California 2 50 Plan guide

Transcription

1 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions California 2 50 Plan guide The health of business, well planned. Plans effective January 1, 2013 For businesses with 2-50 eligible employees CA M (11/12)

2 Team with Aetna for the health of your business Introducing a new suite of products and services designed specifically for companies with 2 to 50 employees. 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. We are 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, we offer 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: 3 Women s preventive health benefits 4 Small business commitment 6 Provider Network 8 Medical overview 13 Medical plan options 30 Dental overview 32 Dental plan options 44 Life overview 46 Life plan options 48 Underwriting guidelines 70 Buy up/buy down Product guide 72 Limitations and exclusions 74 New Business Checklist Health/Dental benefits, health/dental insurance and life insurance plans/policies are offered and/or underwritten by Aetna Health of California Inc., Aetna Dental of California Inc. and/or Aetna Life Insurance Company (Aetna). 2

3 Women s preventive health benefits New changes effective August 1, 2012 To comply with the Patient Protection and Affordable Act and the Health Care Education Reconciliation Act of 2010, when your plan renews on or after August 1, 2012, it will include 100 percent coverage of women s preventive services when performed by an in-network physician. Your Aetna plan already complies with a number of the required women s preventive services. Adjustments will be required to comply with the remainder. We want to let you know about the changes being made and how they will affect your plan. Well-Woman Visits Your plan already covers well-woman preventive care visits and annual routine physicals at 100 percent. Prenatal Care Prenatal care office visits will be considered preventive under Health Care Reform and will be paid at 100 percent. Health Screenings and Counseling Aetna plans already cover most of the screenings and counseling required at 100 percent as part of any routine annual exam or well-woman exam. These include: --Screening for human papillomavirus (HPV) --Counseling for sexually transmitted infections --Counseling and screening for human immune-deficiency virus (HIV) --Screening and counseling for interpersonal and domestic violence Gestational Diabetes Screening We will cover three diabetes lab tests that can be taken during pregnancy. Breastfeeding Support, Supplies and Counseling We have developed a breastfeeding benefit that will cover counseling from a lactation consultant and the purchase of a breast pump within 60 days of the birth of a baby, limited to one electric breast pump every 36 months. Contraceptive Methods and Counseling Includes drugs, implantable devices, sterilization procedures and patient education and counseling for women with reproductive capacity. Coverage for formulary, generic, FDA-approved women s contraceptive covered 100 percent in network. Certain religious organizations or religious employers may be exempt from offering contraceptive services. Female Sterilization (tubal ligation) Will be covered at 100 percent. Aetna will not cover at 100 percent methods and sterilization procedures intended for males, such as male condoms and vasectomies. The changes will be applied to your plan when it renews on or after August 1,

4 We are dedicated to the health of your business Employers and their employees can benefit from Affordable plan options Online self-service tools Improved services for consumer-directed health plans 24-hour access to Employee Assistance Program services Preventive care covered 100% Aetna disease management and wellness programs We know it s about Options We provide a variety of health plan options to help meet your employees needs, including medical, dental, 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 HMO plans HSA* and HRA-compatible plans MC and PPO plans Dental plans Dental DMO Dental PPO Dental Freedom-of-Choice plan design Life plans Basic term life insurance Simplicity We know that the health of your business is your top priority. Our streamlined plans and variety of services make it easier for you to focus on your business by simplifying administration and management. We make 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 they can trust. Aetna resources are designed to strengthen the health of your business You and your employees can: Track medical claims and take advantage of online services with your Aetna Navigator secure member website. It features 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. Get 24/7 access to a nurse to help with personal health-related questions. Work toward health goals with wellness initiatives, such as the Simple Steps To A Healthier Life online program. Take advantage of the Aetna Resource Connection SM, which features goods and services such as office supplies, HR support, payroll, technology assistance, and more. *HSAs are currently not available to HMO members in CA. 4

5 We understand that your business has unique needs. That s why we have streamlined our plan options for employers with 2 to 50 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. Our health plan options are designed with the health of your business in mind Basic plans Provide basic benefits for your employees Limit the expense to your business Allow employees to buy up and share more of the cost --HMO deductible plans --MC $2,500 75/50 --MC $3,500 65/50 --MC Value $2,250 60/50 --MC Value $3,750 50/50 Value plans Encourage employees to make responsible health care decisions Provide tools and resources to support consumerism Provide an innovative plan design --HMO coinsurance plans --MC $10, /50 --HSA-compatible plans* Standard plans Provide standard benefits plans Limit the financial impact on employees --HMO $30 --MC $250 90/70 --MC $500 80/60 --MC $1,250 80/50/50 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 health plans HSA-compatible 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 Consumer-directed health plans Standard 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 Standard plans Consumer-directed health 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 Consumer-directed health plans HSA-compatible plans* *HSA plans are currently not available to HMO members. 5

6 California Provider Network County Aetna Value Network SM HMO MC PPO Alameda Alpine Amador Butte Calaveras Colusa Contra Costa** Del Norte El Dorado Large physician network* -- More than 287,859 physicians and 1,989 hospitals -- Aetna Value Network = 45,891 doctors and 313 hospitals -- HMO Network = 75,336 doctors and 316 hospitals -- Managed Choice Network = 83,245 doctors and 333 hospitals -- PPO Network = 83,387 doctors and 333 hospitals Fresno Glenn Humboldt Imperial Inyo Kern Kings Lake Lassen Los Angeles** Madera Marin Mariposa Mendocino Merced Modoc Mono Monterey Napa Nevada Vitalidad HMO is available in San Diego County. The Basic HMO (formerly Vitalidad Plus) network is available in select areas of Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco, Santa Barbara and Santa Clara Counties. PrimeCare Physicians plan available in Small Group rating area 5. * According to the Aetna Enterprise Provider Database as of August 31, Network subject to change. ** The Aetna Value Network HMO plans are available in select areas of Sonoma, Contra Costa, San Joaquin, San Mateo, Los Angeles, San Bernardino, Riverside and San Diego Counties. Contact Aetna for more information. The HMO network is available in select areas of Fresno, Placer, Riverside, Sacramento, San Bernardino, San Joaquin, Solano, Sonoma and Yolo Counties. Contact Aetna for more information. 6

7 County Aetna Value Network SM HMO MC PPO Orange Placer Plumas Riverside**, Sacramento San Benito San Bernardino**, San Diego** San Francisco San Joaquin**, San Luis Obispo San Mateo** Santa Barbara Santa Clara The following IPAs are not available to HMO Deductible/HMO Coinsurance members: Los Angeles All Care Medical Group Cedars-Sinai Health Associates Cedars-Sinai Medical Care Foundation Family Care Specialists IPA, A Medical Group Prudent Medical Care Orange AMVI Medical Group Mission Heritage Medical Group - Orange Mission Hospital Affiliated Physicians St. Joseph Heritage Medical Group St. Joseph Hospital Affiliated Physicians St. Jude Affiliated Physicians St. Jude Heritage Medical Group San Diego Scripps Clinic Medical Group Scripps Coastal Medical Center Santa Cruz Shasta Sierra Siskiyou Solano Sonoma**, Stanislaus Sutter Tehama Trinity Tulare Tuolumne Ventura Yolo Yuba Vitalidad HMO is available in San Diego County. The Basic HMO (formerly Vitalidad Plus) network is available in select areas of Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco, Santa Barbara and Santa Clara Counties. PrimeCare Physicians plan available in Small Group rating area 5. * According to the Aetna Enterprise Provider Database as of August 31, Network subject to change. ** The Aetna Value Network HMO plans are available in select areas of Sonoma, Contra Costa, San Joaquin, San Mateo, Los Angeles, San Bernardino, Riverside and San Diego Counties. Contact Aetna for more information. The HMO network is available in select areas of Fresno, Placer, Riverside, Sacramento, San Bernardino, San Joaquin, Solano, Sonoma and Yolo Counties. Contact Aetna for more information. 7

8 Aetna Medical Plans We are committed to putting the employee at the center of everything we do. You can count on us to provide health plans that help simplify decision making and plan administration so you can focus on the health of your business. 8

9 Medical Overview We will offer the in-state portfolio (MC) and rating structure to out-of-state employees who live in an out-of-state network area. Out-of-state employees who do not live in an out-of-state network area will be eligible for an indemnity plan. Product Name Product Description PCP Required Referrals Required Network Health Maintenance Organization (HMO) Aetna HMO Deductible Plan Aetna HMO Coinsurance Plan Aetna Value Network SM HMO Vitalidad Mexico con Aetna SM * (Available for California employers) Basic HMO*, ** (Available for California employers) Managed Choice (MC) PPO Indemnity Each family member selects a primary care physician (PCP) participating in our network. The PCP provides routine and preventive care and helps coordinate the member s total health care. The PCP refers members to participating specialists and facilities for medically necessary specialty care. Only services provided or referred by the PCP are covered except for emergency, urgently needed care or direct access benefits, unless approved by the HMO before receiving services. Uses all services of the HMO with a subset of the HMO Network with additional savings by applying a deductible for certain medical services. Uses all services of the HMO with a subset of the HMO Network with additional savings by applying a coinsurance for certain medical services. All the services of the HMO provided by a subset of the full HMO network. Aetna Value Network plans offer similar benefits of the Aetna HMO plan, with premium savings when members access a select network of providers. HMO plans that feature the Sistemas Medicos Nacionales, S.A. de C.V. (SIMNSA) provider network in Northern Mexico service area. San Diego county employees access health care services from participating providers in the Mexican cities of Tijuana, Tecate and Mexicali. Members choose a Mexico-based PCP. Only services provided or referred by their PCP, except for emergency or urgent care, are covered unless approved by the HMO in advance of receiving services. Coverage for employees in select zip codes in California and in the Mexican cities of Tijuana, Tecate, or Mexicali through a specially developed provider network. Plans are available to California employers who provide employees and their dependents access to care from a California-based PCP or a Mexican-based PCP. Covered benefits differ based on PCP country location. Members can access any participating provider for covered services without a referral. Members have the freedom to choose network providers at lower out-of-pocket costs, or non-network providers at higher out-of-pocket costs at any time. Members are able to receive emergency services at the in-network coinsurance/copay level. Members can access any participating provider for covered services without a referral. When 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. Members are able to receive emergency services at the in-network coinsurance/copay level. Employees who live outside the plan s network service area are eligible. Members coordinate their own health care and may access any participating provider for covered services without a referral. Yes Yes HMO Yes Yes HMO Deductible Yes Yes HMO Deductible Yes Yes Aetna Value Network SM HMO Yes Yes Vitalidad HMO* Yes Yes Basic HMO* (formerly Vitalidad Plus HMO) No No Aetna Open Access Managed Choice POS No No Open Choice PPO No No N/A * Provider network through Sistemas Medicos Nacionales, S.A. de C.V. (SIMNSA). This Health Plan may be limited in benefits, rights and remedies under U.S. federal and state law. Este Plan de Salud puede tener limitaciones en sus beneficios, derechos y resoluciones bajo las leyes federales estatales de Los Estados Unidos. **Formerly Vitalidad PlusSM California con Aetna. 9

10 An explanation of out-of-pocket limits MC These limits include coinsurance. These limits do not include amounts over allowable charges, copays, deductibles, failure to precertify penalty payments for non-serious mental disorders, substance abuse, DME, infertility and Rx (including Specialty CareRx). HSA HDHP* These limits include coinsurance, copays and Rx (including Specialty Care Rx). These limits do not include amounts over allowable charges, deductible and failure to precertify penalty. HMO/AVN HMO/HMO Deductible/ Vitalidad HMO/Basic HMO** These limits include coinsurance, copays and deductibles. These limits do not include member cost-sharing for Prescription Drugs. Ways to meet the family deductible and out-of-pocket limit MC HSA HDHP* HMO/AVN HMO/HMO Deductible/ Vitalidad HMO/Basic HMO**/ MC $7500/MC $10,000/MC HRA $3,000 Two- or Three-Member Maximum True Integrated Family (TIF) Embedded Aggregate Once two or three members of a family have satisfied their individual deductible and/or out-of-pocket limit, all family members will be considered as having met these limits. The family deductible and/or out-of-pocket limit can be met by a combination of family members or by a single member. There is no individual deductible and/or out-of-pocket limit to satisfy. The family deductible and/or out-of-pocket limit can be met by a combination of family members. Each covered family member only needs to satisfy his or her individual deductible and/or out-of-pocket limit. *HSAs are currently not available to HMO members. **Formerly Vitalidad Plus. 10

11 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 you have control over HRA plan designs. The fund is available to an employee for qualified expenses on the plan s effective date. Health Savings Accounts (HSA) No set-up or administrative fees The Aetna HealthFund HSA plan is a tax-advantaged savings account that is coupled with an HSA compatible high deductible health benefits and insurance plan. Once enrolled, account contributions can be made by you and/or the employee. The HSA can be used to pay for qualified expenses tax free. The HRA and the HSA provide members with financial support for higher out-of-pocket health care expenses. Our consumer-directed health products and services help lower your costs and give members the information and resources they need to help make informed health care decisions for themselves and their families. COBRA Administration Aetna COBRA administration offers a full range of notification, documentation and record-keeping processes. These processes can assist you with managing the complex billing and notification processes that are required for COBRA compliance, while also helping to same you time and money. Section 125 Cafeteria Plans and Section 132 Transit Reimbursement Accounts You can pay less in payroll taxes and employees can reduce their taxable income. 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. Administrative Fees Fee description HSA Initial set-up $0 Monthly fees $0 Premium Only Plan (POP) Fee Initial set-up* $190 Renewal $125 Health Reimbursement Arrangement (HRA) and Flexible Spending Account (FSA)** Initial set-up 2 25 employees $360 $ employees $460 $ employees $560 $335 Monthly fees $5.45 per participant Additional set-up fee for stacked plans (those electing an Aetna HRA and FSA simultaneously) Participation fee for stacked participants $150 $10.45 per participant Minimum fees 0 25 employees $25 per month minimum employees $50 per month minimum COBRA Services Annual fee employees $ employees $230 Per employee per month Employees $ Employees $1.05 Initial notice fee $3.00 per notice (includes notices at time of implementation and during ongoing administration) Minimum fees Employees $25 per month minimum Employees $50 per month minimum Transit Reimbursement Account (TRA) Annual fee $350 Transit monthly fees $4.25 per participant Parking monthly fees $3.15 per participant Renewal fee * 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 subject to change. HSAs are currently not available to HMO members. Aetna reserves the right to change any of the above fees and to impose additional fees upon prior written notice. 11

12 Plan Type and Value By Price* Plan Name $ $$ $$$ Vitalidad HMO $10 MC $10, /50 MC Value $3,750 50/50 MC $7,500 75/50 MC $4,500 60/50 MC HSA HDHP $3,500 80/50 MC HSA HDHP $2,000 80/50 MC $3,500 65/50 MC HRA HDHP $3,000 70/50 MC Value $2,250 60/50 MC $2,500 75/50 MC $2,000 80/50/50 HMO Coinsurance 60% HMO Deductible $1,500 70% HMO Coinsurance 70% Basic HMO $30** MC $1,250 80/50/50 MC HSA HDHP $3,000 90/50 HMO Deductible $1,000 70% MC $750 80/50/50 MC $1,000 70/50 Value Network HMO $40/$50 HMO $50 Value Network HMO $30/$40 HMO $40 Value Network HMO $20/$30 Basic HMO $10** Value Network HMO $10/$20 HMO $30 HMO $20 MC $500 80/60 HMO $10 MC $250 80/60 MC $250 90/70 PPO $750 80/60 Indemnity *Average prices may vary by county. **Formerly Vitalidad Plus. 12

13 HMO Plans Plan Name HMO $10 HMO $20 HMO $30* HMO $40 HMO $50 Network HMO HMO HMO HMO HMO PCP/Referrals Required Yes Yes Yes Yes Yes Member Benefits In network In network In network In network In network Calendar-Year Plan Deductible None None None None None Out-of-Pocket Limit $1,500 individual $3,000 family $2,500 individual $5,000 family $3,000 individual $6,000 family $3,500 individual $7,000 family $4,000 individual $8,000 family Deductible & Out-of-Pocket Limit Accumulation Not Included In Out-of-Pocket Limit Embedded aggregate Prescription drug copays Embedded aggregate Prescription drug copays Embedded aggregate Prescription drug copays Embedded aggregate Prescription drug copays Embedded aggregate Prescription drug copays Primary Care Physician Office Visit1 $10 copay $20 copay $30 copay $40 copay $50 copay Specialist Office Visit1 $10 copay $20 copay $30 copay $40 copay $50 copay Preventive Care/Screenings/Immunizations No charge No charge No charge No charge No charge Diagnostic Testing1 (X-ray, blood work) Lab: No charge X-ray: $10 copay Lab: No charge X-ray: $20 copay Lab: No charge X-ray: $30 copay Lab: No charge X-ray: $40 copay Lab: No charge X-ray: $50 copay Imaging (CT/PET scans MRI s) $100 copay $100 copay $100 copay $100 copay $100 copay Prescription Drug Deductible None None None None None (applies to brand and nonformulary brand drugs) Prescription Drugs Generic formulary/brand formulary/ Generic & brand nonformulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply $15/$35/$50 $15/$35/$50 $15/$35/$50 $15/$35/$50 $15/$35/$50 Pharmacy Plan Type Aetna Specialty CareRx SM - Includes self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit) Three-tier open formulary Covered under medical Three-tier open formulary Covered under medical Three-tier open formulary Covered under medical Three-tier open formulary Covered under medical Three-tier open formulary Covered under medical Outpatient Surgery OP Hospital Department $100 copay $250 copay $300 copay $400 copay $500 copay Outpatient Surgery Freestanding Facility No charge $100 copay $150 copay $200 copay $250 copay Inpatient Hospital Facility $100 copay per admission $200 copay per day up to 3 days per admission $500 copay per day up to 3 days per admission $750 copay per day up to 3 days per admission $1,000 copay per day up to 3 days per admission Rehabilitation Services2 (PT/OT/ST) $10 copay $20 copay $30 copay $40 copay $50 copay (20 visits PT/OT and 20 visits ST per calendar year unless extended by the medical director) Emergency Room $150 copay $150 copay $150 copay $150 copay $150 copay Emergency Medical Transport $100 copay $100 copay $100 copay $100 copay $100 copay Urgent Care $50 copay $50 copay $50 copay $50 copay $50 copay Primary & Specialist Physician E-Visit Walk-In Clinics Chiropractic $15 copay $15 copay $15 copay $15 copay $15 copay (20 visits per calendar year) Routine Vision (one exam per member every 24-months) $10 copay $20 copay $30 copay $40 copay $50 copay *This plan is available for religious exemption. See pages for footnotes. 13

14 HMO Plans Plan Name HMO Coinsurance 70% HMO Coinsurance 60% HMO Deductible $1,000 70% HMO Deductible $1,500 70% Network HMO Deductible Plan HMO Deductible Plan HMO Deductible Plan HMO Deductible Plan PCP/Referrals Required Yes Yes Yes Yes Member Benefits Calendar-Year Plan Deductible None None $1,000 individual $2,000 family Out-of-Pocket Limit $4,000 individual $8,000 family $4,000 individual $8,000 family $4,000 individual $8,000 family $1,500 individual $3,000 family $4,000 individual $8,000 family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate Embedded aggregate Embedded aggregate Embedded aggregate Not Included In Out-of-Pocket Limit Prescription drug copays Prescription drug copays Prescription drug copays Prescription drug copays Primary Care Physician Office Visit1 $40 copay $40 copay $40 copay; deductible Specialist Office Visit1 $50 copay $50 copay $40 copay; deductible $40 copay; deductible $40 copay; deductible Preventive Care/Screenings/Immunizations No charge No charge No charge No charge Diagnostic Testing1 (X-ray, blood work) Lab: $40 copay Lab: $40 copay X-ray: $40 copay X-ray: $40 copay Lab: $40 copay; deductible X-ray: $40 copay; deductible Lab: $40 copay; deductible X-ray: $40 copay; deductible Imaging (CT/PET scans MRI s) $100 copay $100 copay $100 copay; deductible $100 copay; deductible Prescription Drug Deductible $250 per individual $250 per individual $250 per individual $250 per individual (applies to brand and nonformulary brand drugs) Prescription Drugs Generic formulary/brand formulary/ Generic & brand nonformulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply $20/$40/$60 $20/$40/$60 $20/$40/$60 $20/$40/$60 Pharmacy Plan Type Three-tier open formulary Aetna Specialty CareRx SM - Includes self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit) Three-tier open formulary Three-tier open formulary Three-tier open formulary Covered under medical Covered under medical Covered under medical Covered under medical Outpatient Surgery OP Hospital Department 50% 50% 50% after deductible 50% after deductible Outpatient Surgery Freestanding Facility 30% 40% 30% after deductible 30% after deductible Inpatient Hospital Facility 30% 40% 30% after deductible 30% after deductible Rehabilitation Services2 (PT/OT/ST) (20 visits PT/OT and 20 visits ST per calendar year unless extended by the medical director) $50 copay $50 copay $40 copay; deductible Emergency Room $200 copay $200 copay $150 copay after deductible Emergency Medical Transport 30% 40% $100 copay after deductible Urgent Care $50 copay $50 copay $50 copay; deductible $40 copay; deductible $150 copay after deductible $100 copay after deductible $50 copay; deductible Primary & Specialist Physician E-Visit Walk-In Clinics Chiropractic (20 visits per calendar year) Routine Vision (one exam per member every 24-months) $15 copay $15 copay $15 copay; deductible $50 copay $50 copay $40 copay; deductible $15 copay; deductible $40 copay; deductible See pages for footnotes. 14

15 HMO Plans Plan Name AVN HMO $10/$20 AVN HMO $20/$30 AVN HMO $30/$40* AVN HMO $40/$50 Network Aetna Value Network HMO Aetna Value Network HMO Aetna Value Network HMO Aetna Value Network HMO PCP/Referrals Required Yes Yes Yes Yes Member Benefits Calendar-Year Plan Deductible None None None None Out-of-Pocket Limit $2,000 individual $4,000 family $2,500 individual $5,000 family $3,000 individual $6,000 family $3,500 individual $7,000 family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate Embedded aggregate Embedded aggregate Embedded aggregate Not Included In Out-of-Pocket Limit Prescription drug copays Prescription drug copays Prescription drug copays Prescription drug copays Primary Care Physician Office Visit1 $10 copay $20 copay $30 copay $40 copay Specialist Office Visit1 $20 copay $30 copay $40 copay $50 copay Preventive Care/Screenings/Immunizations No charge No charge No charge No charge Diagnostic Testing1 (X-ray, blood work) Lab: No charge X-ray: $10 copay Lab: No charge X-ray: $20 copay Lab: No charge X-ray: $30 copay Lab: No charge X-ray: $40 copay Imaging (CT/PET scans MRI s) $100 copay $100 copay $100 copay $100 copay Prescription Drug Deductible $150 per individual $150 per individual $150 per individual $150 per individual (applies to brand and nonformulary brand drugs) Prescription Drugs $20/$40/$60 $20/$40/$60 $20/$40/$60 $20/$40/$60 Generic formulary/brand formulary/ Generic & brand nonformulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply Pharmacy Plan Type Three-tier open formulary Three-tier open formulary Three-tier open formulary Three-tier open formulary Aetna Specialty CareRx SM - Includes self-injectable, Covered under medical Covered under medical Covered under medical Covered under medical infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit) Outpatient Surgery OP Hospital Department $200 copay $300 copay $400 copay $500 copay Outpatient Surgery Freestanding Facility $100 copay $200 copay $300 copay $400 copay Inpatient Hospital Facility $100 copay per day up to 3 days per admission $400 copay per day up to 3 days per admission $600 copay per day up to 3 days per admission $800 copay per day up to 3 days per admission Rehabilitation Services2 (PT/OT/ST) $20 copay $30 copay $40 copay $50 copay (20 visits PT/OT and 20 visits ST per calendar year unless extended by the medical director) Emergency Room $150 copay $150 copay $150 copay $150 copay Emergency Medical Transport $100 copay $100 copay $100 copay $100 copay Urgent Care $50 copay $50 copay $50 copay $50 copay Primary & Specialist Physician E-Visit Walk-In Clinics Chiropractic $15 copay $15 copay $15 copay $15 copay (20 visits per calendar year) Routine Vision (one exam per member every 24-months) $20 copay $30 copay $40 copay $50 copay *This plan is available for religious exemption. See pages for footnotes. 15

16 Vitalidad HMO Plans Plan Name Vitalidad HMO $10 Network PCP/Referrals Required Member Benefits Calendar-Year Plan Deductible Out-of-Pocket Limit Deductible & Out-of-Pocket Limit Accumulation Not Included in Out-of-Pocket Limit Primary Care Physician Office Visit1 Specialist Office Visit1 Preventive Care/Screenings/Immunizations Diagnostic Testing1 (X-ray, blood work) Imaging (CT/PET scans MRIs) Prescription Drugs (In SIMNSA network) Retail: 30-day supply Mail Order: Prescription Drugs (Out of SIMNSA network / Closed formulary) Closed formulary is based on medications related to an emergency room or urgent care visit. Aetna Specialty CareRxSM - Includes self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit) Outpatient Surgery OP Hospital Department Outpatient Surgery Freestanding Facility Inpatient Hospital Facility Rehabilitation Services (PT/OT/ST) Emergency Room (In SIMNSA network) Emergency Room (Out of SIMNSA network) Emergency Medical Transport (In SIMNSA network) Emergency Medical Transport (Out of SIMNSA network) Urgent Care (In SIMNSA network) Urgent Care (Out of SIMNSA network) Primary & Specialist Physician E-Visit Walk-In Clinics Chiropractic Routine Vision Vitalidad HMO3 Yes In-Network None $2,000 individual $4,000 family Embedded aggregate Prescription drug copays $10 copay $10 copay No charge No charge No charge $10 generic and brand drugs $10 generic/$20 brand Covered under prescription drug copays No charge No charge $100 copay per day up to 7 days per admission $10 copay $20 copay $100 copay No charge $50 copay $20 copay $35 copay $10 copay See pages for footnotes. 16

17 Basic HMO Plans Plan Name Basic HMO $10 + Basic HMO $30 + Network Basic HMO4 Basic HMO4 PCP/Referrals Required Yes Yes Member Benefits California PCP Selected Mexico PCP Selected California PCP Selected Mexico PCP Selected Calendar-Year Plan Deductible None None Out-of-Pocket Limit $2,000 individual $4,000 family $3,000 individual $6,000 family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate Embedded aggregate Not Included in Out-of-Pocket Limit Prescription drug copays Prescription drug copays Primary Care Physician Office Visit1 $10 copay $5 copay $30 copay $10 copay Specialist Office Visit1 $10 copay $5 copay $30 copay $10 copay Preventive Care/Screenings/Immunization No charge No charge No charge No charge Diagnostic Testing (X-ray, blood work) $10 copay No charge $30 copay No charge Imaging (CT/PET scans MRIs) $10 copay No charge $30 copay No charge Prescription Drugs1 Retail: per 30-day supply Mail Order Prescription Drugs Up to a 90-day supply Aetna Specialty CareRxSM - Includes self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit) $15/$35/$50 $5 generic and brand $15/$35/$50 $10 generic and brand 2x retail copay 2x retail copay Covered under medical Covered under prescription drug copay Covered under medical Covered under prescription drug copay Outpatient Surgery OP Hospital Department $100 copay No charge $300 copay No charge Outpatient Surgery Freestanding Facility $50 copay No charge $150 copay No charge Inpatient Hospital $100 copay per day up to 3 days per admission No charge $600 copay per day up to 3 days per admission $100 copay per day up to 7 days per admission Rehabilitation Services2 (PT/OT/ST) $10 copay $5 copay $30 copay $10 copay Visit Limits 20 visits PT/OT and 20 visits ST per calendar year unless extended by the medical director None 20 visits PT/OT and 20 visits ST per calendar year unless extended by the medical director Emergency Room $100 copay $10 copay $100 copay $20 copay Emergency Medical Transport $100 copay No charge $100 copay No charge Urgent Care $50 copay $10 copay $50 copay $20 copay Primary & Specialist Physician E-Visit Walk-In Clinics Chiropractic Services $15 copay $15 copay Visit Limits 20 visits per calendar NA 20 visits per calendar NA year year Routine Vision $5 copay $10 copay None + Formerly Vitalidad Plus. See pages for footnotes. 17

18 Standard MC Plans Plan Name MC $250 90/70 $20 MC $250 80/60 $20 Network See pages for footnotes. 18 Managed Choice POS (Open Access) NA Managed Choice POS (Open Access) PCP/Referrals Required No NA No NA Member Benefits Participating providers Nonparticipating providers5 Participating providers Nonparticipating providers5 Calendar-Year Plan Deductible $250 per member $250 per member $250 per member $250 per member Out-of-Pocket Limit $3,000 per member $6,000 per member $3,500 per member $7,000 per member Deductible & Out-of-Pocket Limit Accumulation Two-member maximum Two-member maximum Not Included In Out-of-Pocket Limit Primary Care Physician Office Visit1 Specialist Office Visit1 Amounts over allowable charges, copays, deductible, failure to precertify penalty, payments for non-serious mental disorders, substance abuse, Rx (including SpecialtyCareRx), infertility and DME. $20 copay; deductible $20 copay; deductible 30% after deductible $20 copay; deductible 30% after deductible $20 copay; deductible NA Amounts over allowable charges, copays, deductible, failure to precertify penalty, payments for non-serious mental disorders, substance abuse, Rx (including SpecialtyCareRx), infertility and DME. 40% after deductible 40% after deductible Preventive Care/Screenings/Immunizations No charge 30% after deductible No charge 40% after deductible Diagnostic Testing (X-ray, blood work) No charge for the first $300 per member, thereafter covered at 10% after deductible 30% after deductible No charge for the first $300 per member, thereafter covered at 20% after deductible 40% after deductible Imaging (CT/PET scans MRI s) 10% after deductible 40% after deductible; plan pays up to $800 per service Prescription Drug Deductible (applies to brand and nonformulary brand drugs) Prescription Drugs Generic formulary/brand formulary/brand nonformulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply 20% after deductible 50% after deductible; plan pays up to $800 per service None NA None NA $15/$25/$40 $15/$40/$50 Pharmacy Plan Type Four-tier open formulary Four-tier open formulary Four-tier open formulary Four-tier open formulary Aetna Specialty CareRxSM - Includes self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit) 30% up to $250 per prescription 30% up to $250 per prescription Outpatient Surgery OP Hospital Department 20% after deductible 40% after deductible; plan pays up to $400 per surgery Outpatient Surgery Freestanding Facility 10% Deductible Waived 30% after deductible; plan pays up to $400 per surgery Inpatient Hospital Facility 10% after deductible $250 copay plus 30% after deductible per admission Rehabilitation Services2 (PT/OT/Chiropractor) (24 visits per calendar year, participating and non-participating providers combined) Rehabilitation Services2 (ST) (20 visits per calendar year, participating and non-participating providers combined) 10% after deductible 30% after deductible; plan pays up to $50 per visit 30% after deductible 50% after deductible; plan pays up to $400 per surgery 20% deductible 40% after deductible; plan pays up to $400 per surgery 20% after deductible $250 copay plus 40% after deductible per admission 20% after deductible 40% after deductible; plan pays up to $50 per visit 10% after deductible 30% after deductible 20% after deductible 40% after deductible Emergency Room $150 copay plus 10% after deductible per visit $150 copay plus 20% after deductible per visit Emergency Medical Transport 10% after deductible 20% after deductible Urgent Care $50 copay; deductible $50 copay; deductible $50 copay; deductible $50 copay; deductible Primar y & Specialist Physician E-Visit (register at Walk-In Clinics $10 copay; deductible $20 copay; deductible $10 copay; deductible $20 copay; deductible Chiropractic Covered under rehabilitation services Covered under rehabilitation services Routine Vision (one exam per member every 24-months) $20 copay; deductible $20 copay; deductible

19 Standard MC Plans Plan Name MC $500 80/60 $35 MC $1,000 70/50 $25 Network Managed Choice POS (Open Access) NA Managed Choice POS (Open Access) PCP/Referrals Required No NA No NA Member Benefits Participating providers Nonparticipating providers5 Participating providers Nonparticipating providers5 Calendar-Year Plan Deductible $500 per member $500 per member $1,000 per member Out-of-Pocket Limit $4,000 per member $8,000 per member $5,000 per member $10,000 per member Deductible & Out-of-Pocket Limit Accumulation Two-member maximum Two-member maximum Not Included In Out-of-Pocket Limit Primary Care Physician Office Visit1 Specialist Office Visit1 Amounts over allowable charges, copays, deductible, failure to precertify penalty, payments for non-serious mental disorders, substance abuse, Rx (including SpecialtyCareRx), infertility and DME. $35 copay; deductible $35 copay; deductible 40% after deductible $25 copay; deductible 40% after deductible $25 copay; deductible NA Amounts over allowable charges, copays, deductible, failure to precertify penalty, payments for non-serious mental disorders, substance abuse, Rx (including SpecialtyCareRx), infertility and DME. 50% after deductible 50% after deductible Preventive Care/Screenings/Immunizations No charge 40% after deductible No charge 50% after deductible Diagnostic Testing (X-ray, blood work) No charge for the first $300 per member, thereafter covered at 20% after deductible 40% after deductible No charge for the first $300 per member, thereafter covered at 30% after deductible 50% after deductible Imaging (CT/PET scans MRI s) 20% after deductible 50% after deductible; plan pays up to $800 per service Prescription Drug Deductible (applies to brand and nonformulary brand drugs) Prescription Drugs Generic formulary/brand formulary/brand nonformulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply 30% after deductible 50% after deductible; plan pays up to $800 per service None NA None NA $15/$40/$50 $15/$40/$50 Pharmacy Plan Type Four-tier open formulary Four-tier open formulary Four-tier open formulary Four-tier open formulary Aetna Specialty CareRxSM - Includes self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit) 30% up to $250 per prescription 30% up to $250 per prescription Outpatient Surgery OP Hospital Department $150 copay plus 30% after deductible $150 copay plus 50% after deductible; plan pays up to $400 per surgery Outpatient Surgery Freestanding Facility 20% after deductible $150 copay plus 40% after deductible; plan pays up to $400 per surgery Inpatient Hospital Facility 20% after deductible $250 copay plus 40% after deductible; plan pays up to $750 per day Rehabilitation Services2 (PT/OT/Chiropractor) (24 visits per calendar year, participating and non-participating providers combined) Rehabilitation Services2 (ST) (20 visits per calendar year, participating and non-participating providers combined) 20% after deductible 40% after deductible; plan pays up to $50 per visit $250 copay plus 40% after deductible $150 copay plus 30% after deductible $150 copay plus 50% after deductible; plan pays up to $400 per surgery $150 copay plus 50% after deductible; plan pays up to $400 per surgery 30% after deductible $250 copay plus 50% after deductible; plan pays up to $750 per day 30% after deductible 50% after deductible; plan pays up to $50 per visit 20% after deductible 40% after deductible 30% after deductible 50% after deductible Emergency Room $150 copay plus 20% after deductible per visit $150 copay plus 30% after deductible per visit Emergency Medical Transport 20% after deductible 30% after deductible Urgent Care $50 copay; deductible $50 copay; deductible $50 copay; deductible $50 copay; deductible Primary & Specialist Physician E-Visit (register at Walk-In Clinics $10 copay; deductible $35 copay; deductible $10 copay; deductible $25 copay; deductible Chiropractic Covered under rehabilitation services Covered under rehabilitation services Routine Vision (one exam per member every 24-months) $35 copay; deductible $25 copay; deductible See pages for footnotes. 19

20 Standard MC Plans Plan Name MC $750 80/50/50 $25 MC $1,250 80/50/50 $25 Network Managed Choice POS (Open Access) NA Managed Choice POS (Open Access) PCP/Referrals Required No NA No NA Member Benefits Participating providers Nonparticipating providers5 Participating providers Nonparticipating providers5 Calendar-Year Plan Deductible $750 per member $1,250 per member $1,250 per member Out-of-Pocket Limit $5,000 per member $10,000 per member $5,000 per member $10,000 per member Deductible & Out-of-Pocket Limit Accumulation Two-member maximum Two-member maximum Not Included In Out-of-Pocket Limit Primary Care Physician Office Visit1 Specialist Office Visit1 Amounts over allowable charges, copays, deductible, failure to precertify penalty, payments for non-serious mental disorders, substance abuse, Rx (including SpecialtyCareRx), infertility and DME. $25 copay; deductible $25 copay; deductible 50% after deductible $25 copay; deductible 50% after deductible $25 copay; deductible NA Amounts over allowable charges, copays, deductible, failure to precertify penalty, payments for non-serious mental disorders, substance abuse, Rx (including SpecialtyCareRx), infertility and DME. 50% after deductible 50% after deductible Preventive Care/Screenings/Immunizations No charge 50% after deductible No charge 50% after deductible Diagnostic Testing (X-ray, blood work) No charge for the first $300 per member, thereafter covered at 20% after deductible 50% after deductible No charge for the first $300 per member, thereafter covered at 20% after deductible 50% after deductible Imaging (CT/PET scans MRI s) 50% after deductible 50% after deductible; plan pays up to $800 per service Prescription Drug Deductible (applies to brand and nonformulary brand drugs) Prescription Drugs Generic formulary/brand formulary/brand nonformulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply 50% after deductible 50% after deductible; plan pays up to $800 per service $250 per individual NA $250 per individual NA $15/$40/$50 $15/$40/$50 Pharmacy Plan Type Four-tier open formulary Four-tier open formulary Four-tier open formulary Four-tier open formulary Aetna Specialty CareRxSM - Includes self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit) 30% up to $250 per prescription 30% up to $250 per prescription Outpatient Surgery OP Hospital Department Outpatient Surgery Freestanding Facility Inpatient Hospital Facility Rehabilitation Services2 (PT/OT/Chiropractor) (24 visits per calendar year, participating and non-participating providers combined) Rehabilitation Services2 (ST) (20 visits per calendar year, participating and non-participating providers combined) Emergency Room 30% professional and 50% facility after deductible 20% professional and 50% facility after deductible 20% professional and 50% facility after deductible 50% after deductible; plan pays up to $400 per surgery 50% after deductible; plan pays up to $400 per surgery 50% after deductible; plan pays up to $750 per day 20% after deductible 50% after deductible; plan pays up to $50 per visit 30% professional and 50% facility after deductible 20% professional and 50% facility after deductible 20% professional and 50% facility after deductible 50% after deductible; plan pays up to $400 per surgery 50% after deductible; plan pays up to $400 per surgery 50% after deductible; plan pays up to $750 per day 20% after deductible 50% after deductible; plan pays up to $50 per visit 20% after deductible 50% after deductible 20% after deductible 50% after deductible $150 copay plus 20% professional and 50% facility after deductible per visit $150 copay plus 20% professional and 50% facility after deductible per visit Emergency Medical Transport 20% after deductible 20% after deductible Urgent Care $50 copay; deductible $50 copay; deductible $50 copay; deductible $50 copay; deductible Primary & Specialist Physician E-Visit (register at Walk-In Clinics $10 copay; deductible $25 copay; deductible $10 copay; deductible $25 copay; deductible Chiropractic Covered under rehabilitation services Covered under rehabilitation services Routine Vision (one exam per member every 24-months) $25 copay; deductible $25 copay; deductible See pages for footnotes. 20

21 Standard MC Plans Plan Name MC $2,000 80/50/50 $25 MC $2,500 75/50 $25 Network Managed Choice POS (Open Access) NA Managed Choice POS (Open Access) PCP/Referrals Required No NA No NA Member Benefits Participating providers Nonparticipating providers5 Participating providers Nonparticipating providers5 Calendar-Year Plan Deductible $2,000 per member $2,000 per member $2,500 per member Out-of-Pocket Limit $5,000 per member $10,000 per member $5,000 per member $10,000 per member Deductible & Out-of-Pocket Limit Accumulation Two-member maximum Two-member maximum Not Included In Out-of-Pocket Limit Primary Care Physician Office Visit1 Specialist Office Visit1 Amounts over allowable charges, copays, deductible, failure to precertify penalty, payments for non-serious mental disorders, substance abuse, Rx (including SpecialtyCareRx), infertility and DME. $25 copay; deductible $25 copay; deductible 50% after deductible $25 copay; deductible 50% after deductible $25 copay; deductible NA Amounts over allowable charges, copays, deductible, failure to precertify penalty, payments for non-serious mental disorders, substance abuse, Rx (including SpecialtyCareRx), infertility and DME. 50% after deductible 50% after deductible Preventive Care/Screenings/Immunizations No charge 50% after deductible No charge 50% after deductible Diagnostic Testing (X-ray, blood work) No charge for the first $300 per member, thereafter covered at 20% after deductible 50% after deductible 25% after deductible 50% after deductible Imaging (CT/PET scans MRI s) 50% after deductible 50% after deductible; plan pays up to $800 per service Prescription Drug Deductible (applies to brand and nonformulary brand drugs) Prescription Drugs Generic formulary/brand formulary/brand nonformulary Retail: 30-day supply Mail Order: two-times retail copay, up to 90-day supply 25% after deductible 50% after deductible; plan pays up to $800 per service $250 per individual NA $250 per individual NA $20/$40/$70 $20/$40/$70 Pharmacy Plan Type Four-tier open formulary Four-tier open formulary Four-tier open formulary Four-tier open formulary Aetna Specialty CareRxSM - Includes self-injectable, infused and oral specialty drugs (retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit) 30% up to $250 per prescription 30% up to $250 per prescription Outpatient Surgery OP Hospital Department Outpatient Surgery Freestanding Facility Inpatient Hospital Facility Rehabilitation Services2 (PT/OT/Chiropractor) (24 visits per calendar year, participating and non-participating providers combined) Rehabilitation Services2 (ST) (20 visits per calendar year, participating and non-participating providers combined) Emergency Room 30% professional and 50% facility after deductible 20% professional and 50% facility after deductible 20% professional and 50% facility after deductible 50% after deductible; plan pays up to $400 per surgery 50% after deductible; plan pays up to $400 per surgery 50% after deductible; plan pays up to $750 per day 20% after deductible 50% after deductible; plan pays up to $50 per visit $250 copay plus 25% after deductible $150 copay plus 25% after deductible 50% after deductible; plan pays up to $400 per surgery 50% after deductible; plan pays up to $400 per surgery 25% after deductible 50% after deductible; plan pays up to $750 per day 25% after deductible 50% after deductible; plan pays up to $50 per visit 20% after deductible 50% after deductible 25% after deductible 50% after deductible $150 copay plus 20% professional and 50% facility after deductible per visit $150 copay plus 25% after deductible per visit Emergency Medical Transport 20% after deductible 25% after deductible Urgent Care $50 copay; deductible $50 copay; deductible $50 copay; deductible $50 copay; deductible Primar y & Specialist Physician E-Visit (register at Walk-In Clinics $10 copay; deductible $25 copay; deductible $10 copay; deductible $25 copay; deductible Chiropractic Covered under rehabilitation services Covered under rehabilitation services Routine Vision (one exam per member every 24-months) $25 copay; deductible $25 copay; deductible See pages for footnotes. 21