Coverage Period: 01/01/ /31/2014. Coverage for: Individual + Family Plan Type: POS ARCHDIOCESE OF GALVESTON-HOUSTON

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1 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions What is the overall deductible? Are there other deductibles for specific? Is there an out-of-pocket limit on my expenses? Answers For each Calendar Year, In-network: Individual $800 / Family $1,600; Outof-network: Individual $1,600 / Family $3,200. Does not apply to office visits, preventive care, and emergency care innetwork. No. Yes, In-network: Individual $3,300 / Family $6,600; Out-of-network: Individual $6,000 / Family $12,000. Why this Matters: You must pay all the costs up to the deductible amount before this plan begins to pay for covered you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered after you meet the deductible. You don t have to meet deductibles for specific, but see the chart starting on page 2 for other costs for this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered. This limit helps you plan for health care expenses. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, penalties for failure to obtain preauthorization for and health care this plan doesn t cover. Even though you pay these expenses, they don t count toward the out-of-pocket limit. Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there this plan doesn't cover? No. Yes. For a list of in-network providers, see or call No. Yes. The chart starting on page 2 describes any limits on what the plan will pay for specific covered, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered. Be aware, your in-network doctor or hospital may use an out-of-network provider for some. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the this plan doesn t cover are listed on page 6. See your policy or plan document for additional information about excluded. Page 1 of 8

2 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, copayments, and coinsurance amounts. Common Medical Event Services You May Need Primary care visit to treat an injury or illness In-Network Provider $25 copay per visit, Out-Of-Network Provider Limitations & Exceptions Applies to all network physicians of internal medicine, pediatrics, family practice, general medicine and OB/GYN physicians. If you visit a health care provider s office or clinic If you have a test Specialist visit Other practitioner office visit Preventive care/screening/ immunization Diagnostic test (xray, blood work) Imaging (CT/PET scans, MRIs) $40 copay per visit, $40 copay per visit, No Charge, deductible waived; no charge routine mammograms, digital rectal exam / prostate-specific antigen test and colorectal cancer screening Coverage limited to $1,500 each, per calendar year, for chiropractic and acupuncture care. Age and frequency schedules may apply. $25 copay per visit, x-ray; no charge, laboratory Page 2 of 8

3 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at rmacyinsurance/individual s-families If you have outpatient surgery If you need immediate medical attention Services You May Need Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room Emergency medical transportation Urgent care In-Network Provider $10 copay/ prescription (retail), $5 copay/ prescription (mail order) $50 copay/ prescription (retail), $95 copay/ prescription (mail order) $75 copay/ prescription (retail), $145 copay/ prescription (mail order) $10 copay (generic), $50 copay (preferred brand), $75 copay (non-preferred brand), (mail order not covered) $170 copay per visit, $100 copay for ground; $1,000 copay air/water $40 copay per visit, Out-Of-Network Provider (retail), (mail order not covered) (retail), (mail order not covered) (retail), (mail order not covered) $170 copay per visit, $100 copay for ground; $1,000 copay air/water Limitations & Exceptions Covers up to a 30-day supply (retail prescription); day supply (mail order prescription). Includes medically necessary contraceptive drugs and devices obtainable from a pharmacy. Aetna Specialty CareRxSM - First Prescription must be filled at a participating retail pharmacy or Aetna Specialty Pharmacy. Subsequent fills must be through Aetna Specialty Pharmacy. Non-emergency use covered 20% coinsurance,, after $170 copay in-network;,, after $170 copay out-ofnetwork. No coverage for non-urgent use. Page 3 of 8

4 Common Medical Event If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs If you are pregnant Services You May Need Facility fee (e.g., hospital room) Physician/surgeon fee Mental/Behavioral health outpatient Mental/Behavioral health inpatient Substance use disorder outpatient Substance use disorder inpatient Prenatal and postnatal care Delivery and all inpatient In-Network Provider $25 copay per visit, Out-Of-Network Provider Limitations & Exceptions Pre-authorization required for out-of-network care. Benefits will be reduced by $400 if preauthorization is not obtained. Pre-authorization required for out-of-network care. Benefits will be reduced by $400 if preauthorization is not obtained. Page 4 of 8

5 Common Medical Services You Out-Of-Network Event May Need In-Network Provider Provider Limitations & Exceptions Home health care No charge, after deductible Coverage is limited to 100 visits per calendar year. Pre-authorization required for out-ofnetwork care. Benefits will be reduced by $400 if pre-authorization is not obtained. If you need help recovering or have other special health needs Rehabilitation Habilitation Skilled nursing care $40 copay per visit, Coverage is limited to 60 visits per calendar year for occupational, physical and speech therapy combined.. Coverage is limited to 120 days per calendar year. Pre-authorization required for out-ofnetwork care. Benefits will be reduced by $400 if pre-authorization is not obtained. Durable medical equipment Coverage is limited to $10,000 per calendar year. Hospice service Pre-authorization required for out-of-network care. Benefits will be reduced by $400 if preauthorization is not obtained. If your child needs dental or eye care Eye exam Glasses Dental check-up $25 copay per visit, Coverage is limited to 1 routine eye exam per calendar year.. Page 5 of 8

6 Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded.) Bariatric surgery Glasses (Child) Non-emergency care when traveling outside the U.S. Cosmetic surgery Habilitation Routine foot care Dental care (Adult) Long-term care Weight loss programs Dental care (Child) Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered and your costs for these.) Acupuncture $1,500 per calendar year Hearing aids $750 per calendar year Private-duty nursing 70 8-hour shifts combined with Home health care Chiropractic care $1,500 per calendar year Infertility treatment, diagnosis & treatment of Routine eye care (Adult) 1 exam per calendar year underlying medical condition only Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: Aetna at , the Department of Labor s Employee Benefits Security Administration at EBSA (3272) or Additionally, a consumer assistance program can help you file an appeal. Contact information is at Language Access Services: Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 如 果 需 要 中 文 的 帮 助, 请 拨 打 这 个 号 码 Para obtener asistencia en Español, llame al To see examples of how this plan might cover costs for a sample medical situation, see the next page. Page 6 of 8

7 Coverage Examples Aetna Choice POS II Standard Plan About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Amount owed to providers: $7,500 Amount owed to providers: Plan pays: $6,040 Plan pays: $4,040 Patient pays: $1,460 Patient pays: $1,260 Sample care costs: Hospital charges (mother) Routine obstetric care Hospital charges (baby) Anesthesia Laboratory tests Prescriptions Radiology Vaccines, other preventive Total Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total Having a baby (normal delivery) Managing type 2 diabetes (routine maintenance of a well-controlled condition) $5,300 Sample care costs: $ 2,700 Prescriptions $ 2,900 $ 2,100 Medical Equipment and Supplies $ 1,300 $ 900 Office Visits and Procedures $ 700 $ 900 Education $ 300 $ 500 Laboratory tests $ 100 $ 200 Vaccines, other preventive $ - $ 200 Total $ 5,300 $ - $ 7,500 Patient pays: Deductibles $ 800 Copays $ 250 $ 800 Coinsurance $ 130 $ - Limits or exclusions $ 80 $ 510 Total $ 1,260 $ 150 Note: Your plan may have both copays and $ 1,460 coinsurance for covered ; if so, these examples use copays only. Your costs may be higher. Page 7 of 8

8 Coverage Examples Aetna Choice POS II Standard Plan Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient's condition was not an excluded or preexisting condition. All and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Page 8 of 8

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