New Jersey plan guide

Transcription

1 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions New Jersey plan guide Creating the right health benefits package starts with you and your employees Plans effective July 1, 2015 For businesses with 1 50 employees NJ J (4/15)

2 NJ J (4/15) 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 benefits and 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 benefits and health insurance, dental benefits/dental insurance, life insurance and disability insurance plans/ policies are offered, underwritten or administered by Aetna Health Inc., Aetna Health Insurance Company Aetna Dental Inc. and/or Aetna Life Insurance Company (Aetna). Each insurer has sole financial responsibility for its own products.

3 We want to make choosing the right benefits as easy as possible. So we ve organized information in this easy-to-understand guide NJ J (4/15) M D V L&D Health care reform 4 Plans, tools and extras 7 8 Network options, cost sharing and premiums 9 Health and wellness programs 10 Medical plans overview 11 Medical plan options 12 Savings Plus plans 18 Consumer-directed Savings Plus HSA-compatible plans 21 Traditional HMO and HNOnly plans 22 Consumer-directed HMO and HNOnly HSA-compatible plans 24 Traditional QPOS plan 25 Traditional HNOption plans 26 Consumer-directed HNOption HSA-compatible plans 29 Traditional OA EPO plans 31 Consumer-directed OA EPO HSA-compatible plan 32 Traditional Managed Choice (MC) plan 33 Traditional Open Access Managed Choice (OAMC) plans 34 Consumer-directed Open Access Managed Choice (OAMC) HSA-compatible plan 35 Traditional Indemnity plans 36 Dental plans overview 38 Aetna small group dental plans Aetna small group voluntary dental plans Aetna standard and voluntary dental plans Vision plans overview 54 Aetna Vision Preferred 56 Life and disability plans overview 59 Term life plan options 62 Packaged life and disability plan options 63 Limitations and exclusions 64 New business checklist 67 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 providers for amounts over 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. *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 Traditional HMO/ HNOnly/OA EPO plans with no Traditional HMO/ HNOnly/OA EPO plans with Consumerdirected HMO/ HNOnly/OA EPO HSA-compatible plans Traditional HNOption/OAMC plans with no in-network In network In network In network In network Out of network Preventive 0% 0%; 0%; 0% Not covered Dental checkup (a/k/a diagnostic) 0% 0%; 0% after 0% Not covered Dental basic 30% 30% after 30% after 30% Not covered Dental major 50% 50% after 50% after 50% Not covered Dental ortho 50% 50% after 50% after 50% Not covered Plan name Traditional QPOS/HNOption/MC/OAMC plans with in-network Consumer-Directed HNOption and OAMC HSA-Compatible plans Traditional Indemnity plan In network Out of network In network Out of network Out of network Preventive 0%; Not covered 0%; Not covered 0%; Dental checkup (a/k/a diagnostic) 0%; Not covered 0% after Not covered 0%; Dental basic 30% after Not covered 30% after Not covered 30% after Dental major 50% after Not covered 50% after Not covered 50% after Dental ortho 50% after Not covered 50% after Not covered 50% after These plans do not cover all 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 Pediatric vision Plan name Traditional HMO/ HNOnly/OA EPO plans with no Traditional HMO/ HNOnly/OA EPO plans with Consumerdirected HMO/ HNOnly/OA EPO HSA-compatible plans Traditional HNOption/OAMC plans with no in-network In network In network In network In network Out of network Vision exam (one exam per 12 months) Preferred eyeglass frames, prescription lenses or prescription contact lenses* Nonpreferred eyeglass frames, prescription lenses or prescription contact lenses* 0% 0%; 0%; 0% 50% after 0% 0%; 0% after 0% 50% after 50% 50% after 50% after 50% 50% after Plan name Traditional QPOS/HNOption/MC/OAMC plans with in-network Consumer-directed HNOption and OAMC HSA-compatible plans Traditional indemnity plan In network Out of network In network Out of network Out of network Vision exam (one exam per 12 months) Preferred eyeglass frames, prescription lenses or prescription contact lenses* Nonpreferred eyeglass frames, prescription lenses or prescription contact lenses* 0%; 50% after 0%; 50% after 0%; 0%; 50% after 0% after 50% after 0%; 50% after 50% after 50% after 50% after 50% after *The pediatric vision plan will cover the following for members through age 18: --One comprehensive eye examination by an in-network ophthalmologist or optometrist in a 12-month period --One set of eyeglass frames per 12 months --One pair of prescription lenses per 12 months --Prescription contact lenses, maximum per 12 months: daily disposables (up to three-month supply), extended wear disposable (up to six-month supply) and non-disposable lenses (one set) --Important Notes: This plan will cover either one pair of prescription lenses for eyeglass frames or prescription contact lenses, but not both, per 12 months These plans do not cover all vision expenses and have exclusions and limitations. Members should refer to their plan documents to determine which services are covered and to what extent. 6

7 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 offerings. Take a look at what s available. Medical plans Traditional plans Consumer-directed 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 be seeing 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 employees 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 members an estimate of what they would owe for a particular service based on their plan at that very point in time. Actual costs may differ from the estimate if, for example, claims for other services are processed after members get their estimate but before the claim for this service is submitted. Or, if the doctor or facility performs a different service at the time of the 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

8 Dental plans DMO PPO PPO Max Freedom-of-Choice plan design Preventive 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 Life and disability plans Basic term life insurance Packaged life and disability plans 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. 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. *These services are discount programs, not insurance. 8

9 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. 9

10 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 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 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. 10 * 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.

11 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 fit your budget and achieve the right balance of cost and coverage for your business. 11

12 M Medical overview At Aetna, we are committed to putting the employee at the center of everything we do. You can count on Aetna to provide health plans that help simplify decision making and plan administration so you can focus on the health of your business. New Jersey provider network* All plans are available in all New Jersey counties. Northeast Region Small Group Sales Support Center: Atlantic Camden Essex Hunterdon Monmouth Passaic Sussex Bergen Cape May Gloucester Mercer Morris Salem Union Burlington Cumberland Hudson Middlesex Ocean Somerset Warren Product information Plan name Product description PCP required Referrals required Network Aetna HMO Aetna Health Network Only SM (HNOnly) A health maintenance organization (HMO) uses a network of participating providers. Each family member selects a primary care physician (PCP) participating in our network. The PCP provides routine and preventive care and helps coordinate the member s total health care. The PCP refers members to participating specialists and facilities for medically necessary specialty care. Only services provided or referred by the PCP are covered except for emergency, urgently needed care or direct-access benefits, unless approved by the HMO in advance of receiving services. Aetna Health Network Only (HNOnly) is a health maintenance organization plan that uses a network of participating providers. Each family member may select a primary care physician (PCP) participating in the Aetna network to provide routine and preventive care and help coordinate the member s total health care. Members never need a referral when visiting a participating specialist for covered services. Only services rendered by a participating provider are covered, except for emergency or urgently needed care. Yes Yes HMO Optional No Aetna Health Network Only (Open Access) Aetna QPOS The Aetna QPOS plan is a two-tiered product that allows members to access care in one of two ways: 1. PCP referred to network care, or 2. Self-referred to network or non-network care Members have lower out-of-pocket costs when they use the HMO (referred) tier of the plan and follow the PCP referral process. Member cost sharing increases if members decide to self-refer to network or non-network care. Yes Yes, for PCP referred care; no, for self-referred care QPOS 12 *Network subject to change.

13 M Product information Plan name Product description PCP required Referrals required Network Aetna Health Network Option SM (HNOption) Aetna Open Access Elect Choice (OA EPO) Aetna Health Network Option (HNOption) is a two-tiered product that allows members to access care in or out of network. Members have lower out-of-pocket costs when they use the in-network tier of the plan. Member cost sharing increases if members decide to go out of network. Members may go to their PCP or directly to a participating specialist without a referral. It is their choice, each time they seek care. The Aetna Open Access Elect Choice plan provides a networkbased managed care product with comprehensive health care benefits. Members are not required to select a PCP to coordinate their care or to obtain referrals for specialty care. Only services rendered by a network provider are covered, except for emergency or urgently needed care. Optional No Aetna Health Network Option (Open Access) Optional No Elect Choice EPO (Open Access) Aetna Managed Choice (MC) Our Managed Choice POS plan provides all the benefits of a managed care plan combined with the freedom to visit a doctor or hospital of choice. The plan combines cost-control features with member flexibility to choose quality health care providers. MC is a POS product, and members are still required to select a PCP to coordinate their care and obtain referrals for specialty care. Yes Yes, for PCP referred care; no, for self-referred care Managed Choice POS Aetna Open Access Managed Choice (OA MC) Aetna Indemnity Managed Choice members can access any recognized provider for covered services without a referral. Each time members seek health care, they have the freedom to choose either network providers at lower out-of-pocket costs, or non-network providers at higher out-of-pocket costs. The Aetna 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. Optional No Managed Choice POS (Open Access) No No N/A 13

14 M Aetna high HSA-compatible plans These health plan options are compatible with a health savings account (HSA). HSA-compatible plans provide integrated medical and pharmacy benefits. Preventive care services are 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. HSAs can be funded by the employer and/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 an 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. Financial support for out-of-pocket costs Our consumer-directed health products and services give members the information and resources they need to help make informed health care decisions for themselves and their families while helping lower employers costs.** 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. Investment services are independently offered through HealthEquity, Inc. Aetna HealthFund HRAs are subject to employer-defined use and forfeiture rules, and are unfunded liabilities of your employer. Fund balances are not vested benefits. 14

15 Group situs Medical and dental benefits and rates are based on the group s headquarters location, subject to applicable state laws. Eligible employees who live or work in CT, DC, DE, MD, ME NJ, NY, PA and VA (the situs region) will receive the same rates and benefits as the headquarters location. Multi-state solution We offer a multi-state solution to make it easier for businesses like yours to do business with us. We believe it brings more consistency across medical benefits offerings to employers with employees in multiple locations. Employers based in New Jersey can offer NJ OA EPO and OAMC plans to their employees who live and work outside of the situs region. The situs region comprises the following eight states: CT, DC, DE, MD, NJ, NY, PA and VA. The rates and benefits will match those offered in New Jersey. If the out-of-situs employee lives in a non-network area, the employee will be enrolled in an indemnity plan. Plan sponsors will need to continue to meet underwriting guidelines, subject to all applicable state laws. In all instances, extraterritorial benefits that may apply on any of the out-of-situs employees will be implemented where required. 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 $285 Monthly fees *** $5.45 per participant Additional set-up fee for stacked plans (those electing an Aetna HRA and FSA simultaneously) Participation fee for stacked participants $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 $165 Per employee per month Employees $0.95 Initial notice fee $3.00 per notice (includes notices at time of implementation and during ongoing administration) Minimum fees Employees $25 per month minimum Transit reimbursement account (TRA) Annual fee $350 Transit monthly fees $4.25 per participant Parking monthly fees $3.15 per participant M * 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 Aetna for further 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. Aetna reserves the right to change any of the above fees and to impose additional fees upon prior written notice. 15

16 M The health of business, well planned Same quality local care at a lower cost The Aetna Savings Plus health benefits plans provide members with the same type of coverage as other Aetna medical plans, but at a lower premium cost. Cost savings are generated when members use the Savings Plus network The Aetna Savings Plus plans in New Jersey give small businesses the flexibility and choice to best meet their needs. Members are encouraged to use the Aetna New Jersey Savings Plus network. For open-access Health Network Only (HNOnly) plans, members have the freedom to receive care from any hospital or specialist. Members realize the highest benefit level and lowest out-of-pocket costs when they access care through the Savings Plus designated providers. All Savings Plus plans include coverage for doctors visits, hospital stays, preventive care and more. Refer to pages for more details. Each Savings Plus plan has two levels of network benefits: Level 1: When members use the Savings Plus network, they realize maximum savings. Level 2: When members use non-designated network providers, they will see standard savings and higher member costs. The Savings Plus plans do not provide benefits for non-network providers. For referral-based HMO plans, members can select a primary care physician (PCP) from the network of designated network providers to coordinate care for covered services. A smarter network strategy You and your employees save money through a designated network of quality, cost-effective doctors and hospitals. Employees can access helpful decision-making tools and services through their secure member website. Fair value Flexibility Freedom Everyone wants a good deal. Whether you re looking to cut costs as much as possible, or seeking long-term value and greater employee productivity. Choice matters. Every business is different. And the people who make up those businesses have different health needs. Time spent investing with a health plan, should be time well spent. Whether you re managing the business, or an employee on the front line. We try to make it easier with intelligent solutions. Network design = savings Performance network 100 percent preventive care Unlimited lifetime maximums Range of options Multiple benefit levels Use of any physician or hospital Online enrollment and billing Easy to navigate Personal health record Member Payment Estimator 16

17 Savings Plus service area M Savings Plus service areas in New Jersey and New York New Jersey New York Ulster County Sullivan County Dutchess County Orange County Putnam County Rockland County Westchester County The Bronx Manhattan Brooklyn Staten Island Queens Suffolk County Nassau County 17

18 M Savings Plus plans Plan name Referral plan Open access plan NJ Gold Savings Plus HMO /50 (0715) NJ Gold Savings Plus HNOnly /50 (0715) NJ Silver Savings Plus HMO /50 (0715) NJ Silver Savings Plus HNOnly /50 (0715) Member benefits Level 1 Savings Plus designated providers maximum savings Level 2 Savings Plus nondesignated participating providers standard savings Level 1 Savings Plus designated providers maximum savings Level 2 Savings Plus nondesignated participating providers standard savings Benefit year $500/$1,000 $2,000/$4,000 $1,000/$2,000 $1,000/$2,000 Benefit out-of-pocket limit $5,000/$10,000 $5,000/$10,000 $6,000/$12,000 $6,000/$12,000 Deductible & out-of-pocket limit accumulation1 True integrated family (TIF) True integrated family (TIF) Primary care physician office visit Specialist office visit Walk-in clinics Diagnostic testing: Lab $35 copay; $50 copay; $35 copay; Covered in full; 50% after $35 copay; 50% after $50 copay; Paid at the designated level Paid at the designated level $35 copay; Covered in full; 50% after 50% after Paid at the designated level Paid at the designated level Diagnostic testing: X-ray 10% after Paid at the designated level 40% after Paid at the designated level Imaging (CT/PET scans, MRIs) 10% after 50% after 40% after 50% after Inpatient hospital facility 10% after 50% after 40% after 50% after Outpatient surgery: Ambulatory surgical center or facility (ASC) and hospital outpatient facility Emergency room Urgent care Rehabilitation services (PT/OT/ST)2 Coverage limited to 30 visits per calendar year, PT/OT combined. Coverage limited to 30 visits per calendar year, ST/CT combined. Chiropractic2 Coverage is limited to 30 visits per calendar year 10% after 50% after 40% after 50% after $ % after $50 copay; Paid at the designated level Paid at the designated level $ % after $50 copay; Paid at the designated level Paid at the designated level 10% after Paid at the designated level 40% after Paid at the designated level 25% after Paid at the designated level 25% after Paid at the designated level Pharmacy4 Network Network Pharmacy None None Generic drugs $20 copay $20 copay Preferred brand drugs 50% up to $125 50% up to $125 Nonpreferred brand drugs 50% up to $150 50% up to $150 Specialty drugs Applicable cost share as noted above for generic or brand drugs Applicable cost share as noted above for generic or brand drugs Service areas: Plans are offered in northern New Jersey (S1 service area) and southern New Jersey (S2 service area). Refer to page 37 for footnotes. 18

19 Savings Plus plans M Plan name Referral plan Open access plan NJ Silver Savings Plus HMO /50 (0715) NJ Silver Savings Plus HNOnly /50 (0715) NJ Silver Savings Plus HMO /50 (0715) NJ Silver Savings Plus HNOnly /50 (0715) Member benefits Level 1 Savings Plus designated providers maximum savings Level 2 Savings Plus nondesignated participating providers standard savings Level 1 Savings Plus designated providers maximum savings Level 2 Savings Plus nondesignated participating providers standard savings Benefit year $1,000/$2,000 $2,000/$4,000 $1,500/$3,000 $1,500/$3,000 Benefit out-of-pocket limit $6,000/$12,000 $6,000/$12,000 $6,000/$12,000 $6,000/$12,000 Deductible & out-of-pocket limit accumulation1 True integrated family (TIF) True integrated family (TIF) Primary care physician office visit Specialist office visit Walk-in clinics Diagnostic testing: Lab $35 copay; $50 copay; $35 copay; Covered in full after 50% after $35 copay; 50% after $50 copay; Paid at the designated level Paid at the designated level $35 copay; Covered in full after 50% after 50% after Paid at the designated level Paid at the designated level Diagnostic testing: X-ray 30% after Paid at the designated level 30% after Paid at the designated level Imaging (CT/PET scans, MRIs) 30% after 50% after 30% after 50% after Inpatient hospital facility 30% after 50% after 30% after 50% after Outpatient surgery: Ambulatory surgical center or facility (ASC) and hospital outpatient facility Emergency room Urgent care Rehabilitation services (PT/OT/ST)2 Coverage limited to 30 visits per calendar year, PT/OT combined. Coverage limited to 30 visits per calendar year, ST/CT combined. Chiropractic2 Coverage is limited to 30 visits per calendar year 30% after 50% after 30% after 50% after $ % after $50 copay; Paid at the designated level Paid at the designated level $ % after $50 copay; Paid at the designated level Paid at the designated level 30% after Paid at the designated level 30% after Paid at the designated level 25% after Paid at the designated level 25% after Paid at the designated level Pharmacy4 Network Network Pharmacy None None Generic drugs $20 copay $20 copay Preferred brand drugs 50% up to $125 50% up to $125 Nonpreferred brand drugs 50% up to $150 50% up to $150 Specialty drugs Applicable cost share as noted above for generic or brand drugs Applicable cost share as noted above for generic or brand drugs Service areas: Plans are offered in northern New Jersey (S1 service area) and southern New Jersey (S2 service area). Refer to page 37 for footnotes. 19

20 M Savings Plus plans Plan name Referral plan Open access plan NJ Silver Savings Plus HMO /50 (0715) NJ Silver Savings Plus HNOnly /50 (0715) Member benefits Level 1 Savings Plus designated providers maximum savings Level 2 Savings Plus nondesignated participating providers standard savings Benefit year $2,000/$4,000 $2,000/$4,000 Benefit out-of-pocket limit $6,000/$12,000 $6,000/$12,000 Deductible & out-of-pocket limit accumulation1 Primary care physician office visit Specialist office visit Walk-in clinics Diagnostic testing: Lab $35 copay; $50 copay; $35 copay; Covered in full; True integrated family (TIF) 50% after 50% after Paid at the designated level Paid at the designated level Diagnostic testing: X-ray 30% after Paid at the designated level Imaging (CT/PET scans, MRIs) 30% after 50% after Inpatient hospital facility 30% after 50% after Outpatient surgery: Ambulatory surgical center or facility (ASC) and hospital outpatient facility Emergency room Urgent care Rehabilitation services (PT/OT/ST)2 Coverage limited to 30 visits per calendar year, PT/OT combined. Coverage limited to 30 visits per calendar year, ST/CT combined. Chiropractic2 Coverage is limited to 30 visits per calendar year Pharmacy4 Pharmacy Generic drugs 30% after 50% after $ % after $50 copay; Paid at the designated level Paid at the designated level 30% after Paid at the designated level 25% after Paid at the designated level Network None $20 copay Preferred brand drugs 50% up to $125 Nonpreferred brand drugs 50% up to $150 Specialty drugs Applicable cost share as noted above for generic or brand drugs Service areas: Plans are offered in northern New Jersey (S1 service area) and southern New Jersey (S2 service area). Refer to page 37 for footnotes. 20

21 Consumer-directed Savings Plus HSA-compatible plans M Plan name Referral plan Open access plan NJ Silver Savings Plus HMO /50% HSA (0715) NJ Silver Savings Plus HNOnly /50% HSA (0715) Member benefits Level 1 Savings Plus designated providers maximum savings Level 2 Savings Plus nondesignated participating providers standard savings Benefit year $1,650/$3,300 $1,650/$3,300 Benefit out-of-pocket limit $6,000/$12,000 $6,000/$12,000 Deductible & out-of-pocket limit accumulation1 Primary care physician office visit True integrated family (TIF) $35 copay after 50% after Specialist office visit 30% after 50% after Walk-in clinics Diagnostic testing: Lab $35 copay after Paid at the designated level Covered in full after Paid at the designated level Diagnostic testing: X-ray 30% after Paid at the designated level Imaging (CT/PET scans, MRIs) 30% after 50% after Inpatient hospital facility 30% after 50% after Outpatient surgery: Ambulatory surgical center or facility (ASC) and hospital outpatient facility Emergency room 30% after 50% after $ % after Paid at the designated level Urgent care 30% after Paid at the designated level Rehabilitation services (PT/OT/ST)2 Coverage limited to 30 visits per calendar year, PT/OT combined. Coverage limited to 30 visits per calendar year, ST/CT combined. Chiropractic2 Coverage is limited to 30 visits per calendar year Pharmacy4 Pharmacy Generic drugs Preferred brand drugs Nonpreferred brand drugs Specialty drugs 30% after Paid at the designated level 25% after Paid at the designated level Network Integrated with medical $10 copay after $40 copay after 50% up to $150 after Applicable cost share as noted above for generic or brand drugs Service areas: Plans are offered in northern New Jersey (S1 service area) and southern New Jersey (S2 service area). Benefit year: Plans are available on a calendar-year or plan-year basis. Refer to page 37 for footnotes. 21

22 M Traditional HMO and HNOnly plans Plan name Referral plan NJ Gold HMO 500D (0715) NJ Gold HMO 70% (0715) NJ Gold HMO % 10/40/75 Rx (0715) Open access plan NJ Gold HNOnly 500D (0715) NJ Gold HNOnly 70% (0715) NJ Gold HNOnly % 10/40/75 Rx (0715) Member benefits Network care Network care Network care Benefit year $0/$0 $0/$0 $1,500/$3,000 Benefit out-of-pocket limit $6,000/$12,000 $6,000/$12,000 $3,500/$7,000 Deductible & out-of-pocket limit accumulation1 True integrated family (TIF) True integrated family (TIF) True integrated family (TIF) Primary care physician office visit $30 copay $30 copay $20 copay; Specialist office visit $50 copay $50 copay $40 copay; Walk-in clinics $30 copay $30 copay $20 copay; Diagnostic testing: Lab $15 copay $10 copay $5 copay; Diagnostic testing: X-ray $50 copay $50 copay $40 copay; Imaging (CT/PET scans, MRIs) 30% 30% 30%; Inpatient hospital facility Outpatient surgery: Ambulatory surgical center or facility (ASC) and/or hospital outpatient facility $500 copayment per day to a maximum of $2,500 per admission $250 copay at ASC; $500 copay at hospital 30% 30% after 30% 30% after Emergency room (copay if admitted) $ % $ % $ %; Urgent care $50 copay $50 copay $40 copay; Rehabilitation services (PT/OT/ST) Coverage limited to 30 visits per calendar year, PT/OT combined. Coverage limited to 30 visits per calendar year, ST/CT combined. Chiropractic Coverage is limited to 30 visits per calendar year $20 copay $10 copay $20 copay; 25% 25% 25%; Pharmacy4 Network Network Network Pharmacy None None None Generic drugs $20 copay $20 copay $10 copay Preferred brand drugs $50 copay $50 copay $40 copay Nonpreferred brand drugs $75 copay $75 copay $75 copay Specialty drugs Applicable cost share as noted above for generic or brand drugs Applicable cost share as noted above for generic or brand drugs Applicable cost share as noted above for generic or brand drugs Refer to page 37 for footnotes. 22

23 Traditional HMO and HNOnly plans M Plan name Referral plan NJ Gold HMO % 20/50/75 Rx (0715) NJ Silver HMO % (0715) NJ Silver HMO % (0715) Open access plan NJ Gold HNOnly % 20/50/75 Rx (0715) NJ Silver HNOnly % (0715) Not Available Member benefits Network care Network care Network care Benefit year $1,500/$3,000 $2,000/$4,000 $2,000/$4,000 Benefit out-of-pocket limit $3,500/$7,000 $6,000/$12,000 $5,000/$10,000 Deductible & out-of-pocket limit accumulation1 True integrated family (TIF) True integrated family (TIF) Embedded Primary care physician office visit $20 copay; $30 copay; 30% after Specialist office visit $40 copay; $50 copay; 30% after Walk-in clinics $20 copay; $30 copay; 30% after Diagnostic testing: Lab $5 copay; $15 copay; 30% after Diagnostic testing: X-ray $40 copay; $50 copay; 30% after Imaging (CT/PET scans, MRIs) 30%; 50%; 30% after Inpatient hospital facility 30% after 50% after 30% after Outpatient surgery: Ambulatory surgical center or facility (ASC) and/or hospital outpatient facility 30% after 50% after 30% after Emergency room (copay if admitted) $ %; $ %; $ % after Urgent care $40 copay; $50 copay; $75 after Rehabilitation services (PT/OT/ST) Coverage limited to 30 visits per calendar year, PT/OT combined. Coverage limited to 30 visits per calendar year, ST/CT combined. Chiropractic Coverage is limited to 30 visits per calendar year $20 copay; $20 copay; 30% after 25%; 25%; 25% after Pharmacy4 Network Network Network Pharmacy None None None Generic drugs $20 copay $20 copay $20 copay Preferred brand drugs $50 copay $50 copay $50 copay Nonpreferred brand drugs $75 copay $75 copay $75 copay Specialty drugs Applicable cost share as noted above for generic or brand drugs Applicable cost share as noted above for generic or brand drugs Applicable cost share as noted above for generic or brand drugs Refer to page 37 for footnotes. 23

24 M Consumer-directed HMO and HNOnly HSA-compatible plans NJ Bronze HMO % HSA (0715) Plan name NJ Silver HMO % HSA (0715) NJ Silver HNOnly /50/75 Rx HSA (0715) NJ Silver HNOnly % HSA (0715) NJ Bronze HNOnly % HSA (0715) Member benefits Network care Network care Network care Network care Benefit year $2,000/$4,000 $2,000/$4,000 $2,000/$4,000 $2,500/$5,000 Benefit out-of-pocket limit $6,350/$12,700 $4,000/$8,000 $6,350/$12,700 $6,350/$12,700 Deductible & out-of-pocket limit accumulation1 True integrated family (TIF) True integrated family (TIF) True integrated family (TIF) True integrated family (TIF) Primary care physician office visit Specialist office visit Walk-in clinics Covered in full after Covered in full after Covered in full after $30 copay after 10% after 50% after $50 copay after 10% after 50% after $30 copay after 10% after 50% after Diagnostic testing: Lab $15 copay after $15 copay after 10% after 50% after Diagnostic testing: X-ray $50 copay after $50 copay after 10% after 50% after Imaging (CT/PET scans, MRIs) Inpatient hospital facility Outpatient surgery: Ambulatory surgical center or facility (ASC) and/or hospital outpatient facility Covered in full after Covered in full after Covered in full after 30% after 10% after 50% after $400 copay per day to a maximum of $2,000 per admission after $200 copay after Emergency room $100 after $ % after Urgent care Rehabilitation services (PT/OT/ST) Coverage limited to 30 visits per calendar year, PT/OT combined. Coverage limited to 30 visits per calendar year, ST/CT combined. Chiropractic Coverage is limited to 30 visits per calendar year Covered in full after 10% after 50% after 10% after 50% after $ % after $ % after $50 after 10% after 50% after $20 copay after $20 copay after 10% after 50% after Covered in full after 25% after 10% after 25% after Pharmacy4 Network Network Network Network Pharmacy Generic drugs Preferred brand drugs Nonpreferred brand drugs Specialty drugs Integrated with medical Integrated with medical Integrated with medical Integrated with medical $20 copay after $20 copay after $20 copay after 50% after $50 copay after $50 copay after $50 copay after 50% after $75 copay after $75 copay after $75 copay after 50% after Applicable cost share as noted above for generic or brand drugs Applicable cost share as noted above for generic or brand drugs Applicable cost share as noted above for generic or brand drugs Applicable cost share as noted above for generic or brand drugs Benefit year: Plans are available on a calendar-year or plan-year basis. Refer to page 37 for footnotes. 24

25 Traditional QPOS plan M Plan name NJ Silver QPOS /50 (0715) Member benefits Network care Out-of-network care Benefit year $2,000/$4,000 $5,000/$10,000 Benefit out-of-pocket limit $5,000/$10,000 $10,000/$20,000 Deductible & out-of-pocket limit accumulation1 Embedded Primary care physician office visit 30% after 50% after Specialist office visit 30% after 50% after Walk-in clinics 30% after 50% after Diagnostic testing: Lab 30% after 50% after Diagnostic testing: X-ray 30% after 50% after Imaging (CT/PET scans, MRIs) 30% after 50% after Inpatient hospital facility 30% after 50% after Outpatient surgery: Ambulatory surgical center or facility (ASC) and/or hospital outpatient facility Emergency room (Copay if admitted) Urgent care Rehabilitation services (PT/OT/ST)3 Coverage limited to 30 visits per calendar year, PT/OT combined. Coverage limited to 30 visits per calendar year, ST/CT combined. Chiropractic3 Coverage is limited to 30 visits per calendar year 30% after 50% after $ % after Paid as network care $75 copay after Paid as network care 30% after 50% after 25% after 25% after Pharmacy4 Network Out of network Pharmacy None None Generic drugs $20 copay Not covered Preferred brand drugs $50 copay Not covered Nonpreferred brand drugs $75 copay Not covered Specialty drugs Applicable cost share as noted above for generic or brand drugs Not covered Refer to page 37 for footnotes. 25