Aetna HealthFund HMO 7.6 (08/12)

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1 CA Group Business Employees How your HMO Plan Works The Aetna HealthFund HMO includes two parts that work together for you - an HMO plan and a Health Reimbursement Arrangement (HRA) fund. Your HMO Plan Primary Care Physician - You must choose a Primary Care Physician. The Aetna HealthFund HMO provider network gives you access to a wide selection of primary care physicians (PCP's) and Specialists your area. Your PCP will coordinate your care and provide referrals to other participating health care professionals. Preventive Care Physician Office Visit PCP Physician Office Visit Specialist Urgent Care Centers X-Ray and Diagnostic Labs Your HealthFund At the start of each year, you'll have a fund, established by your employer, which will help you pay for eligible out-of-pocket health care expenses that are subject to the HMO deductible. Your fund also counts toward your deductible. This means that when you have an expense subject to the deductible, your fund covers your portion of the deductible- as long as there are dollars available. So your fund helps lower your deductible Deductible A deductible is a set amount of expenses you pay each year before your plan begins to pay toward covered services. You will need to meet a deductible for the following services: - Emergency Care - Hospital Care - Outpatient Surgery - Home Health Care - Durable Medical Equipment Out of Pocket Maximum The out-of-pocket maximum is a limit on the amount you pay out of your pocket in a given year. This feature protects you from financial exposure due to catastrophic health events. When your eligible out-of-pocket expenses reach the maximum limit, your remaining eligible expenses are covered by the HMO plan at 100% for the remainder of the plan year. Lifetime Maximum Unlimited Please turn the page to learn more about this plan. Aetna HealthFund HMO 7.6 (08/12) Covered at the PCP copay, no deductible Covered at the PCP copay, no deductible Covered at the Specialist copay, no deductible Covered at a copay, no deductible Covered at a copay, no deductible AETNA LIFE INSURANCE COMPANY Page 1 of 6 (v )

2 PLAN FEATURES Aetna HealthFund: Amount Contributed to the Fund per contract year. $500 Individual (Single = no dependents) $1,000 Family (Employee + 1 or more dependents ) Fund Coinsurance 100% Percentage at which the Fund will reimburse. Fund Administration The Fund will be used to pay for member responsibility for services that are subject to a deductible. Once the deductible is met, assuming the Fund has been exhausted, the underlying medical plan provides coverage. If a Fund balance still exists, the Fund will pay the member responsibility until the Out-of-Pocket Maximum has been reach or the Fund has been exhausted, whichever comes first. Employee Termination from Aetna HealthFund Any remaining HealthFund benefit amount is forfeited (or terminated) when the employee s Aetna HealthFund coverage Fund Rollover Any remaining HealthFund benefit amount at end of plan year is rolled over into next years HealthFund benefit amount. Eligible Fund Expenses The Fund pays for covered expenses subject to a deductible. Expenses not payable under the Fund are any plan limits, any non-covered expenses, services covered at 100% and physician service copays. Deductible (per contract year) $1,500 Individual (Single = no dependents) $3,000 Family (Employee + 1 or more dependents) Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Once Family Deductible is met, all family members will be considered as having met their Deductible for the remainder of the calendar year. Individual/Single Deductible - The amount of Covered Benefits a member enrolled as an individual/single subscriber must incur before benefits are paid. Family Deductible - The amount of Covered Benefits a member enrolled with one or more dependents must incur before benefits are paid. The Family Deductible can be met by a combination of family members or by any individual/single within the family. Applies to all services indicated on the plan summary. Member Coinsurance 20% payment Out-of-Pocket Maximum (per contract year) $3,500 per Individual (Single = no dependents) $7,000 per Family (Employee + 1 or more dependents) Only those participating providers/referred out of pocket expenses resulting from the application of coinsurance percentage, deductible, and copays may be used to satisfy the Out-of Pocket Maximum. Once Family Out-of-Pocket Maximum is met, all family members will be considered as having met their Out-of-Pocket Maximum for the remainder of the contract year. Transplant Specific Out-of-Pocket Maximum Lifetime Maximum Primary Care Physician Selection Referral Requirements Integrates with Out of Pocket Maximum Unlimited Required Required for all non-emergency, non-urgent and non-primary Care physicians services, except direct access services. AETNA LIFE INSURANCE COMPANY Page 2 of 6 (v )

3 SERVICES COVERED BY A COPAY Multiple copays will be applied when multiple services are rendered. The member will be responsible for one copay for each clinical service provided. PREVENTIVE CARE Routine Adult Physical Exams/ Immunizations One exam every 12 months age 18 and over. Well Child Exams / Immunizations 7 exams in the first 12 months of life, 3 exams in the second 12 months of life, 3 exams in the third 12 months of life, 1 exam every 12 months thereafter. Includes immunizations. Routine Gynecological Care Exams Includes Pap smear, HPV Screening and related lab fees. One routine exam every 12 months. Direct access to participating providers in the same medical group as PCP. Routine Mammograms One baseline mammogram for females age 35-39; and one annual mammogram for females age 40 and over. Women's Health Includes: Screening for gestational diabetes; HPV (Human Papillomavirus) DNA testing, counseling for sexually transmitted infections; counseling and screening for human immunodeficiency virus; screening and counseling for interpersonal and domestic violence; breastfeeding support, supplies and counseling; and contraceptive methods and counseling. Limitations may apply. Routine Digital Rectal Exams / Prostate Specific Antigen Test For males age 40 and over Colorectal Cancer Screening For all members 50 and over. Frequency schedule applies. Routine Eye Exam Direct access to participating providers. One exam every 24 months. Routine Hearing Screening PHYSICIAN SERVICES Primary Care Physician Visits Specialist Office Visits Pre-Natal Maternity Allergy Treatment Allergy Testing DIAGNOSTIC PROCEDURES Diagnostic Laboratory Diagnostic X-ray Complex Imaging URGENT MEDICAL CARE Urgent Care MENTAL HEALTH SERVICES Outpatient Severe Mental Illness and Severe Emotional Disturbances of a Child Outpatient Non-Severe Mental Illness ALCOHOL/DRUG ABUSE SERVICES Outpatient Detoxification Outpatient Rehabilitation Covered as part of Routine Adult/Well Child Exam Office Hours: $30 copay, deductible waived After Office Hours/Home: $35 copay, deductible waived $50 copay, deductible waived Covered 100%; deductible waived Same as applicable participating provider office visit member cost sharing Same as applicable participating provider office visit member cost sharing $50 copay, deductible waived $50 copay, deductible waived $150 copay, deductible waived $35 copay, deductible waived AETNA LIFE INSURANCE COMPANY Page 3 of 6 (v )

4 OTHER SERVICES Outpatient Physical, Occupational, and Speech Therapy $50 per visit copay, deductible waived (Includes speech, physical and occupational therapy) Treatment over a 60-day consecutive period per incident of illness or injury beginning with the first day of treatment for combined therapies. Limits do not apply to autism. Chiropractic/Subluxation $15 copay, deductible waived Limited to 20 visits per calendar year Diabetic Supplies Pharmacy cost sharing applies Private Duty Nursing Not Covered FAMILY PLANNING Infertility Treatment Member cost sharing is based on the type of service Diagnosis and treatment of the underlying medical condition performed and the place of service where it is rendered. Voluntary Sterilization - Vasectomy Member cost sharing is based on the type of service performed and the place of service where it is rendered. Voluntary Sterilization - Tubal LIgation Covered 100%; deductible waived SERVICES SUBJECT TO DEDUCTIBLE & ELIGIBLE FOR FUND REIMBURSEMENT (Provided there is a Fund Balance) PHYSICIAN SERVICES Maternity - Delivery and Post-Partum Care EMERGENCY MEDICAL CARE Emergency Room Ambulance HOSPITAL CARE Inpatient Coverage Inpatient Maternity Coverage Outpatient Surgery in Hospital Outpatient Surgery in Free-Standing Surgery Center MENTAL HEALTH SERVICES Inpatient Severe Mental Illness and Severe Emotional Disturbances of a Child Inpatient Non-Severe Mental Illness ALCOHOL/DRUG ABUSE SERVICES Inpatient Detoxification Inpatient Rehabilitation OTHER SERVICES Autism Treatment Skilled Nursing Facility Limited to 100 days per contract year Home Health Care $30 copay per visit after deductible Limited to 100 visits per contract year Limited to 3 intermittent visit per day by a Participating home health care agency; 1 visit equals a period of 4 hrs or less. Hospice Care - Inpatient Hospice Care - Outpatient Durable Medical Equipment $2,000 maximum benefit per member per contract year Bariatric Surgery Transplants 20%, after deductible $100 copay after deductible $100 copay after deductible $100 copay after deductible Member cost sharing is based on the type of service performed and the place of service where it is rendered. $50 copay per visit after deductible 50% of the cost of the item (of contracted rate), after deductible AETNA LIFE INSURANCE COMPANY Page 4 of 6 (v )

5 PHARMACY - PRESCRIPTION DRUG BENEFITS (Not Eligible for Fund Reimbursement) Retail Covered at the copay supply at participating pharmacies Mail order $30 copay for formulary generic drugs, $50 copay for Covered at the copay formulary brand-name drugs, and $80 copay for nonformulary brand-name and generic drugs up to a day supply at participating pharmacies. No Mandatory Generic (NO MG) - Member is responsible for applicable copay only Plan Includes: Contraceptive drugs and devices obtainable from a pharmacy and Performance Enhancing Medication. Precert included with 90 day Transition of Care for New Business Formulary generic FDA-approved Women s Contraceptives covered 100% in network. EXCLUSIONS AND LIMITATIONS STANDARD CALIFORNIA DISCLAIMERS & EXCLUSIONS WILL APPLY All CALIFORNIA STATE MANDATES WILL APPLY $15 copay for formulary generic drugs, $25 copay for formulary brand-name drugs, and $40 copay for nonformulary brand-name and generic drugs up to a 30 day **For this plan, "participating providers" refers to the Aetna HealthFund HMO participating providers. For any questions or concerns about accessing and obtaining services from Aetna HealthFund HMO specialty physicians, please call Member Services at AETNA ( ) or go to Plans are provided by: Aetna Health of California Inc. While this material is believed to be accurate as of the production date, it is subject to change. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. You may be responsible for the health care provider's full charges for any non-covered services, including circumstances where you have exceeded a benefit limit contained in the plan. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. If you are in a plan that requires the selection of a primary care physician and your primary care physician is part of an integrated delivery system or physician group, your primary care physician will generally refer you to specialists and hospitals that are affiliated with the delivery system or physician group. The following is a list of services and supplies that are generally not covered. However, your plan documents may contain exceptions to this list based on state mandates or the plan design or rider(s) purchased by your employer. All medical and hospital services not specifically covered in, or which are limited or excluded by your plan documents Cosmetic surgery, including breast reduction Custodial care Dental care and dental x-rays Donor egg retrieval Durable medical equipment Experimental and investigational procedures, except for coverage for medically necessary routine patient care costs for members participating in a cancer clinical trial) AETNA LIFE INSURANCE COMPANY Page 5 of 6 (v )

6 Hearing aids Home births Immunizations for travel or work except where medically necessary or indicated Implantable drugs and certain injectable drugs including injectable infertility drugs Infertility services, including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services, unless specifically listed as covered in your plan documents Long-term rehabilitation therapy Non-medically necessary services or supplies Orthotics except diabetic orthotics Outpatient prescription drugs (except for treatment of diabetes), unless covered by a prescription plan rider and over-thecounter medications (except as provided in a hospital) and supplies Radial keratotomy or related procedures Reversal of sterilization Services for the treatment of sexual dysfunction or inadequacies including therapy, supplies or counseling or prescription drugs Special duty nursing Therapy or rehabilitation other than those listed as covered Treatment of behavioral disorders Weight control services including surgical procedures, medical treatments, weight control/loss programs, dietary regimens and supplements, appetite suppressants and other medications; food or food supplements, exercise programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or treat obesity, including M bid Ob it f th f i ht d ti dl f th i t f bid diti This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. Aetna does not provide health care services and therefore, cannot guarantee any results or outcomes. Consult the plan document (i.e. Schedule of Benefits, Certificate of Coverage, Evidence of Coverage, Group Agreement, Group Insurance Certificate and/or Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitations relating to the plan. The availability of a plan or program may vary by geographic service area. Some benefits are subject to limitations or visit maximums. With the exception of Aetna Rx Home Delivery, all participating physicians, hospitals and other health care providers are independent contractors and are neither agents nor employees of Aetna. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change. Notice of the change shall be provided in accordance with applicable state law. Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna's Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. Aetna Rx Home Delivery refers to Aetna Rx Home Delivery, LLC, a licensed pharmacy subsidiary of Aetna Inc., that operates through mail order. The charges that Aetna negotiates with Aetna Rx Home Delivery may be higher than the cost they pay for the drugs and the cost of the mail order pharmacy services they provide. For these purposes, the pharmacy's cost of purchasing drugs takes into account discounts, credits and other amounts that they may receive from wholesalers, manufacturers, suppliers and distributors. In case of emergency, call 911 or your local emergency hotline, or go directly to an emergency care facility Translation of the material into another language may be available. Please call Member Services at AETNA ( ). Plan features and availability may vary by location and group size. For more information about Aetna plans, refer to a AETNA LIFE INSURANCE COMPANY Page 6 of 6 (v )