Pennsylvania Plan guide

Transcription

1 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Pennsylvania Plan guide The health of business, well planned. Plans effective August 1, 2012 For businesses with eligible employees PA B (7/12)

2 PA B (7/12) Team with Aetna for the health of your business Introducing a new suite of products and services designed specifically for companies with 2 to 100 eligible employees. Health benefits and health insurance, dental benefits/dental insurance, life insurance, and disability insurance plans/policies are offered, underwritten, and/or administered by Aetna Health Inc., Aetna Health Insurance Company, and/or Aetna Life Insurance Company (Aetna). Each insurer has sole financial responsibility of its own products.

3 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 PA B (7/12) Aetna is committed to helping employers build healthy businesses. In today s rapidly changing economy, we recognize the need for less expensive, less complex health plan choices. Now, Aetna offers a variety of newly streamlined medical and dental benefits and insurance plans to provide more affordable options and to help simplify plan selection and administration. In this guide: 5 Small-business commitment 5 Benefits for every stage of life 6 Medical overview 8 Managing health care expenses 10 Medical plan options 35 Dental overview 36 Dental plan options 47 Life & disability overview 49 Life & disability plan options 51 Underwriting guidelines 60 Product specifications 69 Limitations and exclusions 3

4 Employers and their employees can benefit from Affordable plan options Online self-service tools and capabilities Enhanced services for consumer-directed health plans 24-hour access to Employee Assistance Program services Preventive care covered 100% Aetna disease management and wellness programs With Aetna, we know it s about... Options We provide a variety of health plan options to help meet your employees needs, including medical, dental, disability and life insurance. And, with access to a wide network of health care providers, you can be sure that employees have options in how they access their health care. Medical plans Cost-sharing plans Consumer-directed plans Traditional plans Dental plans DMO PPO PPO Max Freedom-of-Choice plan design option Life and disability plans Basic life Supplemental life AD&D Ultra Supplemental AD&D Ultra Dependent life Packaged life and disability plans Short-term disability Long-term disability Simplicity We know that the health of your business is your top priority. Aetna s streamlined plans and variety of services make it easier for you to focus on your business by simplifying administration and management. Aetna makes it easy to manage health insurance benefits with simplified enrollment, billing and claims processing so you can focus on what matters most. Trust We work hard to provide health plan solutions you can trust. Our account executives, underwriters and customer service representatives are committed to providing small businesses and their employees with service and care they can trust. Aetna resources are designed to fortify the health of your business Track medical claims and take advantage of online services with your Aetna Navigator secure member website. It features automated enrollment, personal health records and printable temporary member ID cards. Get real cost and health information to help make the right care decision with an online Cost of Care Estimator. Manage health records online with the Personal Health Record. Use the Aetna Health Connections SM Disease Management Program, which provides personal support to members to help them manage their conditions. Leverage 24/7 access to a nurse to help with personal health-related questions. Help members work toward health goals with wellness initiatives, such as the Simple Steps To A Healthier Life online program. Take advantage of discount programs for vision, dental, and general health care that encourage use of plan offerings. 4

5 Aetna is committed to the health of your business We understand that your business has unique needs. That s why we have streamlined our plan options for employers with 2 to 100 employees. We are committed to providing you with value and quality you can count on. Our variety of products and services allows you to focus on the health of your business. Aetna s health plan options are designed with the health of your business in mind Basic plans Basic benefits for your employees Limit the expense to your business Allow employees to buy up and share more of the cost --PA POS 5.7 CY (30/400D) --PA POS CS 2.7 CY (1000 Ded) --PA POS CS 1.7 CY (500 Ded) Value plans Encourage employee responsibility in their health care decisions Tools and resources to support consumerism Innovative plan design --PA POS CS 4.7 CY (2000 Ded) --PA POS HSA Comp NR 1.7 PY (1500 Ded) --PA Health Network Option AHF HRA 2.7 PY (2500 Ded) Traditional plans Traditional benefits plans Limit the financial impact on employees --PA POS 2.7 CY (10/500A) --PA POS 3.7 CY (15/200D) Health insurance benefits for every stage of life For young individuals and couples without children Lower monthly payments Modest out-of-pocket costs Quality preventive care Prescription drug coverage Financial protection Consumer-directed plans For married couples and single parents with teens and college-aged children Checkups and care for injuries and illness Preventive care and screenings that promote a healthy lifestyle National network of health care providers Cost-sharing plans For married couples and single parents with young children or teens Lower fees for office visits Lower monthly payments Caps on out-of-pocket expenses Quality preventive care for the entire family Traditional plans For men and women 55 years of age and over with no children at home Financial security Quality prescription drug coverage Hospital inpatient/outpatient services Emergency care Cost-sharing plans Consumer-directed plans 5

6 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. Pennsylvania provider network* POS, Health Network Option & PPO Plans Adams Clarion Lackawanna Allegheny Clinton Lancaster Armstrong Columbia Lawrence Beaver Cumberland Lebanon Bedford Dauphin Lehigh Berks Delaware Luzerne Blair Erie Lycoming Bradford Fayette Mercer Bucks Franklin Monroe Butler Fulton Montgomery Cambria Greene Northampton Carbon Indiana Perry Chester Jefferson Philadelphia Pike Schuylkill Snyder Somerset Sullivan Susquehanna Venango Washington Wayne Westmoreland Wyoming York PPO Plans Only Cameron Union Centre Warren Clearfield Crawford Elk Forest Huntingdon Juniata McKean Mifflin Montour Potter Tioga Product Information Plan Name Product Description PCP Required Referrals Required Network Aetna POS The Aetna POS plan is a two-tiered product that allows members to access care in one of two ways: PCP-referred, in network or Self-referred, in or out of network 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 in or out of network. Yes Yes for PCP-referred care. No for self-referred care. QPOS Aetna POS No-Referral The Aetna POS No-Referral plan 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. Yes/ Optional No Aetna Choice POS (Open Access) *Network subject to change. 6

7 Product Information (continued) Plan Name Product Description PCP Required Referrals Required Network Aetna Health Network Option SM (Aetna HealthFund ) The Aetna HealthFund plan blends traditional health coverage with a fund benefit to help pay for eligible medical expenses. This health insurance plan offers members the freedom to seek care from any licensed health care professional without a referral, and a fund to help pay for services that are covered under the plan. Members can stretch their fund by seeking the most cost-effective care and services. The Aetna HealthFund plan provides: An opportunity to build the fund and apply it toward future medical expenses. Traditional coverage for eligible expenses over the fund amount. A cap that limits the total amount a member pays annually for eligible expenses. Yes/ Optional No Aetna HealthFund Aetna Health Network Option SM (Open Access) How it works: Use the health fund to pay for medical expenses. Unused fund balance rolls over to next year s fund balance, as long as the member remains in the plan and with his or her current employer. If the fund is depleted, the member pays for remaining or future expenses until the deductible is met. If the fund is depleted and the deductible is met, the base medical benefits plan begins meaning the member pays a coinsurance and/or copayment for remaining covered expenses. Aetna PPO Aetna Indemnity PPO plan 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. 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 7

8 Administrative Fees Fee description HSA Initial set-up $0 Monthly fees $0 POP* Fee Initial set-up $175 Renewal $100 HRA and FSA** Initial set-up 2 25 employees $ employees $ employees $550 Renewal fee 1 25 employees $ employees $ employees $325 Monthly fees*** $5.25 per participant Additional set-up fee for stacked plans $150 (those electing an Aetna HRA and FSA simultaneously) Participation fee for stacked participants $10.25 per participant Minimum fees 1 25 employees $25 per month minimum employees $50 per month minimum TRA Annual fee $350 Transit monthly fees $4.25 per participant Parking monthly fees $3.15 per participant COBRA Annual fee employees $ employees $175 Per employee per month employees $ employees $1.02 Initial notice fee $1.50 per notice (includes notices at time of implementation and during ongoing administration) Aetna High-Deductible HSA-Compatible Health Network Option (Open Access)/PPO plans Aetna high-deductible HSA-compatible health network option (open access) and 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 deductible. 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 or employee and are portable. Fund contributions may be tax-deductible (limits apply). When funds are used to cover qualified out-of-pocket medical and dental expenses, they are not taxed. Note: Employers and employees should consult with their tax advisor to determine eligibility requirements and tax advantages for participation in the HSA plan. 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, 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 Pennsylvania can offer PA PPO 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 Pennsylvania. 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. Monthly fee $0.88 per employee * Non-discrimination testing provided annually after open enrollment for POP and FSA only. Additional off-cycle testing available at employer request for $100 fee. Non-discrimination 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 HealthFund HRAs are subject to employer-defined use and forfeiture rules, and are unfunded liabilities of your employer. Fund balances are not vested benefits. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Information is subject to change. Aetna reserves the right to change any of the above fees and to impose additional fees upon prior written notice. 8

9 Health Savings Account (HSA) No set-up or administrative fees The Aetna HealthFund HSA, when coupled with a HSA-compatible high-deductible 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. Member s HSA plan HSA Advantages You own your HSA Contribute tax free You choose how and when to use your dollars Roll it over each year and let it grow Earns interest, tax free Today Use for qualified expenses with tax-free dollars Future Plan for future and retiree health-related costs High-deductible health plan Eligible in-network preventive care services will not be subject to the deductible You pay 100% until deductible is met, then only pay a share of the cost Meet out-of-pocket maximum, then plan pays 100% 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. 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. Health Reimbursement Arrangement (HRA) The Aetna HealthFund HRA combines the protection of a deductible-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. The fund is available to an employee for qualified expenses on the plan s effective date. The HRA and the HSA provide members with financial support for higher out-of-pocket health care expenses. Aetna s 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. 9

10 Traditional - POS Plan Options Plan Options PA POS 1.7 CY (10/0A) + * PA POS 2.7 CY (10/500A) + * # Member Benefits In-network Out-of-network 1 In-network Out-of-network 1 PCP coordinated No-referral needed PCP coordinated No-referral needed 1 Benefit/Plan Administration Calendar year Calendar year Calendar year Calendar year 2 Member Coinsurance N/A 20% after ded N/A 20% after ded 3 Calendar Year Deductible 2 N/A $1,000 per member $3,000 family 4 Calendar Year Out-of-Pocket Maximum 3 $3,000 per member $6,000 family $5,000 per member $15,000 family N/A $3,000 per member $6,000 family $1,000 per member $3,000 family $5,000 per member $15,000 family 5 Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited 6 Preventive Care 7 Well-Baby/Child/Adult Physical Exams (Age and frequency schedules apply. In-network and out-of-network combined) 8 Routine Gyn Exams (One exam and pap smear per 365 days. In-network and out-of-network combined)) 9 Routine Mammograms (One annual mammogram for females age 40 and over. In-network and out-of-network combined) 10 Routine Eye Exam (One exam per 24 months. $0 copay 20%, ded waived $0 copay 20%, ded waived $0 copay 20%, ded waived $0 copay 20%, ded waived $0 copay 20% after ded $0 copay 20% after ded $0 copay 20% after ded $0 copay 20% after ded 11 Glasses and Contact Lens Reimbursement $100/24-month period. In-network and out-of-network combined. 12 Aetna Vision SM Discount Program Included Not covered Included Not covered 13 Primary Physician Office Visit $10 copay 20% after ded $10 copay 20% after ded 14 Specialist Office Visit $20 copay 20% after ded $20 copay 20% after ded 15 Outpatient Services - Lab / X-ray $0 copay / $20 copay 20% after ded $0 copay / $20 copay 20% after ded 16 Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) 17 Chiropractic Services (20 visits per calendar year. 18 Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per calendar year. In-network and out-of-network combined) 19 Outpatient Speech Therapy (30 visits per calendar year. 20 Durable Medical Equipment ($2,500 calendar year maximum. $200 copay 20% after ded $200 copay 20% after ded $10 copay 20% after ded $10 copay 20% after ded $20 copay 20% after ded $20 copay 20% after ded $20 copay 20% after ded $20 copay 20% after ded 50% 50% after ded 50% 50% after ded 21 Inpatient Hospital $0 copay per admission 20% after ded $500 copay per admission 20% after ded 22 Outpatient Surgery $0 copay 20% after ded $500 copay 20% after ded 23 Emergency Room (Copay waived if admitted) $100 copay $100 copay, ded waived $150 copay $150 copay, ded waived 24 Urgent Care $50 copay 20% after ded $50 copay 20% after ded 25 Prescription Drugs (Includes 90-day transition of coverage (TOC) for prior authorization and step-therapy 4 ) 26 Prescription Drugs: 30-day supply 5 Option 1: $10/$25/$50 Option 2: $10/$35/$60 Option 3: $15/$45/$75 27 Prescription Drugs: 31- to 90-day supply 5 Option 1: $20/$50/$100 Option 2: $20/$70/$120 Option 3: $30/$90/$150 Not covered Option 1: $10/$25/$50 Option 2: $10/$35/$60 Option 3: $15/$45/$75 Not covered Option 1: $20/$50/$100 Option 2: $20/$70/$120 Option 3: $30/$90/$150 Not covered Not covered 28 Aetna Specialty CareRx SM Drugs: 30-day supply $250 copay Not covered $250 copay Not covered 29 *Optional Features: No-referral option 6 : PA POS NR 1.7 CY (10/0A) No-referral option 6 : PA POS NR 2.7 CY (10/500A) See pages for important plan provisions. 10

11 Traditional - POS Plan Options Plan Options PA POS 3.7 CY (15/200D) + * PA POS 4.7 CY (20/300D) + * # Member Benefits In-network Out-of-network 1 In-network Out-of-network 1 PCP coordinated No-referral needed PCP coordinated No-referral needed 1 Benefit/Plan Administration Calendar year Calendar year Calendar year Calendar year 2 Member Coinsurance N/A 30% after ded N/A 50% after ded 3 Calendar Year Deductible 2 N/A $3,000 per member $9,000 family 4 Calendar Year Out-of-Pocket Maximum 3 $3,000 per member $6,000 family $7,500 per member $22,500 family N/A $3,000 per member $6,000 family $5,000 per member $15,000 family 5 Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited 6 Preventive Care 7 Well-Baby/Child/Adult Physical Exams (Age and frequency schedules apply. In-network and out-of-network combined) 8 Routine Gyn Exams (One exam and pap smear per 365 days. In-network and out-of-network combined) 9 Routine Mammograms (One annual mammogram for females age 40 and over. In-network and out-of-network combined) 10 Routine Eye Exam (One exam per 24 months. $10,000 per member $30,000 family $0 copay 30%, ded waived $0 copay 50%, ded waived $0 copay 30%, ded waived $0 copay 50%, ded waived $0 copay 30% after ded $0 copay 50% after ded $0 copay 30% after ded $0 copay 50% after ded 11 Glasses and Contact Lens Reimbursement $100/24-month period. In-network and out-of-network combined. 12 Aetna Vision SM Discount Program Included Not covered Included Not covered 13 Primary Physician Office Visit $15 copay 30% after ded $20 copay 50% after ded 14 Specialist Office Visit $30 copay 30% after ded $40 copay 50% after ded 15 Outpatient Services - Lab / X-ray $0 copay / $30 copay 30% after ded $0 copay / $40 copay 50% after ded 16 Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) 17 Chiropractic Services (20 visits per calendar year. 18 Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per calendar year. In-network and out-of-network combined) 19 Outpatient Speech Therapy (30 visits per calendar year. 20 Durable Medical Equipment ($2,500 calendar year maximum. 21 Inpatient Hospital $200 copay per day, 5-day copay max per admission $200 copay 30% after ded $200 copay 50% after ded $10 copay 25% after ded $10 copay 25% after ded $30 copay 30% after ded $40 copay 50% after ded $30 copay 30% after ded $40 copay 50% after ded 50% 50% after ded 50% 50% after ded 30% after ded $300 copay per day, 5-day copay max per admission 50% after ded 22 Outpatient Surgery $200 copay 30% after ded $300 copay 50% after ded 23 Emergency Room (Copay waived if admitted) $200 copay $200 copay, ded waived $200 copay $200 copay, ded waived 24 Urgent Care $50 copay 30% after ded $50 copay 50% after ded 25 Prescription Drugs (Includes 90-day transition of coverage (TOC) for prior authorization and step-therapy 4 ) 26 Prescription Drugs: 30-day supply 5 Option 1: $10/$25/$50 Option 2: $10/$35/$60 Option 3: $15/$45/$75 27 Prescription Drugs: 31- to 90-day supply 5 Option 1: $20/$50/$100 Option 2: $20/$70/$120 Option 3: $30/$90/$150 Not covered Option 1: $10/$25/$50 Option 2: $10/$35/$60 Option 3: $15/$45/$75 Not covered Option 1: $20/$50/$100 Option 2: $20/$70/$120 Option 3: $30/$90/$150 Not covered Not covered 28 Aetna Specialty CareRx SM Drugs: 30-day supply $250 copay Not covered $250 copay Not covered 29 *Optional Features: No-referral option 6 : PA POS NR 3.7 CY (15/200D) No-referral option 6 : PA POS NR 4.7 CY (20/300D) See pages for important plan provisions. 11

12 Traditional - POS Plan Options Plan Options PA POS 5.7 CY (30/400D) + * PA POS 6.7 CY (40/500D) + * # Member Benefits In-network Out-of-network 1 In-network Out-of-network 1 See pages for important plan provisions. 12 PCP coordinated No-referral needed PCP coordinated No-referral needed 1 Benefit/Plan Administration Calendar year Calendar year Calendar year Calendar year 2 Member Coinsurance N/A 50% after ded N/A 50% after ded 3 Calendar Year Deductible 2 N/A $5,000 per member $15,000 family 4 Calendar Year Out-of-Pocket Maximum 3 $3,000 per member $6,000 family $10,000 per member $30,000 family N/A $3,000 per member $6,000 family $5,000 per member $15,000 family 5 Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited 6 Preventive Care 7 Well-Baby/Child/Adult Physical Exams (Age and frequency schedules apply. 8 Routine Gyn Exams (One exam and pap smear per 365 days. In-network and out-of-network combined) 9 Routine Mammograms (One annual mammogram for females age 40 and over. In-network and out-of-network combined) 10 Routine Eye Exam (One exam per 24 months. $10,000 per member $30,000 family $0 copay 50%, ded waived $0 copay 50%, ded waived $0 copay 50%, ded waived $0 copay 50%, ded waived $0 copay 50% after ded $0 copay 50% after ded $0 copay 50% after ded $0 copay 50% after ded 11 Glasses and Contact Lens Reimbursement $100/24-month period. In-network and out-of-network combined. 12 Aetna Vision SM Discount Program Included Not covered Included Not covered 13 Primary Physician Office Visit $30 copay 50% after ded $40 copay 50% after ded 14 Specialist Office Visit $50 copay 50% after ded $60 copay 50% after ded 15 Outpatient Services - Lab / X-ray $0 copay / $50 copay 50% after ded $0 copay / $60 copay 50% after ded 16 Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) 17 Chiropractic Services (20 visits per calendar year. 18 Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per calendar year. In-network and out-of-network combined) 19 Outpatient Speech Therapy (30 visits per calendar year. 20 Durable Medical Equipment ($2,500 calendar year maximum. 21 Inpatient Hospital $400 copay per day, 5-day copay max per admission $200 copay 50% after ded $200 copay 50% after ded $10 copay 25% after ded $10 copay 25% after ded $50 copay 50% after ded $60 copay 50% after ded $50 copay 50% after ded $60 copay 50% after ded 50% 50% after ded 50% 50% after ded 50% after ded $500 copay per day, 5-day copay max per admission 50% after ded 22 Outpatient Surgery $400 copay 50% after ded $500 copay 50% after ded 23 Emergency Room (Copay waived if admitted) $200 copay $200 copay, ded waived $200 copay $200 copay, ded waived 24 Urgent Care $50 copay 50% after ded $50 copay 50% after ded 25 Prescription Drugs (Includes 90-day transition of coverage (TOC) for prior authorization and step-therapy 4 ) 26 Prescription Drugs: 30-day supply 5 Option 1: $10/$25/$50 Option 2: $10/$35/$60 Option 3: $15/$45/$75 27 Prescription Drugs: 31- to 90-day supply 5 Option 1: $20/$50/$100 Option 2: $20/$70/$120 Option 3: $30/$90/$150 Not covered Option 1: $10/$25/$50 Option 2: $10/$35/$60 Option 3: $15/$45/$75 Not covered Option 1: $20/$50/$100 Option 2: $20/$70/$120 Option 3: $30/$90/$150 Not covered Not covered 28 Aetna Specialty CareRx SM Drugs: 30-day supply $250 copay Not covered $250 copay Not covered 29 *Optional Features: No-referral option 6 : PA POS NR 5.7 CY (30/400D) No-referral option 6 : PA POS NR 6.7 CY (40/500D)

13 Traditional - POS Plan Options Plan Options PA POS 7.7 CY (35/30%) + * # Member Benefits In-network Out-of-network 1 PCP coordinated No-referral needed 1 Benefit/Plan Administration Calendar year Calendar year 2 Member Coinsurance N/A 50% after ded 3 Calendar Year Deductible 2 N/A $5,000 per member $15,000 family 4 Calendar Year Out-of-Pocket Maximum 3 $3,000 per member $6,000 family 5 Lifetime Maximum Benefit Unlimited Unlimited 6 Preventive Care 7 Well-Baby/Child/Adult Physical Exams (Age and frequency schedules apply. 8 Routine Gyn Exams (One exam and pap smear per 365 days. 9 Routine Mammograms (One annual mammogram for females age 40 and over. In-network and out-of-network combined) 10 Routine Eye Exam (One exam per 24 months. $10,000 per member $30,000 family $0 copay 50%, ded waived $0 copay 50%, ded waived $0 copay 50% after ded $0 copay 50% after ded 11 Glasses and Contact Lens Reimbursement $100/24-month period. In-network and out-of-network combined. 12 Aetna Vision SM Discount Program Included Not covered 13 Primary Physician Office Visit $35 copay 50% after ded 14 Specialist Office Visit $60 copay 50% after ded 15 Outpatient Services - Lab / X-ray $0 copay / $60 copay 50% after ded 16 Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) 17 Chiropractic Services (20 visits per calendar year. 18 Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per calendar year. In-network and out-of-network combined) 19 Outpatient Speech Therapy (30 visits per calendar year. 20 Durable Medical Equipment ($2,500 calendar year maximum. 30% 50% after ded $10 copay 25% after ded $60 copay 50% after ded $60 copay 50% after ded 50% 50% after ded 21 Inpatient Hospital/Outpatient Surgery 30% 50% after ded 22 Emergency Room 30% 30%, ded waived 23 Urgent Care 30% 50% after ded 24 Prescription Drugs (Rx Options 1 and 2: 90-day transition of coverage (TOC) for prior authorization and step-therapy 4 Rx Option 3: 90-day transition of coverage (TOC) for prior authorization 4 ) 25 Prescription Drugs: 30-day supply 5 Option 1: $10/$35/$60 Option 2: $15/$45/$75 Option 3: $10 for Generic drugs. Brand-name drugs are not covered, but members may access Aetna s negotiated discount at in-network pharmacies. 26 Prescription Drugs: 31- to 90-day supply 5 Option 1: $20/$70/$120 Option 2: $30/$90/$150 Option 3: $20 for Generic drugs. Brand-name drugs are not covered, but members may access Aetna s negotiated discount at in-network pharmacies. Not covered Not covered 27 Aetna Specialty CareRx SM Drugs: 30-day supply $250 copay Not covered 28 *Optional Features: No-referral option 6 : PA POS NR 7.7 CY (35/30%) See pages for important plan provisions. 13

14 Cost-Sharing - POS Cost-Sharing Plan Options Plan Options PA POS CS 1.7 CY (500 Ded) + * PA POS CS NR 1.7 PY (500 Ded) + * 6 # Member Benefits In-network Out-of-network 1 In-network Out-of-network 1 PCP coordinated No-referral needed No-referral needed No-referral needed 1 Benefit/Plan Administration Calendar year Calendar year Plan year Plan Year 2 Member Coinsurance N/A 50% after ded N/A 50% after ded 3 Benefit Year Deductible 2 $500 per member $1,000 family 4 Benefit Year Out-of-Pocket Maximum 3 $3,000 per member $6,000 family $5,000 per member $10,000 per member $20,000 family $500 per member $1,000 family $3,000 per member $6,000 family $5,000 per member 5 Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited 6 Preventive Care 7 Well-Baby/Child/Adult Physical Exams (Age and frequency schedules apply. 8 Routine Gyn Exams (One exam and pap smear per 365 days. 9 Routine Mammograms (One mammogram for females age 40 and over per benefit year. 10 Routine Eye Exam (One exam per 24 months. $10,000 per member $20,000 family $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded 11 Glasses and Contact Lens Reimbursement $100/24-month period. In-network and out-of-network combined. 12 Aetna Vision SM Discount Program Included Not covered Included Not covered 13 Primary Physician Office Visit $20 copay, ded waived 50% after ded $20 copay, ded waived 50% after ded 14 Specialist Office Visit $40 copay, ded waived 50% after ded $40 copay, ded waived 50% after ded 15 Outpatient Services - Lab $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded 16 Outpatient Services - X-ray $40 copay, ded waived 50% after ded $40 copay, ded waived 50% after ded 17 Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) 18 Chiropractic Services (20 visits per benefit year. 19 Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per benefit year. In-network and out-of-network combined) 20 Outpatient Speech Therapy (30 visits per benefit year. 21 Durable Medical Equipment ($2,500 benefit year maximum. 22 Inpatient Hospital $0 copay per admission after ded $200 copay, ded waived 50% after ded $200 copay, ded waived 50% after ded $10 copay, ded waived 25% after ded $10 copay, ded waived 25% after ded $40 copay, ded waived 50% after ded $40 copay, ded waived 50% after ded $40 copay, ded waived 50% after ded $40 copay, ded waived 50% after ded 50%, ded waived 50% after ded 50%, ded waived 50% after ded 50% after ded $0 copay per admission after ded 50% after ded 23 Outpatient Surgery $0 copay after ded 50% after ded $0 copay after ded 50% after ded 24 Emergency Room (Copay waived if admitted) $200 copay, ded waived $200 copay, ded waived $150 copay, ded waived $150 copay, ded waived 25 Urgent Care $50 copay, ded waived 50% after ded $50 copay, ded waived 50% after ded 26 Prescription Drugs (Includes 90-day transition of coverage (TOC) for prior authorization and step-therapy 4 ) 27 Prescription Drugs: 30-day supply 5 Option 1: $10/$25/$50 Option 2: $10/$35/$60 Option 3: $15/$45/$75 28 Prescription Drugs: 31- to 90-day supply 5 Option 1: $20/$50/$100 Option 2: $20/$70/$120 Option 3: $30/$90/$150 Not covered Option 1: $10/$25/$50 Option 2: $10/$35/$60 Option 3: $15/$45/$75 Not covered Option 1: $20/$50/$100 Option 2: $20/$70/$120 Option 3: $30/$90/$150 Not covered Not covered 29 Aetna Specialty CareRx SM Drugs: 30-day supply $250 copay Not covered $250 copay Not covered 30 *Optional Features: No-referral option 6 : PA POS CS NR 1.7 CY (500 Ded) Not applicable See pages for important plan provisions. 14

15 Cost-Sharing - POS Cost-Sharing Plan Options Plan Options PA POS CS 2.7 CY (1000 Ded) + * PA POS CS NR 2.7 PY (1000 Ded) + * 6 # Member Benefits In-network Out-of-network 1 In-network Out-of-network 1 PCP coordinated No-referral needed No-referral needed No-referral needed 1 Benefit/Plan Administration Calendar year Calendar year Plan year Plan year 2 Member Coinsurance N/A 50% after ded N/A 50% after ded 3 Benefit Year Deductible 2 $1,000 per member $2,000 family 4 Benefit Year Out-of-Pocket Maximum 3 $3,000 per member $6,000 family $5,000 per member $10,000 per member $20,000 family $1,000 per member $2,000 family $3,000 per member $6,000 family $5,000 per member 5 Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited 6 Preventive Care 7 Well-Baby/Child/Adult Physical Exams (Age and frequency schedules apply. 8 Routine Gyn Exams (One exam and pap smear per 365 days. 9 Routine Mammograms (One mammogram for females age 40 and over per benefit year. 10 Routine Eye Exam (One exam per 24 months. $10,000 per member $20,000 family $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded 11 Glasses and Contact Lens Reimbursement $100/24-month period. In-network and out-of-network combined. 12 Aetna Vision SM Discount Program Included Not covered Included Not covered 13 Primary Physician Office Visit $25 copay, ded waived 50% after ded $25 copay, ded waived 50% after ded 14 Specialist Office Visit $50 copay, ded waived 50% after ded $50 copay, ded waived 50% after ded 15 Outpatient Services - Lab $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded 16 Outpatient Services - X-ray $50 copay, ded waived 50% after ded $50 copay, ded waived 50% after ded 17 Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) 18 Chiropractic Services (20 visits per benefit year. 19 Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per benefit year. In-network and out-of-network combined) 20 Outpatient Speech Therapy (30 visits per benefit year. 21 Durable Medical Equipment ($2,500 benefit year maximum. 22 Inpatient Hospital $0 copay per admission after ded $200 copay, ded waived 50% after ded $200 copay, ded waived 50% after ded $10 copay, ded waived 25% after ded $10 copay, ded waived 25% after ded $50 copay, ded waived 50% after ded $50 copay, ded waived 50% after ded $50 copay, ded waived 50% after ded $50 copay, ded waived 50% after ded 50%, ded waived 50% after ded 50%, ded waived 50% after ded 50% after ded $0 copay per admission after ded 50% after ded 23 Outpatient Surgery $0 copay after ded 50% after ded $0 copay after ded 50% after ded 24 Emergency Room (Copay waived if admitted) $200 copay, ded waived $200 copay, ded waived $150 copay, ded waived $150 copay, ded waived 25 Urgent Care $50 copay, ded waived 50% after ded $50 copay, ded waived 50% after ded 26 Prescription Drugs (Includes 90-day transition of coverage (TOC) for prior authorization and step-therapy 4 ) 27 Prescription Drugs: 30-day supply 5 Option 1: $10/$25/$50 Option 2: $10/$35/$60 Option 3: $15/$45/$75 28 Prescription Drugs: 31- to 90-day supply 5 Option 1: $20/$50/$100 Option 2: $20/$70/$120 Option 3: $30/$90/$150 Not covered Option 1: $10/$25/$50 Option 2: $10/$35/$60 Option 3: $15/$45/$75 Not covered Option 1: $20/$50/$100 Option 2: $20/$70/$120 Option 3: $30/$90/$150 Not covered Not covered 29 Aetna Specialty CareRx SM Drugs: 30-day supply $250 copay Not covered $250 copay Not covered 30 *Optional Features: No-referral option 6 : PA POS CS NR 2.7 CY (1000 Ded) Not applicable See pages for important plan provisions. 15

16 Cost-Sharing - POS Cost-Sharing Plan Options Plan Options PA POS CS 3.7 CY (1500 Ded) + * PA POS CS NR 3.7 PY (1500 Ded) + * 6 # Member Benefits In-network Out-of-network 1 In-network Out-of-network 1 PCP coordinated No-referral needed No-referral needed No-referral needed 1 Benefit/Plan Administration Calendar year Calendar year Plan year Plan year 2 Member Coinsurance N/A 50% after ded N/A 50% after ded 3 Benefit Year Deductible 2 $1,500 per member $3,000 family 4 Benefit Year Out-of-Pocket Maximum 3 $3,000 per member $6,000 family $5,000 per member $10,000 per member $20,000 family $1,500 per member $3,000 family $3,000 per member $6,000 family $5,000 per member 5 Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited 6 Preventive Care 7 Well-Baby/Child/Adult Physical Exams (Age and frequency schedules apply. 8 Routine Gyn Exams (One exam and pap smear per 365 days. 9 Routine Mammograms (One mammogram for females age 40 and over per benefit year. 10 Routine Eye Exam (One exam per 24 months. $10,000 per member $20,000 family $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded 11 Glasses and Contact Lens Reimbursement $100/24-month period. In-network and out-of-network combined. 12 Aetna Vision SM Discount Program Included Not covered Included Not covered 13 Primary Physician Office Visit $30 copay, ded waived 50% after ded $30 copay, ded waived 50% after ded 14 Specialist Office Visit $50 copay, ded waived 50% after ded $50 copay, ded waived 50% after ded 15 Outpatient Services - Lab $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded 16 Outpatient Services - X-ray $50 copay, ded waived 50% after ded $50 copay, ded waived 50% after ded 17 Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) 18 Chiropractic Services (20 visits per benefit year. 19 Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per benefit year. In-network and out-of-network combined) 20 Outpatient Speech Therapy (30 visits per benefit year. 21 Durable Medical Equipment ($2,500 benefit year maximum. 22 Inpatient Hospital $0 copay per admission after ded $200 copay, ded waived 50% after ded $200 copay, ded waived 50% after ded $10 copay, ded waived 25% after ded $10 copay, ded waived 25% after ded $50 copay, ded waived 50% after ded $50 copay, ded waived 50% after ded $50 copay, ded waived 50% after ded $50 copay, ded waived 50% after ded 50%, ded waived 50% after ded 50%, ded waived 50% after ded 50% after ded $0 copay per admission after ded 50% after ded 23 Outpatient Surgery $0 copay after ded 50% after ded $0 copay after ded 50% after ded 24 Emergency Room (Copay waived if admitted) $200 copay, ded waived $200 copay, ded waived $150 copay, ded waived $150 copay, ded waived 25 Urgent Care $50 copay, ded waived 50% after ded $50 copay, ded waived 50% after ded 26 Prescription Drugs (Includes 90-day transition of coverage (TOC) for prior authorization and step-therapy 4 ) 27 Prescription Drugs: 30-day supply 5 Option 1: $10/$25/$50 Option 2: $10/$35/$60 Option 3: $15/$45/$75 28 Prescription Drugs: 31- to 90-day supply 5 Option 1: $20/$50/$100 Option 2: $20/$70/$120 Option 3: $30/$90/$150 Not covered Option 1: $10/$25/$50 Option 2: $10/$35/$60 Option 3: $15/$45/$75 Not covered Option 1: $20/$50/$100 Option 2: $20/$70/$120 Option 3: $30/$90/$150 Not covered Not covered 29 Aetna Specialty CareRx SM Drugs: 30-day supply $250 copay Not covered $250 copay Not covered 30 *Optional Features: No-referral option 6 : PA POS CS NR 3.7 CY (1500 Ded) Not applicable See pages for important plan provisions. 16

17 Cost-Sharing - POS Cost-Sharing Plan Options Plan Options PA POS CS 4.7 CY (2000 Ded) + * PA POS CS NR 4.7 PY (2000 Ded) + * 6 # Member Benefits In-network Out-of-network 1 In-network Out-of-network 1 PCP coordinated No-referral needed No-referral needed No-referral needed 1 Benefit/Plan Administration Calendar year Calendar year Plan year Plan year 2 Member Coinsurance N/A 50% after ded N/A 50% after ded 3 Benefit Year Deductible 2 $2,000 per member $4,000 family 4 Benefit Year Out-of-Pocket Maximum 3 $5,000 per member $5,000 per member $10,000 per member $20,000 family $2,000 per member $4,000 family $5,000 per member $5,000 per member 5 Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited 6 Preventive Care 7 Well-Baby/Child/Adult Physical Exams (Age and frequency schedules apply. 8 Routine Gyn Exams (One exam and pap smear per 365 days. 9 Routine Mammograms (One mammogram for females age 40 and over per benefit year. 10 Routine Eye Exam (One exam per 24 months. $10,000 per member $20,000 family $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded 11 Glasses and Contact Lens Reimbursement $100/24-month period. In-network and out-of-network combined. 12 Aetna Vision SM Discount Program Included Not covered Included Not covered 13 Primary Physician Office Visit $35 copay, ded waived 50% after ded $35 copay, ded waived 50% after ded 14 Specialist Office Visit $60 copay, ded waived 50% after ded $60 copay, ded waived 50% after ded 15 Outpatient Services - Lab $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded 16 Outpatient Services - X-ray $60 copay, ded waived 50% after ded $60 copay, ded waived 50% after ded 17 Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) 18 Chiropractic Services (20 visits per benefit year. 19 Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per benefit year. In-network and out-of-network combined) 20 Outpatient Speech Therapy (30 visits per benefit year. 21 Durable Medical Equipment ($2,500 benefit year maximum. 22 Inpatient Hospital $0 copay per admission after ded $200 copay, ded waived 50% after ded $200 copay, ded waived 50% after ded $10 copay, ded waived 25% after ded $10 copay, ded waived 25% after ded $60 copay, ded waived 50% after ded $60 copay, ded waived 50% after ded $60 copay, ded waived 50% after ded $60 copay, ded waived 50% after ded 50%, ded waived 50% after ded 50%, ded waived 50% after ded 50% after ded $0 copay per admission after ded 50% after ded 23 Outpatient Surgery $0 copay after ded 50% after ded $0 copay after ded 50% after ded 24 Emergency Room (Copay waived if admitted) $200 copay, ded waived $200 copay, ded waived $150 copay, ded waived $150 copay, ded waived 25 Urgent Care $50 copay, ded waived 50% after ded $50 copay, ded waived 50% after ded 26 Prescription Drugs (Includes 90-day transition of coverage (TOC) for prior authorization and step-therapy 4 ) 27 Prescription Drugs: 30-day supply 5 Option 1: $10/$25/$50 Option 2: $10/$35/$60 Option 3: $15/$45/$75 28 Prescription Drugs: 31- to 90-day supply 5 Option 1: $20/$50/$100 Option 2: $20/$70/$120 Option 3: $30/$90/$150 Not covered Option 1: $10/$25/$50 Option 2: $10/$35/$60 Option 3: $15/$45/$75 Not covered Option 1: $20/$50/$100 Option 2: $20/$70/$120 Option 3: $30/$90/$150 Not covered Not covered 29 Aetna Specialty CareRx SM Drugs: 30-day supply $250 copay Not covered $250 copay Not covered 30 *Optional Features: No-referral option 6 : PA POS CS NR 4.7 CY (2000 Ded) Not applicable See pages for important plan provisions. 17

18 Cost-Sharing - POS Cost-Sharing Plan Options Plan Options PA POS CS 5.7 CY (2500 Ded) + * PA POS CS NR 5.7 PY (2500 Ded) + * 6 # Member Benefits In-network Out-of-network 1 In-network Out-of-network 1 PCP coordinated No-referral needed No-referral needed No-referral needed 1 Benefit/Plan Administration Calendar year Calendar Year Plan year Plan year 2 Member Coinsurance N/A 50% after ded N/A 50% after ded 3 Benefit Year Deductible 2 $2,500 per member $5,000 family 4 Benefit Year Out-of-Pocket Maximum 3 $5,000 per member $5,000 per member $10,000 per member $20,000 family $2,500 per member $5,000 family $5,000 per member $5,000 per member 5 Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited 6 Preventive Care 7 Well-Baby/Child/Adult Physical Exams (Age and frequency schedules apply. 8 Routine Gyn Exams (One exam and pap smear per 365 days. 9 Routine Mammograms (One mammogram for females age 40 and over per benefit year. 10 Routine Eye Exam (One exam per 24 months. $10,000 per member $20,000 family $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded 11 Glasses and Contact Lens Reimbursement $100/24-month period. In-network and out-of-network combined. 12 Aetna Vision SM Discount Program Included Not covered Included Not covered 13 Primary Physician Office Visit $40 copay, ded waived 50% after ded $40 copay, ded waived 50% after ded 14 Specialist Office Visit $60 copay, ded waived 50% after ded $60 copay, ded waived 50% after ded 15 Outpatient Services - Lab $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded 16 Outpatient Services - X-ray $60 copay, ded waived 50% after ded $60 copay, ded waived 50% after ded 17 Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) 18 Chiropractic Services (20 visits per benefit year. 19 Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per benefit year. In-network and out-of-network combined) 20 Outpatient Speech Therapy (30 visits per benefit year. 21 Durable Medical Equipment ($2,500 benefit year maximum. 22 Inpatient Hospital $0 copay per admission after ded $200 copay, ded waived 50% after ded $200 copay, ded waived 50% after ded $10 copay, ded waived 25% after ded $10 copay, ded waived 25% after ded $60 copay, ded waived 50% after ded $60 copay, ded waived 50% after ded $60 copay, ded waived 50% after ded $60 copay, ded waived 50% after ded 50%, ded waived 50% after ded 50%, ded waived 50% after ded 50% after ded $0 copay per admission after ded 50% after ded 23 Outpatient Surgery $0 copay after ded 50% after ded $0 copay after ded 50% after ded 24 Emergency Room (Copay waived if admitted) $200 copay, ded waived $200 copay, ded waived $150 copay, ded waived $150 copay, ded waived 25 Urgent Care $50 copay, ded waived 50% after ded $50 copay, ded waived 50% after ded 26 Prescription Drugs (Includes 90-day transition of coverage (TOC) for prior authorization and step-therapy 4 ) 27 Prescription Drugs: 30-day supply 5 Option 1: $10/$25/$50 Option 2: $10/$35/$60 Option 3: $15/$45/$75 28 Prescription Drugs: 31- to 90-day supply 5 Option 1: $20/$50/$100 Option 2: $20/$70/$120 Option 3: $30/$90/$150 Not covered Option 1: $10/$25/$50 Option 2: $10/$35/$60 Option 3: $15/$45/$75 Not covered Option 1: $20/$50/$100 Option 2: $20/$70/$120 Option 3: $30/$90/$150 Not covered Not covered 29 Aetna Specialty CareRx SM Drugs: 30-day supply $250 copay Not covered $250 copay Not covered 30 *Optional Features: No-referral option 6 : PA POS CS NR 5.7 CY (2500 Ded) Not applicable See pages for important plan provisions. 18

19 Cost-Sharing - POS Cost-Sharing Plan Options Plan Options PA POS CS 6.7 CY (3000 Ded) + * PA POS CS NR 6.7 PY (3000 Ded) + * 6 # Member Benefits In-network Out-of-network 1 In-network Out-of-network 1 PCP coordinated No-referral needed No-referral needed No-referral needed 1 Benefit/Plan Administration Calendar year Calendar year Plan year Plan year 2 Member Coinsurance N/A 50% after ded N/A 50% after ded 3 Benefit Year Deductible 2 $3,000 per member $6,000 family 4 Benefit Year Out-of-Pocket Maximum 3 $5,000 per member $5,000 per member $10,000 per member $20,000 family $3,000 per member $6,000 family $5,000 per member $5,000 per member 5 Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited 6 Preventive Care 7 Well-Baby/Child/Adult Physical Exams (Age and frequency schedules apply. 8 Routine Gyn Exams (One exam and pap smear per 365 days. 9 Routine Mammograms (One mammogram for females age 40 and over per benefit year. 10 Routine Eye Exam (One exam per 24 months. $10,000 per member $20,000 family $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded 11 Glasses and Contact Lens Reimbursement $100/24-month period. In-network and out-of-network combined. 12 Aetna Vision SM Discount Program Included Not covered Included Not covered 13 Primary Physician Office Visit $45 copay, ded waived 50% after ded $45 copay, ded waived 50% after ded 14 Specialist Office Visit $65 copay, ded waived 50% after ded $65 copay, ded waived 50% after ded 15 Outpatient Services - Lab $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded 16 Outpatient Services - X-ray $65 copay, ded waived 50% after ded $65 copay, ded waived 50% after ded 17 Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) 18 Chiropractic Services (20 visits per benefit year. 19 Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per benefit year. In-network and out-of-network combined) 20 Outpatient Speech Therapy (30 visits per benefit year. 21 Durable Medical Equipment ($2,500 benefit year maximum. 22 Inpatient Hospital $0 copay per admission after ded $200 copay, ded waived 50% after ded $200 copay, ded waived 50% after ded $10 copay, ded waived 25% after ded $10 copay, ded waived 25% after ded $65 copay, ded waived 50% after ded $65 copay, ded waived 50% after ded $65 copay, ded waived 50% after ded $65 copay, ded waived 50% after ded 50%, ded waived 50% after ded 50%, ded waived 50% after ded 50% after ded $0 copay per admission after ded 50% after ded 23 Outpatient Surgery $0 copay after ded 50% after ded $0 copay after ded 50% after ded 24 Emergency Room (Copay waived if admitted) $200 copay, ded waived $200 copay, ded waived $150 copay, ded waived $150 copay, ded waived 25 Urgent Care $50 copay, ded waived 50% after ded $50 copay, ded waived 50% after ded 26 Prescription Drugs (Includes 90-day transition of coverage (TOC) for prior authorization and step-therapy 4 ) 27 Prescription Drugs: 30-day supply 5 Option 1: $10/$25/$50 Option 2: $10/$35/$60 Option 3: $15/$45/$75 28 Prescription Drugs: 31- to 90-day supply 5 Option 1: $20/$50/$100 Option 2: $20/$70/$120 Option 3: $30/$90/$150 Not covered Option 1: $10/$25/$50 Option 2: $10/$35/$60 Option 3: $15/$45/$75 Not covered Option 1: $20/$50/$100 Option 2: $20/$70/$120 Option 3: $30/$90/$150 Not covered Not covered 29 Aetna Specialty CareRx SM Drugs: 30-day supply $250 copay Not covered $250 copay Not covered 30 *Optional Features: No-referral option 6 : PA POS CS NR 6.7 CY (3000 Ded) Not applicable See pages for important plan provisions. 19

20 Cost-Sharing - POS Cost-Sharing Plan Options Plan Options PA POS CS 7.7 CY (4000 Ded) + * PA POS CS NR 7.7 PY (4000 Ded) + * 6 # Member Benefits In-network Out-of-network 1 In-network Out-of-network 1 PCP coordinated No-referral needed No-referral needed No-referral needed 1 Benefit/Plan Administration Calendar year Calendar year Plan year Plan year 2 Member Coinsurance N/A 50% after ded N/A 50% after ded 3 Benefit Year Deductible 2 $4,000 per member $8,000 family 4 Benefit Year Out-of-Pocket Maximum 3 $5,000 per member $5,000 per member $10,000 per member $20,000 family $4,000 per member $8,000 family $5,000 per member $5,000 per member 5 Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited 6 Preventive Care 7 Well-Baby/Child/Adult Physical Exams (Age and frequency schedules apply. 8 Routine Gyn Exams (One exam and pap smear per 365 days. 9 Routine Mammograms (One mammogram for females age 40 and over per benefit year. 10 Routine Eye Exam (One exam per 24 months. $10,000 per member $20,000 family $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded 11 Glasses and Contact Lens Reimbursement $100/24-month period. In-network and out-of-network combined. 12 Aetna Vision SM Discount Program Included Not covered Included Not covered 13 Primary Physician Office Visit $20 copay, ded waived 50% after ded $20 copay, ded waived 50% after ded 14 Specialist Office Visit $40 copay, ded waived 50% after ded $40 copay, ded waived 50% after ded 15 Outpatient Services - Lab $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded 16 Outpatient Services - X-ray $40 copay, ded waived 50% after ded $40 copay, ded waived 50% after ded 17 Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans) 18 Chiropractic Services (20 visits per benefit year. 19 Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per benefit year. In-network and out-of-network combined) 20 Outpatient Speech Therapy (30 visits per benefit year. 21 Durable Medical Equipment ($2,500 benefit year maximum. 22 Inpatient Hospital $0 copay per admission after ded $200 copay, ded waived 50% after ded $200 copay, ded waived 50% after ded $10 copay, ded waived 25% after ded $10 copay, ded waived 25% after ded $40 copay, ded waived 50% after ded $40 copay, ded waived 50% after ded $40 copay, ded waived 50% after ded $40 copay, ded waived 50% after ded 50%, ded waived 50% after ded 50%, ded waived 50% after ded 50% after ded $0 copay per admission after ded 50% after ded 23 Outpatient Surgery $0 copay after ded 50% after ded $0 copay after ded 50% after ded 24 Emergency Room (Copay waived if admitted) $200 copay, ded waived $200 copay, ded waived $150 copay, ded waived $150 copay, ded waived 25 Urgent Care $50 copay, ded waived 50% after ded $50 copay, ded waived 50% after ded 26 Prescription Drugs (Includes 90-day transition of coverage (TOC) for prior authorization and step-therapy 4 ) 27 Prescription Drugs: 30-day supply 5 Option 1: $10/$25/$50 Option 2: $10/$35/$60 Option 3: $15/$45/$75 28 Prescription Drugs: 31- to 90-day supply 5 Option 1: $20/$50/$100 Option 2: $20/$70/$120 Option 3: $30/$90/$150 Not covered Option 1: $10/$25/$50 Option 2: $10/$35/$60 Option 3: $15/$45/$75 Not covered Option 1: $20/$50/$100 Option 2: $20/$70/$120 Option 3: $30/$90/$150 Not covered Not covered 29 Aetna Specialty CareRx SM Drugs: 30-day supply $250 copay Not covered $250 copay Not covered 30 *Optional Features: No-referral option 6 : PA POS CS NR 7.7 CY (4000 Ded) Not applicable See pages for important plan provisions. 20