Tennessee plan guide

Transcription

1 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Tennessee plan guide The health of business, well planned. Plans effective January 1, 2013 For businesses with eligible employees TN (11/12)

2 TN (11/12) Team with Aetna for the health of your business Introducing a new suite of products and services designed specifically for companies with 2 to 100 employees. You can count on us to provide health plans that 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 insurance plans to provide more affordable options and to simplify plan selection and administration. In this guide: 5 Small business commitment 5 Benefits for every stage of life 6 Medical overview 7 Provider network 10 Managing health care expenses 11 Medical plan options 17 Dental overview 19 Dental plan options 25 Life & disability overview 28 Life & disability plan options 35 Underwriting guidelines 44 Product specifications 55 Limitations and exclusions 57 Group enrollment checklist Health/dental insurance plans, life and disability insurance plans are offered, underwritten and/or administered by Aetna Life Insurance Company (Aetna). 2

3 Women s preventive health benefits New changes effective August 1, TN (11/12) As you may know, the Affordable Care Act (ACA, or Health Care Reform law) includes changes that are being phased in over a number of years. The latest set of changes includes additional benefits for certain Women s Preventive Health Services. When plans renew or are effective on or after August 1, 2012, all of the following women s health services will be considered preventive (some were already covered). These services generally will be covered at no cost share, when provided in network: Well-woman visits (annually and now including prenatal visits) Screening for gestational diabetes Human papillomavirus (HPV) DNA testing Counseling for sexually transmitted infections Counseling and screening for human immunodeficiency virus (HIV) Screening and counseling for interpersonal and domestic violence Breastfeeding support, supplies and counseling Generic formulary contraceptives are covered without member cost share (for example, no copayment). Certain religious organizations or religious employers may be exempt from offering contraceptive services. 3

4 Employers can expect more Affordable plan options Online self-service tools and capabilities Enhanced services for consumer-directed health plans 24-hour access to Employee Assistance Program services Preventive care covered 100% Aetna disease management and wellness programs We know it s about... Options We provide a variety of health plan options to help meet your employees needs, including medical, dental, disability and life insurance. And, with access to a wide network of health care providers, you can be sure that employees have options in how they access their health care. Medical plans Traditional plans 100 percent plans Consumer-directed health plans HSA-compatible plans Dental plans DMO PPO Freedom-of-Choice plan design Dual Option Voluntary options for dental Life and disability plans Basic term life insurance, supplemental life, spouse and dependent life, and AD&D Flexible disability options 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 and care they can trust. Members get free access to these resources Our plans allow members to: Track medical claims and take advantage of online services with our secure Aetna Navigator member website. It features automated enrollment, personal health records and printable temporary member ID cards. Get real cost and health information to help make the right care decision with an online Cost of Care Estimator. Manage health records online with the Personal Health Record. Use the Aetna Health Connections SM disease management program, which provides personal support to 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 discount programs for vision, dental and general health care that encourage use of plan offerings. 4

5 We are committed to the health of your business We understand that your business has unique needs. That s why we have streamlined our plan options for employers with 2 to 100 employees. We are committed to providing you with value and quality you can count on. Our variety of products and services allows you to focus on the health of your business. 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 --Traditional Plans (12-06, 12-07, 12-08, 12-09, 12-10, 12-11) --Consumer-Directed Plans (12-31, 12-41) Value plans Encourage employee responsibility in their health care decisions Provide tools and resources to support consumerism Provide innovative plan design --HSA-Compatible Plans (12-21, 12-22, 12-23) --Consumer-Directed Plans (12-31) Traditional plans Provide traditional benefits plans Limit the financial impact on employees --Traditional Plans (12-01, 12-02, 12-03, 12-04, 12-05) 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 Traditional plans 100% Plans For married couples and single parents with young children or teens Lower fees for office visits Lower monthly payments Caps on out-of-pocket expenses Quality preventive care for the entire family Traditional plans For men and women 55 years of age and over with no children at home Financial security Quality prescription drug coverage Hospital inpatient/outpatient services Emergency care Consumer-directed health plans HSA-compatible plans 5

6 Aetna Medical Overview 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. 6

7 Medical Overview Wellness on Us SM Provider network* Wellness for employees means a healthier business for employers. Our small business health benefits and insurance plans in Tennessee offer $0 copays for in-network eye exams on top of $0 copays for in-network preventive care. It s one more way for us to help employees get a step closer to better health. See what employees can get for $0: PPO and MC OA Plans Anderson Fayette Bedford Franklin Benton Gibson Bledsoe Giles Blount Grainger Lake Lauderdale Lawrence Lewis Lincoln Scott Sequatchie Sevier Shelby Smith PPO only Clay Cumberland Fentress Hickman Jackson Immunizations Routine vision exams Routine physicals Child wellness visits Routine mammogram Routine ob/gyn visits $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay Bradley Campbell Cannon Carroll Carter Cheatham Chester Greene Grundy Hamblen Hamilton Hancock Hardeman Hardin Loudon McMinn McNairy Macon Madison Marion Marshall Stewart Sullivan Sumner Tipton Trousdale Unicoi Union Monroe Overton Perry Pickett Polk Putnam Rhea Claiborne Hawkins Maury Van Buren Wayne Cocke Haywood Meigs Warren White Coffee Henderson Montgomery Washington Crockett Henry Moore Weakley Davidson Houston Morgan Williamson Decatur Humphreys Obion Wilson Dekalb Jefferson Roane Dickson Johnson Robertson Dyer Knox Rutherford Product Name Product Description PCP Required Referrals Required Network Aetna Open Access Managed Choice (MC OA) Traditional Choice (Indemnity) PPO Managed Choice members can access any recognized provider for covered services without a referral. Each time members seek health care, they have the freedom to choose either network providers at lower out-of-pocket costs, or non-network providers at higher out-of-pocket costs. This indemnity plan option is available for employees who live outside the plan s network service area. Members coordinate their own health care and may access any recognized provider for covered services without a referral. PPO plan members can access any recognized provider for covered services without a referral. Each time members seek health care, they have the freedom to choose either network providers at lower out-of-pocket costs, or non-network providers at higher out-of-pocket costs. No No Managed Choice POS (Open Access) No No N/A No No Open Choice PPO *Network subject to change. PPO = Preferred Provider Organization MC OA = Managed Choice Open Access 7

8 Consumer Flex Choice Consumer Flex Choice makes it possible for a Small Group employer to tailor benefits to better meet the needs of their employees. Consumer Flex Choice allows a Small Group employer to offer their employees as many medical plan designs as they would like (using the current portfolio). This means you can offer a variety of plan designs to your employees to meet their specific health care needs. What are the advantages of Consumer Flex Choice? Employers can manage costs. Your contribution is based on the least expensive plan in the portfolio, regardless of the plans selected or how many plans are offered. Employees can manage choice. Employees can select the benefits plan that meets their individual needs. Employees and their families want different things from their medical plans. For instance, if an employer has employees who fit the basic buyer profile, they may want a medical plan where they share in more of the cost, but employees who are value seekers may want a plan with more investment options, such as an HSA-compatible plan. Still other employees may prefer a more traditional plan with fixed costs. With Consumer Flex Choice, you can manage your costs and provide flexibility in choice for your employees. Easy administration Employer contribution. 50 percent of the employee-only cost of the lowest cost plan in the portfolio (even if the you do not select that plan). Standard participation underwriting guidelines apply: Simply Savings Simply Savings* is the Aetna suite of plans designed specifically for small businesses. Simply Savings offers reduced minimum participation and employer contribution requirements. Simply Savings offers the following advantages: Lower participation and contribution requirements Value plans have lower participation and contribution requirements, except when offered with a non-simply Savings plan.** Greater employee choice You can offer up to three of the Simply Savings plans. Flexibility and affordability By choosing a Simply Savings plan, you are now able to offer benefits to help meet the needs of your employees. Total freedom We are committed to providing solutions to help meet the needs of small businesses. You can now offer quality coverage at affordable prices. Easy administration Setting up this program is simple: You choose up to three of the Simply Savings plans to offer on the Employer Application. You choose how much to contribute. Each employee chooses the plan that s right for him or her. For non-contributory plans, 100 percent participation is required, excluding valid waivers. For contributory plans, 75 percent of eligible employees, excluding valid waivers. At least one employee must be enrolled in each plan offered. Simply Savings Target audience Simply Savings plans available Plan choices Minimum participation Small businesses ($2,000 deductible) (HSA with $3,000 deductible) ($10,000 plan) Up to 3 of the Simply Savings plans 4 or more enrolled employees Employer contribution Employee participation 25% of the employee premium or $50 per employee per month 50% 8 *Available with four or more enrolled employees. **If an employer chooses a Simply Savings plan to offer with a non-simply Savings plan, the standard participation and contribution requirements on the non-simply Savings plan will apply to both plans offered.

9 Administrative Fees Fee description HSA Fee Initial setup $0 Monthly fees $0 POP* Initial setup** $175 Monthly fees $100 HRA and FSA*** fees Initial setup** 2 25 Employees $ Employees $ Employees $550 Renewal fee 2 25 Employees $ Employees $ Employees $325 Monthly fees $5.25 per participant Additional setup fee for stacked plans $150 (those electing an Aetna HRA and FSA simultaneously) Participation fee for stacked participants $10.25 per participant Minimum fees 0 25 Employees $25 per month minimum Employees $50 per month minimum COBRA Annual fee Employees $ Employees $175 Per employee per month Employees $ Employees $1.02 Initial notice fee $1.50 per notice (includes notices at time of implementation and during ongoing administration) TRA Annual fee $350 Transit monthly fees Parking monthly fees $4.25 per participant $3.15 per participant Health Reimbursement Arrangement (HRA) The Aetna HealthFund HRA combines the protection of a deductible-based health plan with a health fund that pays for eligible health care services. The member cannot contribute to the HRA, and employers have control over HRA plan designs. The fund is available to an employee for qualified expenses on the plan s effective date. The HRA and the HSA provide members with financial support for higher out-of-pocket health care expenses. Our consumer-directed health products and services give members the information and resources they need to help make informed health care decisions for themselves and their families, while helping to reduce your costs. COBRA administration Aetna COBRA administration offers a full range of notification, documentation and record-keeping processes that can help you manage the complex billing and notification processes that are required for COBRA compliance, while also saving time and money. Section 125 Cafeteria Plans and Section 132 Transit Reimbursement Accounts Employees can reduce their taxable income, and you can pay less in payroll taxes. There are three ways to save: Premium Only Plan (POP) Employees can pay for their portion of the group health insurance expenses on a pretax basis. Flexible Spending 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. *First-year POP fees waived with the purchase of medical with five plus enrolled employees. **Non-discrimination testing provided annually after open enrollment for POP and FSA only. Additional off-cycle testing available at employee 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 you opt 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. Initial setup fee for HRA is waived. 9

10 A way to manage health care expenses Health Savings Account (HSA) No setup or administrative fees The Aetna HealthFund HSA, when coupled with an HSA-compatible high-deductible health benefits and health insurance plan, is a tax-advantaged savings account. Once enrolled, you or the employee can make account contributions. Employees can use the HSA to pay for qualified expenses tax free. Member s HSA Plan The HSA Plan allows members to: Own their HSA Contribute tax free Choose how and when to use their dollars Roll it over each year and let it grow Earn interest, tax free No Cost Health Incentive Credit Members can earn $50 in just a few simple steps Members earn a $50 credit toward their out-of-pocket expenses when they: Complete or update their Health Assessment on Simple Steps To A Healthier Life, and Complete one Online Wellness Program If the employee s spouse is covered under the plan, he or she is also eligible for the same incentive credit. So a family could save $100 in out-of-pocket expenses each year. Incentive rewards will be credited toward the deductible and maximum out-of-pocket limit. This program is included at no additional cost on all plans except the HSA-compatible plans. Today Use for qualified expenses with tax-free dollars Future Plan for the future and retiree health-related costs High-deductible health plan Eligible in-network preventive care services will not be subject to the deductible Members pay 100% until deductible is met, then they only pay a share of the cost After members meet the out-of-pocket maximum, the plan pays 100% 10

11 Traditional Deductible and Coinsurance Plans (2 100 Employees) Plan Options In-Network Services Coinsurance 80% 80% 80% 80% Annual Deductible: Individual/Family $500/$1,000 $1,000/$2,000 $1,000/$2,000 $1,500/$3,000 Type of Deductible Embedded Embedded Embedded Embedded Annual Out of Pocket (OOP): Individual/Family (Deductible applies to OOP) $2,500/$5,000 $2,500/$5,000 $3,000/$6,000 $3,000/$6,000 Wellness On Us SM Preventive Care, including annual Adult Physicals, Well-Women Visits, Mammograms, Colorectal Cancer Screening and other preventive care services $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived Vision Screening Services (1 time every 12 months) $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived Prescription Lens Allowance $125 every 24 months $125 every 24 months $125 every 24 months $125 every 24 months Physician Services Primary Care Physician Office Visit $25, deductible waived $25, deductible waived $30, deductible waived $25, deductible waived Specialist Office Visit $50, deductible waived $50, deductible waived $60, deductible waived $50, deductible waived Walk-In Clinic Visit $25, deductible waived $25, deductible waived $30, deductible waived $25, deductible waived Mental Health Outpatient Visits (25 visits per year Mental Health Parity applies to groups over 50) $50, deductible waived $50, deductible waived $60, deductible waived $50, deductible waived Inpatient Services Hospital Inpatient 80%, deductible applies 80%, deductible applies 80%, deductible applies 80%, deductible applies Mental Health Inpatient (30 days per year Mental Health Parity applies to groups over 50) 80%, deductible applies 80%, deductible applies 80%, deductible applies 80%, deductible applies Outpatient/Other Services Diagnostic Lab $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived Diagnostic X-ray $50, deductible waived $50, deductible waived $60, deductible waived $50, deductible waived Diagnostic Complex Imaging (CAT, MRI, MRA/MRS and PET scans) 80%, deductible applies 80%, deductible applies 80%, deductible applies 80%, deductible applies Outpatient Surgery 80%, deductible applies 80%, deductible applies 80%, deductible applies 80%, deductible applies Emergency Room (copay waived if admitted) $250, deductible waived $250, deductible waived $250, deductible waived $250, deductible waived Urgent Care $75, deductible waived $75, deductible waived $75, deductible waived $75, deductible waived Outpatient Rehabilitative Therapy (60 visits per year, includes physical therapy, occupational therapy, speech therapy and chiropractic/subluxation services) 80%, deductible applies 80%, deductible applies 80%, deductible applies 80%, deductible applies Pharmacy Retail Pharmacy Copay (Aetna Specialty Pharmacy available at 30% with a minimum copay of $30 and maximum copay of $120) Mail-Order Drugs (MOD) (31-90 day supply retail/mod) $10/$30/$60 $10/$30/$60 $10/$30/$60 $10/$30/$60 2X 2X 2X 2X Out-of-Network (OON) Services Coinsurance 50% 50% 50% 50% Annual Deductible: Individual/Family $1,000/$2,000 $2,000/$4,000 $2,000/$4,000 $3,000/$6,000 Annual Out of Pocket (OOP): Individual/Family (Deductible applies to OOP) $7,500/$15,000 $7,500/$15,000 $9,000/$18,000 $9,000/$18,000 Emergency Room Paid as in-network benefits Paid as in-network benefits Paid as in-network benefits Paid as in-network benefits Retail Pharmacy 70% after copay 70% after copay 70% after copay 70% after copay Plan Options Available Managed Choice Open Access (MC OA) X X X X Preferred Provider Organization (PPO) X X See page 16 for footnotes. 11

12 Traditional Deductible and Coinsurance Plans (2 100 Employees) Plan Options In-Network Services Coinsurance 80% 80% 80% 80% Annual Deductible: Individual/Family $1,500/$3,000 $2,000/$4,000 $2,000/$4,000 $2,500/$5,000 Type of Deductible Embedded Embedded Embedded Embedded Annual Out of Pocket (OOP): Individual/Family (Deductible applies to OOP) $3,500/$7,000 $3,500/$7,000 $4,000/$8,000 $4,000/$8,000 Wellness On Us SM Preventive Care, including annual Adult Physicals, Well-Women Visits, Mammograms, Colorectal Cancer Screening and other preventive care services $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived Vision Screening Services (1 time every 12 months) $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived Prescription Lens Allowance $125 every 24 months $125 every 24 months $125 every 24 months $125 every 24 months Physician Services Primary Care Physician Office Visit $30, deductible waived $25, deductible waived $30, deductible waived $25, deductible waived Specialist Office Visit $60, deductible waived $50, deductible waived $60, deductible waived $50, deductible waived Walk-In Clinic Visit $30, deductible waived $25, deductible waived $30, deductible waived $25, deductible waived Mental Health Outpatient Visits (25 visits per year Mental Health Parity applies to groups over 50) $60, deductible waived $50, deductible waived $60, deductible waived $50, deductible waived Inpatient Services Hospital Inpatient 80%, deductible applies 80%, deductible applies 80%, deductible applies 80%, deductible applies Mental Health Inpatient (30 days per year Mental Health Parity applies to groups over 50) 80%, deductible applies 80%, deductible applies 80%, deductible applies 80%, deductible applies Outpatient/Other Services Diagnostic Lab $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived Diagnostic X-ray $60, deductible waived $50, deductible waived $60, deductible waived $50, deductible waived Diagnostic Complex Imaging (CAT, MRI, MRA/MRS and PET scans) 80%, deductible applies 80%, deductible applies 80%, deductible applies 80%, deductible applies Outpatient Surgery 80%, deductible applies 80%, deductible applies 80%, deductible applies 80%, deductible applies Emergency Room (copay waived if admitted) $250, deductible waived $250, deductible waived $300, deductible waived $250, deductible waived Urgent Care $75, deductible waived $75, deductible waived $100, deductible waived $75, deductible waived Outpatient Rehabilitative Therapy (60 visits per year, includes physical therapy, occupational therapy, speech therapy and chiropractic/subluxation services) 80%, deductible applies 80%, deductible applies 80%, deductible applies 80%, deductible applies Pharmacy Retail Pharmacy Copay (Aetna Specialty Pharmacy available at 30% with a minimum copay of $30 and maximum copay of $120) Mail-Order Drugs (MOD) (31-90 day supply retail/mod) $10/$30/$60 $10/$30/$60 $15/$45/$60 $10/$30/$60 2X 2X 2X 2X Out-Of-Network (OON) Services Coinsurance 50% 50% 50% 50% Annual Deductible: Individual/Family $3,000/$6,000 $4,000/$8,000 $4,000/$8,000 $5,000/$10,000 Annual Out of Pocket (OOP): Individual/Family (Deductible applies to OOP) $10,500/$21,000 $10,500/$21,000 $12,000/$24,000 $12,000/$24,000 Emergency Room Paid as in-network benefits Paid as in-network benefits Paid as in-network benefits Paid as in-network benefits Retail Pharmacy 70% after copay 70% after copay 70% after copay 70% after copay Plan Options Available Managed Choice Open Access (MC OA) X X X X Preferred Provider Organization (PPO) See page 16 for footnotes. 12

13 Traditional Deductible and Coinsurance Plans (2 100 Employees) Plan Options In-Network Services Coinsurance 80% 80% 80% Annual Deductible: Individual/Family $2,500/$5,000 $3,000/$6,000 $3,000/$6,000 Type of Deductible Embedded Embedded Embedded Annual Out of Pocket (OOP): Individual/Family (Deductible applies to OOP) $5,000/$10,000 $5,000/$10,000 $6,000/$12,000 Wellness On Us SM Preventive Care, including annual Adult Physicals, Well-Women Visits, Mammograms, Colorectal Cancer Screening and other preventive care services $0, deductible waived $0, deductible waived $0, deductible waived Vision Screening Services (1 time every 12 months) $0, deductible waived $0, deductible waived $0, deductible waived Prescription Lens Allowance $125 every 24 months $125 every 24 months $125 every 24 months Physician Services Primary Care Physician Office Visit $30, deductible waived $25, deductible waived $30, deductible waived Specialist Office Visit $60, deductible waived $50, deductible waived $60, deductible waived Walk-In Clinic Visit $30, deductible waived $25, deductible waived $30, deductible waived Mental Health Outpatient Visits (25 visits per year Mental Health Parity applies to groups over 50) $60, deductible waived $50, deductible waived $60, deductible waived Inpatient Services Hospital Inpatient 80%, deductible applies 80%, deductible applies 80%, deductible applies Mental Health Inpatient (30 days per year Mental Health Parity applies to groups over 50) 80%, deductible applies 80%, deductible applies 80%, deductible applies Outpatient/Other Services Diagnostic Lab $0, deductible waived $0, deductible waived $0, deductible waived Diagnostic X-ray $60, deductible waived $50, deductible waived $60, deductible waived Diagnostic Complex Imaging (CAT, MRI, MRA/MRS and PET scans) 80%, deductible applies 80%, deductible applies 80%, deductible applies Outpatient Surgery 80%, deductible applies 80%, deductible applies 80%, deductible applies Emergency Room (copay waived if admitted) $300, deductible waived $250, deductible waived $300, deductible waived Urgent Care $100, deductible waived $75, deductible waived $100, deductible waived Outpatient Rehabilitative Therapy (60 visits per year, includes physical therapy, occupational therapy, speech therapy and chiropractic/subluxation services) 80%, deductible applies 80%, deductible applies 80%, deductible applies Pharmacy Retail Pharmacy Copay (Aetna Specialty Pharmacy available at 30% with a minimum copay of $30 and maximum copay of $120) Mail-Order Drugs (MOD) (31-90 day supply retail/mod) $15/$45/$60 $10/$30/$60 $15/$45/$60 2X 2X 2X Out-of-Network (OON) Services Coinsurance 50% 50% 50% Annual Deductible: Individual/Family $5,000/$10,000 $6,000/$12,000 $6,000/$12,000 Annual Out of Pocket (OOP): Individual/Family (Deductible applies to OOP) $15,000/$30,000 $15,000/$30,000 $18,000/$36,000 Emergency Room Paid as in-network benefits Paid as in-network benefits Paid as in-network benefits Retail Pharmacy 70% after copay 70% after copay 70% after copay Plan Options Available Managed Choice Open Access (MC OA) X X X Preferred Provider Organization (PPO) See page 16 for footnotes. 13

14 HSA Compatible Plans (2 100 Employees) Plan Options (HDHP) (HDHP) (HDHP) In-Network Services Coinsurance 80% 80% 80% Annual Deductible: Individual/Family $2,500/$5,000 $3,000/$6,000 $5,000/$10,000 Type of Deductible Embedded Embedded Embedded Annual Out of Pocket (OOP): Individual/Family (Deductible applies to OOP) $4,000/$8,000 $5,000/$10,000 $6,000/$12,000 Wellness On Us SM Preventive Care, including annual Adult Physicals, Well-Women Visits, Mammograms, Colorectal Cancer Screening and other preventive care services $0, deductible waived $0, deductible waived $0, deductible waived Vision Screening Services (1 time every 12 months) $0, deductible waived $0, deductible waived $0, deductible waived Prescription Lens Allowance $125 every 24 months $125 every 24 months $125 every 24 months Physician Services Primary Care Physician Office Visit 80%, deductible applies 80%, deductible applies 80%, deductible applies Specialist Office Visit 80%, deductible applies 80%, deductible applies 80%, deductible applies Walk-In Clinic Visit 80%, deductible applies 80%, deductible applies 80%, deductible applies Mental Health Outpatient Visits (25 visits per year Mental Health Parity applies to groups over 50) 80%, deductible applies 80%, deductible applies 80%, deductible applies Inpatient Services Hospital Inpatient 80%, deductible applies 80%, deductible applies 80%, deductible applies Mental Health Inpatient (30 days per year Mental Health Parity applies to groups over 50) 80%, deductible applies 80%, deductible applies 80%, deductible applies Outpatient/Other Services Diagnostic Lab 80%, deductible applies 80%, deductible applies 80%, deductible applies Diagnostic X-ray 80%, deductible applies 80%, deductible applies 80%, deductible applies Diagnostic Complex Imaging (CAT, MRI, MRA/MRS and PET scans) 80%, deductible applies 80%, deductible applies 80%, deductible applies Outpatient Surgery 80%, deductible applies 80%, deductible applies 80%, deductible applies Emergency Room (copay waived if admitted) 80%, deductible applies 80%, deductible applies 80%, deductible applies Urgent Care 80%, deductible applies 80%, deductible applies 80%, deductible applies Outpatient Rehabilitative Therapy (60 visits per year, includes physical therapy, occupational therapy, speech therapy and chiropractic/subluxation services) 80%, deductible applies 80%, deductible applies 80%, deductible applies Pharmacy Retail Pharmacy Copay (Aetna Specialty Pharmacy available at 30% with a minimum copay of $30 and maximum copay of $120) $10/$30/$60 includes Preventive Care Waiver $10/$30/$60 includes Preventive Care Waiver $10/$30/$60 includes Preventive Care Waiver Mail-Order Drugs (MOD) (31-90 day supply retail/mod) 2X 2X 2X Out-Of-Network (OON) Services Coinsurance 50% 50% 50% Annual Deductible: Individual/Family $5,000/$10,000 $6,000/$12,000 $10,000/$20,000 Annual Out of Pocket (OOP): Individual/Family (Deductible applies to OOP) $12,000/$24,000 $15,000/$30,000 $18,000/$36,000 Emergency Room Paid as in-network benefits Paid as in-network benefits Paid as in-network benefits Retail Pharmacy 70% after copay 70% after copay 70% after copay Plan Options Available Managed Choice Open Access (MC OA) X X X Preferred Provider Organization (PPO) See page 16 for footnotes. 14

15 100% Plans and Indemnity Plan (2 100 Employees) Plan Options In-Network Services Coinsurance 100% 100% 80% Annual Deductible: Individual/Family $10,000/$10,000 $5,000/$10,000 $1,500/$3,000 Type of Deductible Embedded Embedded Embedded Annual Out of Pocket (OOP): Individual/Family (Deductible applies to OOP) $10,000/$10,000 $5,000/$10,000 $5,000/$10,000 Wellness On Us SM Preventive Care, including annual Adult Physicals, $0, deductible waived $0, deductible waived $0, deductible waived Well-Women Visits, Mammograms, Colorectal Cancer Screening and other preventive care services Vision Screening Services (1 time every 12 months) $0, deductible waived $0, deductible waived $0, deductible waived Prescription Lens Allowance $125 every 24 months $125 every 24 months $125 every 24 months Physician Services Primary Care Physician Office Visit $30, deductible waived $25, deductible waived 80%, deductible applies Specialist Office Visit $75, deductible waived $50, deductible waived 80%, deductible applies Walk-In Clinic Visit $30, deductible waived $25, deductible waived 80%, deductible applies Mental Health Outpatient Visits (25 visits per year Mental Health Parity applies to groups over 50) $75, deductible waived $50, deductible waived 80%, deductible applies Inpatient Services Hospital Inpatient 100%, deductible applies 100%, deductible applies 80%, deductible applies Mental Health Inpatient (30 days per year Mental Health Parity applies to groups over 50) 100%, deductible applies 100%, deductible applies 80%, deductible applies Outpatient/Other Services Diagnostic Lab 100%, deductible applies $0, deductible waived 80%, deductible applies Diagnostic X-ray 100%, deductible applies $50, deductible waived 80%, deductible applies Diagnostic Complex Imaging (CAT, MRI, MRA/MRS and PET scans) 100%, deductible applies 100%, deductible applies 80%, deductible applies Outpatient Surgery 100%, deductible applies 100%, deductible applies 80%, deductible applies Emergency Room (copay waived if admitted) 100%, deductible applies $250, deductible waived 80%, deductible applies Urgent Care 100%, deductible applies $75, deductible waived 80%, deductible applies Outpatient Rehabilitative Therapy (60 visits per year, includes physical therapy, occupational therapy, speech therapy and chiropractic/subluxation services) 100%, deductible applies $50, deductible waived 80%, deductible applies Pharmacy Retail Pharmacy Copay (Aetna Specialty Pharmacy available at 30% with a minimum copay of $30 and maximum copay of $120) Mail-Order Drugs (MOD) (31-90 day supply retail/mod) $20/$50/$70 $10/$30/$60 $15/$45/$65 2X 2X 2X Out-Of-Network (OON) Services Coinsurance 70% 70% Annual Deductible: Individual/Family $10,000/$20,000 $10,000/$20,000 Annual Out of Pocket (OOP): Individual/Family (Deductible applies to OOP) $15,000/$30,000 $15,000/$30,000 Same as in-network benefits Emergency Room Paid as in-network benefits Paid as in-network benefits Retail Pharmacy 70% after copay 70% after copay Plan Options Available Managed Choice Open Access (MC OA) X X Preferred Provider Organization (PPO) Indemnity Only See page 16 for footnotes. 15

16 Footnotes This is a partial description of plans and benefits available; for more information, refer to the specific plan design summary. The dollar-amount copayments indicate what the member is required to pay, and the percentage copayments indicate what Aetna is required to pay. NOTE: Some benefits are subject to limitations or visit maximums. Members or providers may be required to precertify or obtain prior approval for certain services, such as non-emergency hospital care. For a summary list of Limitations and Exclusions, refer to page 55. Copays apply to the out-of-pocket maximum (OOP) on all plans except Plan Members must continue to pay applicable copays after OOP is met under Plan Prescription drug cost sharing does not apply to the OOP, and members must continue to pay applicable prescription drug cost sharing after the OOP is met on all plans except HSA-compatible plans (prescription drug cost sharing applies to the HSA-compatible plans, OOP). Mandatory Generic (MG) with Dispensed as Written Override (DAW) Member pays the applicable coinsurance only, if the physician requires brand. If the member requests brand when a generic is available, the member pays the applicable coinsurance plus the difference between the generic price and the brand. Plan includes contraceptive drugs and devices obtainable from a pharmacy and diabetic supplies. Precertification included. For all HSA-compatible plans (12-21, 12-22, 12-23), the full cost of the drug is applied to the deductible before any benefits are considered for payment under the pharmacy plan; however, the deductible is waived for certain preventive medications. A full list of these drugs is available on Aetna Navigator. Unless otherwise indicated, the deductible must be met prior to benefits being payable. All covered expenses accumulate toward the preferred and non-preferred deductible separately. Once the family deductible is met by any combination of family members, all family members will be considered as having met their deductible for the remainder of the calendar year. No one family member may contribute more than the individual deductible amount to the family deductible. Members may choose providers in the Aetna network (physicians and facilities), or they may visit an out-of-network provider. Typically, members will pay substantially more money out of their own pockets if they choose to use an out-of-network doctor or hospital. The out-of-network provider will be paid based on Aetna s recognized charge. This is not the same as the billed charge from the doctor. Aetna pays a percentage of the recognized charge, as defined in the plan. The recognized charge for out-of-network hospitals, doctors and other out-of-network health care providers is a percentage (100 percent or above) of the rate that Medicare pays them. You may have to pay the difference between the out-of-network provider s billed charge and Aetna s recognized charge, plus any coinsurance and deductibles due under the plan. Note that any amount the doctor or hospital bills you above Aetna s recognized charge does not count toward your deductible or out-of-pocket maximums. This benefit applies when you choose to get care out of network. When you have no choice in the doctors you see (for example, an emergency room visit after a car accident), your deductible and coinsurance for the in-network level of benefits will be applied, and you should contact Aetna if your doctor asks you to pay more. Generally, you are not responsible for any outstanding balance billed by your doctors in an emergency situation. 16

17 Aetna Dental Overview Small business decision makers can choose from a variety of plan design options that help you offer a dental benefits and dental insurance plan that s just right for your employees. 17

18 Dental Overview The Mouth Matters SM Research suggests that serious gum disease, known as periodontitis, may be associated with many health problems. This is especially true if gum disease continues without treatment. 1 Now, here s the good news. Researchers are discovering that a healthy mouth may be important to your overall health. 1 The Aetna Dental/Medical Integration SM (DMI) program,* available at no additional charge to plan sponsors who have both medical and dental coverages with Aetna, focuses on those who are pregnant or have diabetes, coronary artery disease (heart disease) or cerebrovascular disease (stroke) and have not had a recent dental visit. We proactively educate those at-risk members about the impact oral health care can have on their condition. Our member outreach has been proven to successfully motivate those at-risk members who do not normally seek dental care to visit the dentist. Once at the dentist, these at-risk members will receive enhanced dental benefits, including an extra cleaning and full coverage for certain periodontal services. The Dental Maintenance Organization (DMO ) Members select a primary care dentist to coordinate their care from the available managed dental network. Each family member may choose a different primary care dentist and may switch dentists at any time via Aetna Navigator or with a call to Member Services. If specialty care is needed, a member s primary care dentist can refer the member to a participating specialist. However, members may visit orthodontists without a referral. There are virtually no claim forms to file, and benefits are not subject to deductibles or annual maximums. Preferred Provider Organization (PPO) plan Members can choose a dentist who participates in the network or choose a licensed dentist who does not. Participating dentists have agreed to offer our members covered services at a negotiated rate and will not balance-bill members Freedom-of-Choice plan design option Get maximum flexibility with our two-in-one dental plan design. The Freedom-of-Choice plan design option provides the administrative ease of one plan, yet members get to choose between the DMO and PPO plans on a monthly basis. One blended rate is paid. Members may switch between the plans on a monthly basis by calling Member Services. Plan changes must be made by the 15 th of the month to be effective the following month. Voluntary Dental option The Voluntary Dental option provides a solution to meet the individual needs of members in the face of rising health care costs. Administration is easy, and members benefit from low group rates and the convenience of payroll deductions. Aetna Dental Preventive Care SM plan The Preventive Care plan is a lower-cost dental plan that covers preventive and diagnostic procedures. Dual Option** plan In the Dual Option plan design, the DMO plan may be packaged with any one of the PPO plans. Employees may choose between the DMO and PPO offerings at enrollment. 1 MayoClinic.com. Oral health: A window to your overall health. [article online]. February 5, Accessed November *DMI may not be available in all states. **Dual Option does not apply to Voluntary Dental plans in the 2 9 group and all Preventive Dental Plans. 18

19 Standard Dental Plans (2 9 Employees) Option 1 Option 2 Option 3 Low Passive PPO 100/80/50 Medium Passive PPO 100/80/50 High Passive PPO 100/80/50 Office Visit Copay N/A N/A N/A Annual Deductible per Member (does not apply to Diagnostic & Preventive services) $50; 3X Family Maximum $50; 3X Family Maximum $50; 3X Family Maximum Annual Maximum Benefit $1,000 $1,500 $2,000 Diagnostic Services Oral Exams Periodic oral exam 100% 100% 100% Comprehensive oral exam 100% 100% 100% Problem-focused oral exam 100% 100% 100% X-rays Bitewing single film 100% 100% 100% Complete series 100% 100% 100% Preventive Services Adult cleaning 100% 100% 100% Child cleaning 100% 100% 100% Sealants per tooth 100% 100% 100% Fluoride application with cleaning 100% 100% 100% Space maintainers 100% 100% 100% Basic Services Amalgam filling 2 surfaces 80% 80% 80% Resin filling 2 surfaces, anterior 80% 80% 80% Oral Surgery Extraction exposed root or erupted tooth 80% 80% 80% Extraction of impacted tooth soft tissue 80% 80% 80% Major Services* Complete upper denture 50% 50% 50% Partial upper denture (resin base) 50% 50% 50% Crown Porcelain with noble metal 50% 50% 50% Pontic Porcelain with noble metal 50% 50% 50% Inlay Metallic (3 or more surfaces) 50% 50% 50% Oral Surgery Removal of impacted tooth partially bony 50% 80% 80% Endodontic Services Bicuspid root canal therapy 50% 80% 80% Molar root canal therapy 50% 80% 80% Periodontic Services Scaling & root planing per quadrant 50% 80% 80% Osseous surgery per quadrant 50% 80% 80% Orthodontic Services Not covered Not covered Not covered Orthodontic Lifetime Maximum Does not apply Does not apply Does not apply See page 24 for footnotes. 19

20 Standard Dental Plans (2 9 Employees) Option 4 Option 5 High Active PPO In Network 100/90/60 High Active PPO Out of Network 80/60/50 Office Visit Copay N/A N/A N/A Annual Deductible per Member (does not apply to Diagnostic & Preventive services) $50; 3X Family Maximum $50; 3X Family Maximum None Annual Maximum Benefit $2,000 $1,500 None Diagnostic Services Passive PPO Aetna Dental Preventive Care Oral Exams Periodic oral exam 100% 80% 100% Comprehensive oral exam 100% 80% 100% Problem-focused oral exam 100% 80% 100% X-rays Bitewing single film 100% 80% 100% Complete series 100% 80% 100% Preventive Services Adult cleaning 100% 80% 100% Child cleaning 100% 80% 100% Sealants per tooth 100% 80% 100% Fluoride application with cleaning 100% 80% 100% Space maintainers 100% 80% 100% Basic Services Amalgam filling 2 surfaces 90% 60% Not covered Resin filling 2 surfaces, anterior 90% 60% Not covered Oral Surgery Extraction exposed root or erupted tooth 90% 60% Not covered Extraction of impacted tooth soft tissue 90% 60% Not covered Major Services* Complete upper denture 60% 50% Not covered Partial upper denture (resin base) 60% 50% Not covered Crown Porcelain with noble metal 60% 50% Not covered Pontic Porcelain with noble metal 60% 50% Not covered Inlay Metallic (3 or more surfaces) 60% 50% Not covered Oral Surgery Removal of impacted tooth partially bony 90% 60% Not covered Endodontic Services Bicuspid root canal therapy 90% 60% Not covered Molar root canal therapy 90% 60% Not covered Periodontic Services Scaling & root planing per quadrant 90% 60% Not covered Osseous surgery per quadrant 90% 60% Not covered Orthodontic Services Not covered Not covered Not covered Orthodontic Lifetime Maximum Does not apply Does not apply Does not apply See page 24 for footnotes. 20

21 Voluntary Dental Plans (3 9 Employees) Voluntary Option 1 Voluntary Option 2 Voluntary Option 3 Voluntary Option 4 Low Passive PPO 100/80/50 Medium Passive PPO 100/80/50 High Passive PPO 100/80/50 Office Visit Copay N/A N/A N/A N/A Annual Deductible per Member (does not apply to Diagnostic & Preventive services) $75; 3X Family Maximum $75; 3X Family Maximum $75; 3X Family Maximum None Annual Maximum Benefit $1,000 $1,500 $2,000 None Diagnostic Services Passive PPO Aetna Dental Preventive Care Oral Exams Periodic oral exam 100% 100% 100% 100% Comprehensive oral exam 100% 100% 100% 100% Problem-focused oral exam 100% 100% 100% 100% X-rays Bitewing single film 100% 100% 100% 100% Complete series 100% 100% 100% 100% Preventive Services Adult cleaning 100% 100% 100% 100% Child cleaning 100% 100% 100% 100% Sealants per tooth 100% 100% 100% 100% Fluoride application with cleaning 100% 100% 100% 100% Space maintainers 100% 100% 100% 100% Basic Services Amalgam filling 2 surfaces 80% 80% 80% Not covered Resin filling 2 surfaces, anterior 80% 80% 80% Not covered Oral Surgery Extraction exposed root or erupted tooth 80% 80% 80% Not covered Extraction of impacted tooth soft tissue 80% 80% 80% Not covered Major Services* Complete upper denture 50% 50% 50% Not covered Partial upper denture (resin base) 50% 50% 50% Not covered Crown Porcelain with noble metal 50% 50% 50% Not covered Pontic Porcelain with noble metal 50% 50% 50% Not covered Inlay Metallic (3 or more surfaces) 50% 50% 50% Not covered Oral Surgery Removal of impacted tooth partially bony 50% 80% 80% Not covered Endodontic Services Bicuspid root canal therapy 50% 80% 80% Not covered Molar root canal therapy 50% 80% 80% Not covered Periodontic Services Scaling & root planing per quadrant 50% 80% 80% Not covered Osseous surgery per quadrant 50% 80% 80% Not covered Orthodontic Services Not covered Not covered Not covered Not covered Orthodontic Lifetime Maximum Does not apply Does not apply Does not apply Not covered See page 24 for footnotes. 21

22 Standard and Voluntary Plan Selections ( Employees) Option 1A DMO Access Option 1B DMO Coinsurance Option 2A Freedom-of-Choice Monthly selection between the DMO and PPO Copay plan 42 DMO 100/80/50 100/100/50 PPO Plan 100/80/50 Office Visit Copay $10 $5 $5 None Annual Deductible per Member (Does not apply to diagnostic and preventive services) None None None $50; 3X Family Maximum Annual Maximum Benefit Unlimited None None $1,000 Diagnostic Services Oral Exams Periodic oral exam No charge 100% 100% 100% Comprehensive oral exam No charge 100% 100% 100% Problem-focused oral exam No charge 100% 100% 100% X-rays Bitewing single film No charge 100% 100% 100% Complete series No charge 100% 100% 100% Preventive Services Adult cleaning No charge 100% 100% 100% Child cleaning No charge 100% 100% 100% Sealants per tooth $10 100% 100% 100% Fluoride application with cleaning No charge 100% 100% 100% Space maintainers (Fixed) $ % 100% 100% Basic Services Amalgam filling 2 surfaces $32 80% 100% 80% Resin filling 2 surfaces, anterior $55 80% 100% 80% Endodontic Services Bicuspid root canal therapy $195 80% 100% 80% Periodontic Services Scaling & root planing per quadrant $65 80% 100% 80% Oral Surgery Extraction exposed root or erupted tooth $30 80% 100% 80% Extraction of impacted tooth soft tissue $80 80% 100% 80% Major Services* Complete upper denture $500 50% 50% 50% Crown Porcelain with noble metal 1 $488 50% 50% 50% Pontic Porcelain with noble metal 1 $488 50% 50% 50% Inlay Metallic (3 or more surfaces) $463 50% 50% 50% Oral Surgery Removal of impacted tooth partially bony $175** 50% 50% 50% Endodontic Services Molar root canal therapy $435** 50% 50% 50% Periodontic Services Osseous surgery per quadrant $445** 50% 50% 50% Orthodontic Services* (optional) $2,300 copay $2,300 copay $2,300 copay 50% Orthodontic Lifetime Maximum Does not apply Does not apply Does not apply $1,000 See page 24 for footnotes. 22

23 Standard and Voluntary Plan Selections ( Employees) Option 3A Preventive care Option 4A PPO 1000 Option 5A PPO 1000 Plus Option 6A PPO 1500 PPO 100/0/0 PPO 1000 Plan 100/80/50 PPO 1000 Plan 100/80/50 Office Visit Copay N/A None None None Annual Deductible per Member (Does not apply to diagnostic and preventive services) PPO 1500 Plan 100/80/50 None $50; 3X Family Maximum $50; 3X Family Maximum $50; 3X Family Maximum Annual Maximum Benefit Unlimited $1,000 $1,000 $1,500 Diagnostic Services Oral Exams Periodic oral exam 100% 100% 100% 100% Comprehensive oral exam 100% 100% 100% 100% Problem-focused oral exam 100% 100% 100% 100% X-rays Bitewing single film 100% 100% 100% 100% Complete series 100% 100% 100% 100% Preventive Services Adult cleaning 100% 100% 100% 100% Child cleaning 100% 100% 100% 100% Sealants per tooth 100% 100% 100% 100% Fluoride application with cleaning 100% 100% 100% 100% Space maintainers (Fixed) 100% 100% 100% 100% Basic Services Amalgam filling 2 surfaces Not covered 80% 80% 80% Resin filling 2 surfaces, anterior Not covered 80% 80% 80% Endodontic Services Bicuspid root canal therapy Not covered 50% 80% 80% Periodontic Services Scaling & root planing per quadrant Not covered 50% 80% 80% Oral Surgery Extraction exposed root or erupted tooth Not covered 80% 80% 80% Extraction of impacted tooth soft tissue Not covered 80% 80% 80% Major Services* Complete upper denture Not covered 50% 50% 50% Crown Porcelain with noble metal 1 Not covered 50% 50% 50% Pontic Porcelain with noble metal 1 Not covered 50% 50% 50% Inlay Metallic (3 or more surfaces) Not covered 50% 50% 50% Oral Surgery Removal of impacted tooth partially bony Not covered 50% 80% 50% Endodontic Services Molar root canal therapy Not covered 50% 80% 50% Periodontic Services Osseous surgery per quadrant Not covered 50% 80% 50% Orthodontic Services* (optional) Not covered 50% 50% 50% Orthodontic Lifetime Maximum Does not apply $1,000 $1,000 $1,000 See page 24 for footnotes. 23