Aetna HealthFund Health Reimbursement Account Plan (Aetna HealthFund Open Access Managed Choice POS II )

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1 Health Fund The Health Fund amount reflected is on a per calendar year basis. If you do not use the entire fund by 12/31/2015, it will be moved into a Limited-Purpose Flexible Spending Account. Health Fund Administration $ 750 Employee $1,125 Employee + 1 Dependent $1,500 Family The Health Fund will be used to pay for your member responsibility, including your deductible and coinsurance. Once the deductible is met, the underlying medical plan provides coverage and if a Health Fund balance still exists, the Health Fund will pay your member responsibility (i.e. your share of coinsurance) until the Coinsurance Limit has been reached or the Health Fund has been exhausted, whichever comes first. Services covered at 100% with no deductible will be paid by the plan and not by the Health Fund. Health Fund Rollover If you do not use the entire fund by 12/31/2015, it will be moved into a Limited-Purpose Flexible Spending Account. If the employee s plan coverage is terminated, all remaining funds are forfeited. Health Fund Pro-ration for Family Status Change No pro-ration. Change to new tier based on new employee status. Eligible Expenses The Health Fund covers the same expenses as the medical and pharmacy plan. Prescription Drug expenses are integrated with the medical plan (subject to deductible) and with the Health Fund (eligible for reimbursement from the Health Fund). Expenses above the Reasonable & Customary limit, any plan limits, and any non-covered expenses are not eligible for reimbursement under the Health Fund. Plan Features Deductible (per calendar year) All covered expenses, including prescription drugs, accumulate toward both the In-Network and Out-of-Network Deductible. Unless otherwise indicated, the Deductible must be met prior to benefits being payable. $1,250 Employee $1,875 Employee + 1 Dependent $2,500 Family $1,250 Employee $1,875 Employee + 1 Dependent $2,500 Family Member Coinsurance Applies to all expenses unless otherwise stated. Coinsurance Limit (per calendar year) All covered expenses, excluding prescription drugs, accumulate toward both the In-Network and Out-of-Network Coinsurance Limit. Certain member cost sharing elements may not apply toward the Coinsurance Limit. $1,750 Employee $3,750 Employee + 1 Dependent $5,750 Family $5,750 Employee $11,750 Employee + 1 Dependent $17,750 Family Primary Care Physician Selection Optional Not applicable Certification Requirements Certification for certain types of Non-Preferred care must be obtained to avoid a reduction in benefits paid for that care. Certification for Hospital Admissions, Treatment Facility Admissions, Convalescent Facility Admissions, Home Health Care, Hospice Care and Private Duty Nursing is required - excluded amount applied separately to each type of expense is $500 per occurrence. Preventive Care Routine Adult Physical Exams/Immunizations 1 exam per 12 months for members age 22 to age 65; 1 exam per 12 months for adults age 65 and older. Routine 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 per year thereafter to age 22. Routine Gynecological Care Exams Includes routine tests and related lab fees. 1 exam per calendar year. Page 1 of 6

2 Preventive Care con t. Routine Mammograms For covered females age 40 and over. 1 exam per calendar year. Routine Digital Rectal Exam/Prostate-specific Antigen Test For covered males age 40 and over. 1 exam per calendar year. Colorectal Cancer Screening For all members age 50 and over. Routine Eye Exam 1 routine exam per 12 months. Routine Hearing Exams 1 routine exam per 12 months. Women s Health Women s health screenings and services 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. Contraceptive methods, sterilization procedures, patient education and counseling. Limitations may apply. Maternity OB Visits Pre-Natal Maternity Maternity and Post Partum Care Covered at 100%, deductible waived 10%, after deductible Generic FDA-approved Women s Contraceptives Physician Services Office visits to Primary Care Physician Includes services of an internist, general physician, family practitioner or pediatrician. Covered at 100%, deductible waived Specialist Office visits Allergy Testing Allergy Injections 10%, after deductible 10%, after deductible Diagnostic Procedures Diagnostic Laboratory and X-ray If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the applicable physician's office visit member cost sharing. Emergency Medical Care Urgent Care Provider (Benefit availability may vary by location.) 10%, after deducible Emergency Room 10%, after deducible 10%, after deductible Ambulance 10%, after deducible Page 2 of 6

3 Hospital Care Inpatient member's inpatient visit. Inpatient Maternity Coverage member's inpatient stay. Outpatient Surgery Outpatient Hospital Expenses (excluding surgery) Gender Reassignment Surgery Includes transgender surgery coverage. Limited to one surgery per lifetime to a maximum of $50,000. Requires that clinical criteria must be met. Details can be found at Mental Health Services Inpatient member's inpatient stay. Outpatient Alcohol/Drug Abuse Services Inpatient member's inpatient stay. Outpatient Other Services Convalescent Facility Limited to 120 days per calendar year. The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Home Health Care Limited to 100 visits per calendar year. Includes unlimited Private Duty Nursing. Each visit by a nurse or therapist is one visit. Each visit up to 4 hours by a home health care aide is one visit. Covered 100%, after deductible Hospice Care - Inpatient The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Hospice Care - Outpatient Outpatient Speech Therapy Covers all conditions. Limited to 25 visits per calendar year. Additional visits may be authorized if medically necessary. No calendar year limit for members with autism or pervasive developmental disorder. Page 3 of 6

4 Other Services con t. Outpatient Physical and Occupational Therapy Limited to 24 visits per calendar year. Additional visits may be authorized if medically necessary. Covers injury, development delays, autism and organic disease. No calendar year limit for members with autism or pervasive developmental disorder. Applied Behavioral Analysis 10%, after deductible Not Covered Covered same as any other outpatient mental health benefit. Pre-certification and in-network providers required. Spinal Manipulation Therapy Limited to 20 visits per calendar year. Durable Medical Equipment Unlimited calendar year maximum. Therapeutic shoes and inserts for members with diabetes. Hearing Aids Limited to $5,000 per calendar year. 10%, after deductible 50%, after deductible Diabetic Supplies Contraceptive drugs and devices not obtainable at a pharmacy (Includes coverage for contraceptive visits.) Transplants Covered same as any other medical expense; after deductible 10% (payable as any other covered expense) after deductible 10% In-Network coverage is provided at an IOE contracted facility only; after deductible Covered same as any other medical expense; after deductible 30% (payable as any other covered expense) after deductible 30% Out-of-Network coverage is provided at a Non-IOE facility; after deductible Bariatric Surgery 10%, after deductible Not Covered Acupuncture Limited to 12 visits per calendar year. Mouth, Jaws and Teeth (Oral surgery procedures that are medical in nature.) Out of Area Dependents Family Planning Infertility Treatment Diagnosis and treatment of the underlying medical condition. Member cost sharing is based on the type of service performed and the place of service where it is rendered; after deductible Coverage provided at 10%. All non-preferred benefits and limitations apply. Coverage provided at 10%. All non-preferred benefits and limitations apply. Voluntary Sterilization Vasectomy. Tubal ligation. Comprehensive Infertility Services Coverage includes Artificial Insemination and Ovulation Induction Combined Comprehensive Infertility Services and Advanced Reproductive Technology (ART) $7,000 lifetime maximum for Medical and $3,000 lifetime for Prescriptions, applies to all procedures covered by any Aetna plan except where prohibited by law. Member cost sharing is based on the type of service performed and the place of service where it is rendered; after deductible 100%, deductible waived 50%, after deductible Not Covered Vasectomy and tubal ligation: Member cost sharing is based on the type of service performed and the place of service where it is rendered; after deductible Page 4 of 6

5 Family Planning con t. Advanced Reproductive Technology (ART) 50%, after deductible Not Covered ART coverage includes: In vitro fertilization (IVF), zygote intra-fallopian transfer (ZIFT), gamete intrafallopian transfer (GIFT), cryopreserved embryo transfers, intracytoplasmic sperm injection (ICSI) or ovum microsurgery. Combined Comprehensive Infertility Services and Advanced Reproductive Technology (ART) $7,000 lifetime maximum for Medical and $3,000 lifetime for Prescriptions, applies to all procedures covered by any Aetna plan except where prohibited by law. Maximum applies to all procedures covered by any Aetna plan except where prohibited by law. Pharmacy The full cost of the drug is applied to the deductible before benefits are considered for payment under the pharmacy plan. Retail Mail Order Preventive and Chronic Medications Covered 100% after combined medical/rx plan deductible is met; then $10 copay for generic drugs, $20 copay for formulary brandname drugs, and $40 copay for non-formulary brand-name drugs up to a 30 day supply at participating pharmacies. Covered 100% after combined medical/rx plan deductible is met; then $20 copay for generic drugs, $40 copay for formulary brandname drugs, and $80 copay for non-formulary brand-name drugs up to a day supply from Aetna Rx Home Delivery. Deductible is waived for certain preventive and chronic medications such that only the copay applies. A full list of these drugs is available on Aetna Navigator. 50% after combined medical/rx plan deductible and submitted cost for all drugs up to a 30 -day supply. Not applicable Deductible is waived for certain preventive and chronic medications such that only the copay applies. A full list of these drugs is available on Aetna Navigator. Pharmacy Managed Self Injectables (PMSI) No Mandatory Generic (No MG) Plan also includes: Performance Enhancing Medication, Contraceptive drugs and devices obtainable from a pharmacy, oral fertility drugs, Diabetic supplies. Precertification for growth hormones included. First prescription fill at any retail or mail order drug facility. Subsequent fills must be through Aetna Specialty Pharmacy. Member is responsible to pay the applicable copay only. First prescription fill at any retail or mail order drug facility. Subsequent fills must be through Aetna Specialty Pharmacy. Member is responsible to pay the applicable copay only. Page 5 of 6

6 General Provisions Dependent Eligibility Spouse, domestic partner, children from birth to age 26 Pre-existing Conditions Exclusion On effective date: Waived After effective date: Waived This plan does not cover all health care expenses and includes exclusions and limitations. Members should refer to their plan documents to determine which health care services are covered and to what extent. The following is a partial 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 or hospital services not specifically covered in, or which are limited or excluded in the plan documents; Charges related to any eye surgery mainly to correct refractive errors; Cosmetic surgery, including breast reduction; Custodial care; Dental care and X-rays; Donor egg retrieval; Experimental and investigational procedures; Hearing aids; Immunizations for travel or work; Infertility services, including, but not limited to, 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. Nonmedically necessary services or supplies; Orthotics; Over-the-counter medications and supplies; Reversal of sterilization; Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies, or counseling; and special duty nursing. 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 Morbid Obesity, or for the purpose of weight reduction, regardless of the existence of comorbid conditions. 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 results or outcomes. Consult the plan documents (i.e. Group Insurance Certificate and/or Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitation relating to the plan. With the exception of Aetna Rx Home Delivery, all preferred providers and vendors are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change without notice. Some benefits are subject to limitations or visit maximums. Certain services require precertification, or prior approval of coverage. Failure to precertify for these services may lead to substantially reduced benefits or denial of coverage. Some of the benefits requiring precertification may include, but are not limited to, inpatient hospital, inpatient mental health, inpatient skilled nursing, outpatient surgery, substance abuse (detoxification, inpatient and outpatient rehabilitation). When the Member s preferred provider is coordinating care, the preferred provider will obtain the precertification. When the member utilizes a non-preferred provider, Member must obtain the precertification. Precertification requirements may vary. Depending on the plan selected, new prescription drugs not yet reviewed by our medication review committee are either available under plans with an open formulary or excluded from coverage unless a medical exception is obtained under plans that use a closed formulary. They may also be subject to precertification or step-therapy. Non-prescription drugs and drugs in the Limitations and Exclusions section of the plan documents (received after open enrollment) are not covered, and medical exceptions are not available for them. While this information is believed to be accurate as of the print date, it is subject to change. Plan is administered by Aetna Life Insurance Company. Page 6 of 6

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