aetna health plans, your employees get online tools and helpful resources that let them make the most of their benefits. Our most popular tools include: Secure member website. Your employees get self-service tools, plus health plan and health information through their Aetna Navigator website. Think of it as the key that unlocks the full value of their health benefits package. Encourage them to sign up at Member Payment Estimator. With an Aetna health plan, your employees can compare and estimate costs* for office visits, tests, surgeries and more. This means they can save money** and avoid surprises. This online tool factors in their, coinsurance and copays, plus contracted rates. They can see how much they have to pay and how much the plan will pay. They can log in to their Aetna Navigator member website to use the tool. Online provider directory. Finding doctors, specialists, hospitals and more in the Aetna network is easy with our DocFind search tool. It s available at and the Aetna Navigator member website. My Life Values. Your employees get 24/7 online services and support for managing their everyday personal and work matters. itriage. This is a free mobile app that lets members research symptoms and diseases, find a medical provider and even book an appointment all from the convenience of their mobile device. itriage will guide them to network doctors, hospitals and facilities based on your company health plan. It can help direct your employees to the most appropriate, cost-effective care. * Estimated costs not available in all markets. The tool gives you an estimate of what you would owe for a particular service based on your plan at that very point in time. Actual costs may differ from the estimate if, for example, claims for other services are processed after you get your estimate but before the claim for this service is submitted. Or, if the doctor or facility performs a different service at the time of your visit. ** In 2011, members who used Member Payment Estimator before receiving care saved an average of $170 out of pocket on 34 common procedures, according to the Member Payment Estimator Study, Aetna Informatics and Product Development, August

7 Dental plans PPO PPO Max Freedom-of-Choice plan design Voluntary dental option Dental plan extras There s extra value built into our dental portfolio: Dental-medical integration. Our program encourages preventive dental care among employees who have diabetes or heart disease, or who are pregnant. This can lead to more of your employees taking steps to stay healthy. Vision plans Aetna Vision SM Preferred plans Vision plan extras Choice and convenience and flexibility. Members have the choice to go to any vision provider. Plus, for added convenience, members can easily schedule an eye exam online with some participating providers. Our plans help members fit vision care in to their lifestyle and our bundled plan options provide the administrative ease of having one bill, one renewal and one trusted company to work for you. The value of a balanced network. We offer a balanced network of independent eye care providers as well as in-network retail providers that include most preferred national optical retail chains offering flexible evening and weekend hours. Discounts. Aetna Vision Preferred plan offers additional savings on contact lenses, eyeglasses, prescription sunglasses, LASIK vision correction and more at most in-network locations.* Availability varies by state. Life and disability plans Basic life Supplemental life AD&D Ultra Supplemental AD&D Ultra Dependent life Short-term disability Long-term disability Life and disability plan extras Aetna Life Essentials SM. Through our program, your employees get access to expert advice on legal and financial matters at no added cost. Plus, they get discounts on health products and services, like fitness and vision care.* Funeral planning and concierge service. Through our collaboration with Everest, we offer our life members pre-planning and at-need services. Aetna Return to Work Solutions SM Program. Our return to work solutions provide customers with the support and resources they need to help get valued employees back to work safely and as soon as possible. *These services are discount programs, not insurance. 7

8 Choose from a wide range of health benefits and insurance options to fit your needs About our benefits Choose from numerous, integrated benefits options that can lead to improved employee engagement and health, while helping you manage your costs. This includes medical, pharmacy, dental, life, disability and vision. Plus, online tools that help employees use their benefits wisely and get help when they need it. About our network We have many full-network and tiered-network options to lower employer costs while still providing employees with access to quality care. Our doctor networks prioritize quality and efficiency to improve the health care experience and make it easy for individuals to get the care they need. About our cost sharing Some of our cost-sharing arrangements encourage employees to become more involved in their own health care and become better health care consumers. Employees with these plans receive more preventive care, have lower overall costs and use online tools more frequently. About our funding options We can show you how a combined network, cost sharing and benefits approach can help you manage your premium to meet your budget. We also offer a range of funding options from traditional fully insured to enhanced self-insured solutions that provide different levels of cost, plan control and information access. Network options for healthy outcomes and lower costs Our network solutions help lower your costs while providing employees with access to trusted doctors and hospitals. Your employees can still get care within the broad Aetna network. But they pay less out of pocket when they use doctors and hospitals in our special networks. The more they use health care providers in these networks, the more likely you are to see lower medical costs. We make it easier for your employees, too. They get online tools for estimating costs and finding the right doctors and hospitals. Cost sharing and premiums for every budget Your focus is on lower costs. Increasingly, that means greater levels of employee cost sharing. With Aetna in your corner, you can map out a strategy based on your employee base and price point. And you can choose from the full spectrum of health plan types: Our fully insured portfolio, traditionally a mainstay for small businesses, provides plans with a range of robust coverage options. New self-funded options for small businesses may help you manage costs while simplifying administration and making monthly expenses more predictable. Our defined contribution offering combines an attractive benefits package with more controlled costs. As well as motivation for your employees to get more involved in their health care. Our consumer-directed health plans have long offered fully featured coverage, along with lower premiums and higher s. Our research has found that members with these plans have lower overall health care costs, receive more preventive care and use online tools more frequently than members with traditional plans. 8

9 Health and wellness programs Having a happier, healthier workforce is important to you. So is cost management. We ve found that helping your employees get more involved in managing their health and well-being is a great way to meet these goals. Talk to your broker or Aetna representative to learn more about our programs. Wellness on us Wellness for employees means a healthier business for employers. As always, our health benefits and insurance plans offer $0 copays for in-network eye exams and $0 copay for in-network preventive care. It s one more way to help employees get a step closer to better health. Preventive care benefits with no copay: Immunizations Routine physicals Child wellness visits Routine mammogram Routine OB/GYN visits No-cost health incentive credit Members can earn $50 in just a few simple steps. Members earn a $50 credit toward their out-of-pocket expenses when they: Complete or update their Simple Steps To A Healthier Life health assessment, and Complete one online wellness program If the employee s spouse is covered under the plan, he or she is also eligible for the same incentive credit. So a family could save $100 in out-of-pocket expenses each year. Incentive rewards will be credited toward the and coinsurance amounts. This program is included at no additional cost on all plans except the HSA-compatible plans. Women s preventive health benefits These services are generally covered at no cost share, when provided in network: Well-woman visits (annually and now including prenatal visits) Screening for gestational diabetes Human papillomavirus (HPV) DNA testing Counseling for sexually transmitted infections Counseling and screening for human immunodeficiency virus (HIV) Screening and counseling for interpersonal and domestic violence Breastfeeding support, supplies and counseling Generic formulary contraceptives and certain brand formulary contraceptives are covered without member copayment; certain religious organizations or religious employers may be exempt from offering contraceptive services We make things easy for you Health plan management and administration is our specialty, which makes it easier for you to manage your health benefits and insurance plans with: eenrollment. Handle enrollments, terminations and other changes online, with less paperwork and greater efficiency. ebilling. Save time and simplify reconciliation and payment, anytime, anywhere, with our secure system. It lets you get, view and pay all your medical and dental bills online. Wellness programs can make health and fitness part of everyday living Women s health and preventive health reminders Simple Steps To A Healthier Life program Informed Health 24-hour nurse line* Aetna discount programs Personal Health Record * While only your doctor can diagnose, prescribe or give medical advice, the Informed Health Line nurses can provide information on more than 5,000 health topics. Contact your doctor first with any questions or concerns regarding your health care needs. 9

10 10 Aetna medical overview Medical coverage can be a deal-breaker in recruiting and keeping talented employees. Our medical plan portfolio was designed with the needs of businesses like yours in mind. You ll find flexible options, from traditional indemnity to consumer-directed plans. You can choose the plan design and benefits level that fits your budget and achieve the right balance of cost and coverage for your business.

11 Medical overview M All AWH plans are within the Aurora service area. See page 13 for details. Product name Product description PCP required Referrals required DocFind network name PPO Indemnity Members can access any participating provider for covered services without a referral. When members seek health care, they have the freedom to choose either network providers at lower out-of-pocket costs, or non-network providers at higher out-of-pocket costs. Members are able to receive emergency services at the in-network coinsurance/copay level. 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. No No Open Choice PPO No No N/A Religious exemption plans Available for every plan design; the benefits listed below are not covered: Contraceptives (oral drugs, injectable drugs and devices) Contraceptive counseling, voluntary sterilization (male and female) tubal ligation and vasectomy Elective abortions 11

12 M Aetna high-, HSA-compatible PPO plans Aetna high- PPO health plans are compatible with a health savings account (HSA). HSA-compatible plans provide integrated medical and pharmacy benefits. Preventive care services are exempt from the. 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 help cover their future medical and dental expenses. HSA accounts can be funded by the employer or employee and are portable. Fund contributions may be tax- (limits apply). When funds are used to cover qualified out-of-pocket medical and dental expenses, they are not taxed. It is completely at the discretion of the employer or employee whether or not to establish an HSA. Note: Employers and employees should consult with their tax advisor to determine eligibility requirements and tax advantages for participation in the HSA plan. Health savings account (HSA) No set-up or administrative fees The Aetna HealthFund HSA, when coupled with a HSA-compatible, high- 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. HSA Account Member owns the HSA Contributions are tax free Member chooses how and when to use HSA dollars Roll it over each year and let it grow Earns interest, tax free Today or in the future Use now for qualified expenses with tax-free dollars Plan for future and retiree health-related costs High- health plan Eligible in-network preventive care services will not be subject to the Members pay 100 percent until is met, then only pay a share of the cost Meet out-of-pocket maximum, then plan pays 100 percent Health reimbursement arrangement (HRA) The Aetna HealthFund HRA combines the protection of a -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 and fund rollover. The fund is available to an employee for qualified expenses on the plan s effective date. COBRA administration Aetna COBRA administration offers a full range of notification, documentation and record-keeping processes that can help employers manage the complex billing and notification processes 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. First-year POP fees are with the purchase of medical with five or more enrolled employees. 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 out-of-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. 12

13 Better care leads to lower costs Aetna Whole Health M This groundbreaking new program incorporates coordinated decision making among care providers. It features a network of Aurora Accountable Care Network physicians who manage patients throughout all levels of care whether they are healthy, at risk, acutely ill or suffering from chronic diseases. Aetna and Aurora Health Care have formed this distinct collaboration to offer businesses a unique opportunity to help their employees optimize and manage their health. We work together to get members more engaged in their overall health and well-being. Our goal is to achieve better care and provide more effective health outcomes for the residents of Wisconsin. With Aetna Whole Health, members will have primary care doctors that coordinate the work of a team of specialists, nurses and other care managers. The team creates and implements care plans that are specially designed to meet individual needs. Together, these providers share accountability for improving the patient s health. The secret to our success At least one of your employees is likely to need serious medical care every year. Recognizing this, we developed a model to identify at-risk employees early, before they actually require care. We engage with them through proactive care and support to help them make smarter health care decisions and achieve their health goals, all while reducing costs. The statistics below highlight some of the shortcomings of the health care system that Aetna Whole Health addresses. We empower your employees to advance their health with support from their Aurora Accountable Care Network care team. Through improved coordination of the care provided, our model aims to improve care and eliminate waste leading to healthier employees, a better patient experience and lower cost. How it works By using technology to identify patients at risk for serious conditions like heart disease, we can spot gaps in their care. This allows us to reach out to those patients with specialized care options, thus reducing the need for costly medical procedures down the road.1 Employers health costs have risen Medication-related injuries harm The US ranks 20% in five years, 9.3% in the last year million people per year and cost $3.5 billion.3 31 st internationally for infant mortality.4 1Source: Aetna analytics, CY Towers Watson/National Business Group on Health Employer Survey. 3June 2010 Academy of Managed Care Pharmacy, The Academy of Managed Care Pharmacy s Concepts in Managed Care Pharmacy Medication Errors Adapted from Organization for Economic Cooperation and Development, OECD Health Data. 13

14 M One way that the Aurora Accountable Care Network offers additional benefit is by providing care management from Nurse Navigator telephone support for all employee groups. This program offers: Assistance with provider selection based on health situation and established protocols Personal guidance, assisting you from illness/injury to improved health and wellness Education so employees and their families understand their diagnosis, treatment plan and care options Information on wellness programs, health education, preventive care and screenings Second-opinion evaluation when appropriate for understanding care options Two ways to reach one industry-changing goal Aetna Whole Health and Aurora Accountable Care Network will take a two-pronged approach to help change the way you think about health care with: A better health care experience achieved through technology-based information sharing and care coordination New payment models and incentives that encourage accountability to help improve patient health while controlling costs With these two goals in mind, Aetna and Aurora Accountable Care Network have created a strong alliance. We work to constantly coordinate and evaluate the care we provide to improve health and the patient experience. We focus on value over volume Without a dramatic change in how providers are paid, health care costs will continue to soar. We recognize that a new approach is needed to reduce health care costs and bring stability to health insurance premiums. It s a bold strategy designed to bring value and health to our customers and the community. Quality local care at a lower cost We provide Wisconsin members with the same types of coverage as other Aetna medical plans, but premiums are lower. Savings are generated through the use of the Aurora Accountable Care Network, a quality network of local health care providers. With Aetna Whole Health, doctors are paid, in part, based on quality care and better outcomes rather than volume billing for more procedures and tests. The goal is to establish incentives that are based on delivery of efficient, quality care, instead of fee-for-service medicine. How does Aetna Whole Health work? There are a total of 10 different Aetna Whole Health plans in Wisconsin, giving you the flexibility and the choice to best meet your needs. Our Aetna Whole Health plans with Aurora Accountable Care Network have two levels of benefits: In Network: When members use Aurora Accountable Care Network designated doctors and hospitals to provide and to coordinate all of their care, they realize maximum savings Out of Network: When members choose to use out-of-network doctors and hospitals, they will likely pay significantly higher out-of-pocket costs Premiums and out-of-pocket expense levels vary select the plan that s right for you and your employees. Aetna Whole Health and the Aurora Accountable Care Network offer a complete continuum of benefits, including: Affordability that meets the needs of employers looking to reduce their costs while providing access to the nationally recognized Aurora Accountable Care Network Our industry-recognized1 care management programs and best-in-class2 online tools for members Extensive experience managing employee populations, including 48,000 members in Aurora s own employee health plan A fully integrated health care delivery system of more than 1,500 employed physicians across all specialties serving 31 counties and 90 communities Access to the sixth largest medical group in the nation and Wisconsin s leading health care provider, with 15 hospitals, including Children s Hospital of Wisconsin and 172 clinics Choosing a physician Aetna Whole Health plans are available to Wisconsin businesses wishing to offer the Aurora Accountable Care Network. Aurora Accountable Care Network physicians are employed and independently contracted. To find a doctor who participates in the Aurora Accountable Care Network, visit and select from the options under Search for. Then, select Aetna Whole Health SM Aurora Accountable Care Network in the Select a Plan menu. Look for doctors who have the Aetna Whole Health symbol. 1 CIO Magazine Winner Profile: Healthagen, an Aetna subsidiary. Available at: Accessed October Highbeam Research KLAS Research Recognizes Aetna as Transformational Partner for Providers. Available at: Accessed October

15 Aurora Northeastern Wisconsin Health Care Facilities M Marinette Oconto Shawano Door Waupaca Outagamie Brown Kewaunee Clinic Waushara Winnebago Calumet Manitowoc Hospital Fond du Lac Sheboygan Aurora has pharmacy, QuickCare Clinic and vision center locations throughout the state for your convenience. Brown County * 1881 Chicago Street De Pere, WI Aurora QuickCare Clinic at Walmart 1415 Lawrence Drive De Pere, WI Solvang Way Denmark, WI Aurora BayCare Health Center* 2253 W. Mason Street Green Bay, WI Aurora BayCare Medical Center* 2845 Greenbrier Road Green Bay, WI Aurora Medical Group 2845 Greenbrier Road Green Bay, WI Aurora Medical Group 1565 Allouez Avenue Green Bay, WI Lineville Road Green Bay, WI Aurora Visiting Nurse Association 931 Discovery Road Green Bay, WI Brown County Dialysis Center 1751 Deckner Avenue Green Bay, WI Aurora Orthopedics & Sports Medicine Center 1160 Kepler Drive Green Bay, WI Aurora QuickCare Clinic at Walmart 2440 W. Mason Street Green Bay, WI *Urgent care or walk-in care is available at this facility. 15

16 M 4070 Equestrian Road New Franken, WI S. St. Augustine Street Pulaski, WI Calumet County 2020 Madison Street New Holstein, WI Door County Aurora Nor-Door Clinic 2521 S. Bay Shore Drive Sister Bay, WI Aurora Dialysis Center 108 S. 10 th Avenue Sturgeon Bay, WI S. State Street Mishicot, WI Mill Street Reedsville, WI Aurora Medical Center 5000 Memorial Drive Two Rivers, WI Aurora Two Rivers Clinic 2219 Garfield Street Two Rivers, WI Memorial Drive Two Rivers, WI Calumet Drive Valders, WI Aurora Medical Group 2700 Crooks Avenue Kaukauna, WI Orchard Drive Seymour, WI Shawano County 101 Express Way Bonduel, WI E. Green Bay Street Shawano, WI Sheboygan County Aurora Sheboygan Clinic 313 S. Main Street Cedar Grove, WI Aurora QuickCare Clinic at Walmart 3711 S. Taylor Drive Sheboygan, WI Plankview Green Boulevard Sheboygan Falls, WI Waupaca County N430 Wood Duck Drive Fremont, WI Waushara County 900 E. Division Street Wautoma, WI Winnebago County * 1910 Alabama Street Sturgeon Bay, WI Fond du Lac County * 210 Wisconsin American Drive, Hwy. 23 East Fond du Lac, WI Park Ridge Lane North Fond du Lac, WI W. Fond du Lac Street Ripon, WI Manitowoc County Aurora Manitowoc Clinic 601 Reed Avenue Manitowoc, WI Aurora Manitowoc Clinic South* 4100 Dewey Street Manitowoc, WI Marinette County 4061 Old Peshtigo Road Marinette, WI Marinette Menominee Clinic 3130 Shore Drive Marinette, WI Marinette Menominee Clinic 1510 University Drive Marinette, WI French Street Peshtigo, WI Oconto County 530 Smith Avenue Oconto, WI Outagamie County N1750 Lily of the Valley Road Greenville, WI Aurora Sheboygan Clinic 620 S. Wisconsin Drive Howards Grove, WI Aurora Sheboygan Clinic 1001 Service Road Kiel, WI * 2600 Kiley Way Plymouth, WI Aurora Sheboygan Clinic 110 Butler Street Random Lake, WI Aurora Sheboygan Memorial Medical Center 2629 N. 7 th Street Sheboygan, WI Aurora Sheboygan Clinic* 2414 Kohler Memorial Drive Sheboygan, WI Aurora Sheboygan Clinic 1813 Ashland Avenue Sheboygan, WI * 1136 Westowne Drive Neenah, WI Huckleberry Avenue Omro, WI Aurora Medical Center 855 N. Westhaven Drive Oshkosh, WI * 855 N. Westhaven Drive Oshkosh, WI Aurora Medical Group 414 Doctors Court Oshkosh, WI Aurora QuickCare Clinic at Walmart 351 S. Washburn Street Oshkosh, WI Harbour View Drive Winneconne, WI *Urgent care or walk-in care is available at this facility. 16

17 Aurora Southeastern Wisconsin Health Care Facilities M Dodge Washington Ozaukee Waukesha Jefferson Milwaukee Walworth Racine Clinic Hospital Kenosha Aurora has pharmacy, QuickCare Clinic and vision center locations throughout the state for your convenience. Dodge County 375 East Avenue Lomira, WI Jefferson County Aurora Wilkinson Medical Clinic 1532 Utah Street Watertown, WI Kenosha County Aurora Medical Center th Street Kenosha, WI * th Street Kenosha, WI nd Avenue Kenosha, WI th Street Kenosha, WI th Street Kenosha, WI th Place Kenosha, WI Aurora QuickCare Clinic at Piggly Wiggly th Place Kenosha, WI th Street Paddock Lake, WI N. Lake Avenue Twin Lakes, WI Milwaukee County Aurora Advanced Healthcare 3119 S. Clement Avenue Bay View, WI Aurora St. Luke s South Shore 5900 S. Lake Drive Cudahy, WI Aurora St. Luke s South Shore Physician Office Building 5900 S. Lake Drive Cudahy, WI Aurora St. Luke s Health Center* 9200 W. Loomis Road Franklin, WI Aurora Women s Pavilion in Franklin/Aurora Advanced Healthcare/ Lakeshore Medical Clinic 4202 W. Oakwood Park Court Franklin, WI Aurora QuickCare Clinic at Southridge Mall 5300 S. 76 th Street Greendale, WI *Urgent care or walk-in care is available at this facility. 17

18 M Lakeshore Medical Clinic* 4131 W. Loomis Road Greenfield, WI Lakeshore Medical Clinic 4448 W. Loomis Road Greenfield, WI * 6901 W. Edgerton Avenue Greenfield, WI Aurora Advanced Healthcare 4848 S. 76 th Street Greenfield, WI * 5250 S. 108 th Street Hales Corners, WI Aurora St. Luke s Medical Center 2900 W. Oklahoma Avenue Milwaukee, WI Aurora Sinai Medical Center 945 N. 12 th Street Milwaukee, WI Aurora Advanced Healthcare 945 N. 12 th Street Milwaukee, WI N. River Center Drive Milwaukee, WI Aurora St. Luke s Physician Office Building 2801 W. Kinnickinnic River Parkway Milwaukee, WI Aurora St. Luke s Physician Office Building 2901 W. Kinnickinnic River Parkway Milwaukee, WI Aurora UW Medical Group 1020 N. 12 th Street Milwaukee, WI Aurora Sinai Physician Office Building 1218 W. Kilbourn Avenue Milwaukee, WI Aurora Urgent Care of Aurora Sinai Medical Center* 946 N. Van Buren Milwaukee, WI Aurora Advanced Healthcare* 3003 W. Good Hope Road Milwaukee, WI Aurora Advanced Healthcare 7878 North 76th Street Milwaukee, WI W. Mitchell Street Milwaukee, WI W. Capitol Drive Milwaukee, WI Lakeshore Medical Clinic 163 N. Milwaukee Street Milwaukee, WI Lakeshore Medical Clinic 3305 S. 20 th Street Milwaukee, WI Lakeshore Medical Clinic* 331 E. Puetz Road Oak Creek, WI Lakeshore Medical Clinic* 902 Milwaukee Avenue South Milwaukee, WI Lakeshore Medical Clinic 3611 S. Chicago Avenue South Milwaukee, WI Lakeshore Medical Clinic 2000 E. Layton Avenue St. Francis, WI Aurora Psychiatric Hospital 1220 Dewey Avenue Wauwatosa, WI Aurora Wiselives Center 8320 W. Bluemound Road, Ste. 125 Wauwatosa, WI Aurora Advanced Healthcare* 3289 N. Mayfair Road Wauwatosa, WI Aurora Advanced Healthcare 1055 N. Mayfair Road Wauwatosa, WI Aurora Medical Center 2999 N. Mayfair Road Wauwatosa, WI Aurora West Allis Medical Center/Aurora Women s Pavilion 8901 W. Lincoln Avenue West Allis, WI Aurora West Allis Physician Office Building 2424 S. 90 th Street West Allis, WI * 7220 W. National Avenue West Allis, WI Aurora Advanced Healthcare 325 E. Silver Spring Drive Whitefish Bay, WI Ozaukee County Aurora Medical Center 975 Port Washington Road Grafton, WI Aurora Medical Center Grafton Physician Office Building 975 Port Washington Road Grafton, WI Aurora Advanced Healthcare* 215 W. Washington Street Grafton, WI Aurora Advanced Healthcare N. Corporate Parkway Mequon, WI Aurora Advanced Healthcare 6425 West Mequon Road Mequon, WI Aurora QuickCare Clinic at Aurora Pharmacy N. Port Washington Road Mequon, WI Aurora Advanced Healthcare 1777 W. Grand Avenue Port Washington, WI Aurora Advanced Healthcare 1475 W. Grand Avenue Port Washington, WI Racine County Aurora Cancer Care 116 N. Dodge Street, Suite 8 Burlington, WI Aurora Memorial Hospital of Burlington 252 McHenry Street Burlington, WI Aurora Burlington Clinic* 248 McHenry Street Burlington, WI Douglas Avenue Caledonia, WI Washington Avenue Racine, WI *Urgent care or walk-in care is available at this facility. 18

19 8400 Washington Avenue Racine, WI Aurora Cancer Care* 1151 Warwick Way Racine, WI th Drive Union Grove, WI * 818 Forrest Lane Waterford, WI Walworth County 1550 Hobbs Drive Delavan, WI Corporate Circle Drive East Troy, WI Aurora Lakeland Medical Center W3985 County Road NN Elkhorn, WI E. Commerce Court Elkhorn, WI N. Church Street Elkhorn, WI * 146 E. Geneva Square Lake Geneva, WI Kenosha Street Walworth, WI Washington County Aurora Advanced Healthcare N112 W17975 Mequon Road Germantown, WI Aurora Medical Center 1032 E. Sumner Street Hartford, WI Aurora Advanced Healthcare* 1640 E. Sumner Street Hartford, WI Aurora Advanced Healthcare 3055 Hubertus Road Hubertus, WI Aurora Advanced Healthcare 1020 Fond du Lac Avenue Kewaskum, WI Aurora Advanced Healthcare 1061 E. Commerce Blvd. Slinger, WI Aurora Advanced Healthcare* 205 Valley Avenue West Bend, WI Aurora Advanced Healthcare 5595 County Road Z West Bend, WI Waukesha County Aurora Advanced Healthcare W. Capitol Drive Brookfield, WI Aurora QuickCare Clinic at Brookfield Square 95 N. Moorland Road Brookfield, WI Aurora Wilkinson Medical Clinic 2808 Heritage Drive Delafield, WI Aurora Wilkinson Medical Clinic 600 Walnut Ridge Drive Hartland, WI Aurora QuickCare Clinic at Walmart 250 E. Wolf Run Mukwonago, WI * S74 W16775 Janesville Road Muskego, WI Lakeshore Medical Clinic* S68 W15500 Janesville Road Muskego, WI Aurora Advanced Healthcare* N84 W16889 Menomonee Avenue Menomonee Falls, WI Aurora Advanced Healthcare* W. National Avenue New Berlin, WI Aurora St. Luke s Health Center* W. National Avenue New Berlin, WI Aurora Wilkinson Medical Clinic* 1284 Summit Avenue Oconomowoc, WI Aurora QuickCare Clinic at Walmart 411 Pewaukee Road Pewaukee, WI Aurora Medical Center Aurora Drive Summit, WI Aurora Wilkinson Medical Clinic Aurora Drive Summit, WI Aurora Wilkinson Medical Clinic 144 E. Summit Avenue Wales, WI * W231 N1440 Corporate Court Waukesha, WI Aurora Cancer Care N14 W23833 Stone Ridge Drive Waukesha, WI M *Urgent care or walk-in care is available at this facility. 19

20 M Administrative fees Fee description Premium only plan (POP) Fee Initial set-up* $190 Renewal fee $125 Health reimbursement arrangement (HRA) and flexible spending account (FSA)** Initial set-up 2 25 employees $360 $ employees $460 $ employees $560 $335 Monthly fees*** Additional set-up fee for stacked plans (those electing an Aetna HRA and FSA simultaneously) Participation fee for stacked participants $5.45 per participant $150 $10.45 per participant Renewal fee Minimum fees 0 25 employees $25 per month minimum employees $50 per month minimum COBRA services Annual fee employees $ employees $230 Per employee per month employees $ employees $1.05 Initial notice fee $3.00 per notice (includes notices at time of implementation and during ongoing administration) Minimum fees employees $25 per month minimum employees $50 per month minimum Transit reimbursement account (TRA) Annual fee $350 Transit monthly fees $4.25 per participant Parking monthly fees $3.15 per participant Wisconsin differences for 2 to 50 versus 51 to 100 Plan feature 2 to 50 market segment 51 to 100 market segment Pediatric dental Included Not included Pediatric vision Included Not included For the 51 to 100 plans you will not see the metallic name included in the plan name. Pharmacy tier information A plan offers programs that encourage members to choose lower cost drugs over brand-name drugs. This helps members get the most value from their benefits by reducing what they pay. A list of drugs that a health plan covers is called a formulary. It can include up to five tiers. Think of tier as a level. For example a three-tier formulary means a member could pay three different amounts, depending on the drug prescribed. Members pay either a flat fee, known as a copay, or a percent of the prescription s price, coinsurance. The formulary tiers start with the most affordable options. Here is an example of what formulary tiering might look like: Health care reform zero dollar drugs (HCR $0 drugs) Tier 1A (Value Drugs) Preferred low cost generics and brand over-the-counter (OTC) drugs. Tier 1 Preferred generics. Tier 2 Preferred brand-name drugs. Tier 3 Nonpreferred brand-name and nonpreferred generic drugs. Tier 4 Preferred specialty drugs. Tier 5 Nonpreferred specialty drugs. Members pay the highest amount for nonpreferred specialty drugs in this level. Specialty drugs may be injected, infused or taken by mouth. You can learn more about covered drugs at Members can log in at and use our Price a Drug SM tool to see what they will pay for their medicine. They ll get an estimated cost of a prescription from their local retail pharmacy or from mail order. It provides a cost comparison between generic and brand-name drugs. * Nondiscrimination testing provided annually after open enrollment for POP and FSA only. Additional off-cycle testing available at employer request for $100 fee. Nondiscrimination testing only available for FSA and POP products. **Aetna FSA pricing is inclusive for POP. Debit cards are available for FSA only. Contact us for more information. *** For HRA, if the employer opts out of Streamline, the fee is increased $1.50 per participant. For FSA, the debit card is available for an additional $1 per participant per month. Mailing reimbursement checks direct to employee homes is an additional $1 per participant per month. We reserve the right to change any of the above fees and to impose additional fees upon prior written notice. 20

21 PPO plans M 2 50 Gold PPO /50 Gold PPO /50 Plan name PPO /50 PPO /50 Member benefits* Network care Out-of-network care Network care Out-of-network care Calendar year $500/$1,000 $1,000/$2,000 $1,000/$2,000 $2,000/$4,000 Calendar year out-of-pocket limit $2,500/$5,000 $5,000/$10,000 $2,500/$5,000 $5,000/$10,000 Deductible & out-of-pocket limit accumulation Embedded1 Embedded1 Primary care physician office visit Specialist office visit Walk-in clinics $25 copay; $50 copay; $25 copay; 50% after $25 copay; 50% after $50 copay; $25 copay; 50% after 50% after Diagnostic testing: Lab $75 copay after 50% after $75 copay after 50% after Diagnostic testing: X-ray 20% after 50% after 20% after 50% after Imaging (CT/PET scans, MRIs) 20% after 50% after 20% after 50% after Inpatient hospital facility 20% after 50% after 20% after 50% after Outpatient surgery 20% after 50% after 20% after 50% after Emergency room (copay if admitted) Urgent care Rehabilitation services (PT/OT/ST)2 Coverage is limited to 20 visits per therapy, rehabilitation, habilitation and autism combined. Chiropractic $250 copay; ; then 20% $75 copay; $50 copay; $50 copay; Paid as network care $250 copay; ; then 20% 50% after $75 copay; 50% after $50 copay; 50% after $50 copay; Paid as network care 50% after 50% after 50% after 2 50 pharmacy** Network Out of network Network Out of network Pharmacy None None None None Preferred generic drugs*** Preferred brand drugs Nonpreferred drugs T1A-$3 copay; / T1-$10 copay; $50 copay; $75 copay; Specialty drugs P: 25% up to $750; NP: 50%; T1A-$3 copay plus 30%; / T1-$10 copay plus 30%; $50 copay plus 30%; $75 copay plus 30%; T1A-$3 copay; / T1-$10 copay; $50 copay; $75 copay; P: 25% up to $750; NP: 50%; T1A-$3 copay plus 30%; / T1-$10 copay plus 30%; $50 copay plus 30%; $75 copay plus 30%; pharmacy** Network Out of network Network Out of network Pharmacy None None None None Preferred generic drugs Preferred brand drugs Nonpreferred drugs $10 copay; $50 copay; $75 copay; Specialty drugs P: 25% up to $750; NP: 50%; $10 copay plus 30%; $50 copay plus 30%; $75 copay plus 30%; $10 copay; $50 copay; $75 copay; P: 25% up to $750; NP: 50%; $10 copay plus 30%; $50 copay plus 30%; $75 copay plus 30%; Refer to page 36 for footnotes. 21

22 M PPO plans 2 50 Silver PPO /50 Silver PPO /50 Plan name PPO /50 PPO /50 Member benefits* Network care Out-of-network care Network care Out-of-network care Calendar year $1,500/$3,000 $3,000/$6,000 $2,000/$4,000 $4,000/$8,000 Calendar year out-of-pocket limit $5,500/$11,000 $11,000/$22,000 $5,000/$10,000 $10,000/$20,000 Deductible & out-of-pocket limit accumulation Embedded1 Embedded1 Primary care physician office visit Specialist office visit Walk-in clinics $30 copay; $60 copay; $30 copay; 50% after $30 copay; 50% after $60 copay; $30 copay; 50% after 50% after Diagnostic testing: Lab $75 copay after 50% after $75 copay after 50% after Diagnostic testing: X-ray 20% after 50% after 20% after 50% after Imaging (CT/PET scans, MRIs) 20% after 50% after 20% after 50% after Inpatient hospital facility 20% after 50% after 20% after 50% after Outpatient surgery 20% after 50% after 20% after 50% after Emergency room (copay if admitted) Urgent care Rehabilitation services (PT/OT/ST)2 Coverage is limited to 20 visits per therapy, rehabilitation, habilitation and autism combined. Chiropractic $250 copay; ; then 20% $75 copay; $60 copay; $60 copay; Paid as network care $300 copay; ; then 20% 50% after $75 copay; 50% after $60 copay; 50% after $60 copay; Paid as network care 50% after 50% after 50% after 2 50 pharmacy** Network Out of network Network Out of network Pharmacy None None None None Preferred generic drugs*** Preferred brand drugs Nonpreferred drugs T1A-$3 copay; / T1-$10 copay; $70 copay; $100 copay; Specialty drugs P: 25% up to $750; NP: 50%; T1A-$3 copay plus 30%; / T1-$10 copay plus 30%; $70 copay plus 30%; $100 copay plus 30%; T1A-$3 copay; / T1-$10 copay; $70 copay; $100 copay; P: 25% up to $750; NP: 50%; T1A-$3 copay plus 30%; / T1-$10 copay plus 30%; $70 copay plus 30%; $100 copay plus 30%; pharmacy** Network Out of network Network Out of network Pharmacy None None None None Preferred generic drugs Preferred brand drugs Nonpreferred drugs $10 copay; $70 copay; $100 copay; Specialty drugs P: 25% up to $750; NP: 50%; $10 copay plus 30%; $70 copay plus 30%; $100 copay plus 30%; $10 copay; $70 copay; $100 copay; P: 25% up to $750; NP: 50%; $10 copay plus 30%; $70 copay plus 30%; $100 copay plus 30%; Refer to page 36 for footnotes. 22

23 PPO plans M 2 50 Silver PPO /50 Silver PPO /50 Plan name PPO /50 PPO /50 Member benefits* Network care Out-of-network care Network care Out-of-network care Calendar year $2,500/$5,000 $5,000/$10,000 $3,000/$6,000 $6,000/$12,000 Calendar year out-of-pocket limit $5,000/$10,000 $10,000/$20,000 $6,400/$12,800 $12,800/$25,600 Deductible & out-of-pocket limit accumulation Embedded1 Embedded1 Primary care physician office visit Specialist office visit Walk-in clinics $30 copay; $60 copay; $30 copay; 50% after $45 copay; 50% after $90 copay; $45 copay; 50% after 50% after Diagnostic testing: Lab $75 copay after 50% after $75 copay after 50% after Diagnostic testing: X-ray 20% after 50% after $150 copay after 50% after Imaging (CT/PET scans, MRIs) 20% after 50% after 10% after 50% after Inpatient hospital facility 20% after 50% after 10% after 50% after Outpatient surgery 20% after 50% after 10% after 50% after Emergency room (copay if admitted) Urgent care Rehabilitation services (PT/OT/ST)2 Coverage is limited to 20 visits per therapy, rehabilitation, habilitation and autism combined. Chiropractic $250 copay; ; then 20% $75 copay; $60 copay; $60 copay; Paid as network care $250 copay; ; then 10% 50% after $75 copay; 50% after $90 copay; 50% after $90 copay; Paid as network care 50% after T1A-$3 copay plus 30%/ T1-$10 copay plus 30% 50% after 2 50 pharmacy** Network Out of network Network Out of network Pharmacy None None None None Preferred generic drugs*** Preferred brand drugs Nonpreferred drugs T1A-$3 copay; / T1-$10 copay; $90 copay; $125 copay; Specialty drugs P: 25% up to $750; NP: 50%; T1A-$3 copay plus 30%; / T1-$10 copay plus 30%; $90 copay plus 30%; $125 copay plus 30%; T1A-$3 copay; / T1-$10 copay; $50 copay; $75 copay; P: 25% up to $750; NP: 50%; T1A-$3 copay plus 30%; / T1-$10 copay plus 30%; $50 copay plus 30%; $75 copay plus 30%; pharmacy** Network Out of network Network Out of network Pharmacy None None None None Preferred generic drugs Preferred brand drugs Nonpreferred drugs $10 copay; $90 copay; $125 copay; Specialty drugs P: 25% up to $750; NP: 50%; $10 copay plus 30%; $90 copay plus 30%; $125 copay plus 30%; $10 copay; $50 copay; $75 copay; P: 25% up to $750; NP: 50%; $10 copay plus 30%; $50 copay plus 30%; $75 copay plus 30%; Refer to page 36 for footnotes. 23