Arizona plan guide. Creating the right health benefits package starts with you and your employees

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1 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Arizona plan guide Creating the right health benefits package starts with you and your employees Plans effective January 1, 2015 For businesses with eligible employees XX.XX.XXX.X AZ (X/14) B (7/14)

2 Choosing the right health plan Every company has its own particular needs, driven in part by the health of its employees, by its commitment to health and wellness and, of course, by its financial resources. We believe creating the right health benefits and insurance plan means combining these four options to meet a company s specific needs: benefits, network, cost sharing, funding. Experience matters We take the time to listen and learn about your needs. Our experience allows us to share knowledge and provide tools to help achieve the right balance of cost and coverage. Our approach makes all the difference in the value you get from your plan, and in the satisfaction of your employees. Today s health care environment demands a new set of solutions to meet new challenges. Together, we can create a healthy future for your company and your employees. Health benefits and health insurance, dental benefits/dental insurance, life insurance and disability insurance plans/ policies are offered, underwritten or administered by Aetna Health Inc., Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). Each insurer has sole financial responsibility for its own products.

3 We want to make choosing the right benefits as easy as possible. So we ve organized information in this easy-to-understand guide. M D V L&D U Health care reform 4 Plans, tools and extras 6 7 Network options, cost-sharing and premiums 8 Health and wellness programs 9 Medical plans overview 10 Medical plan options 11 Traditional medical plans 23 HMO and HNOption plans 31 Indemnity plan 32 Dental plans overview 34 Aetna dental plans Aetna voluntary dental plans Aetna standard and voluntary dental plan selections Vision plans overview 46 Aetna Vision Preferred 48 Life and disability plans overview 51 Life plan options 54 Disability plan options short term 55 Disability plan options long term 56 Packaged life and disability plan options 57 Underwriting guidelines 58 Limitations and exclusions 81 New business checklist 84 3

4 Changes to your plan due to health care reform Signed into law in March 2010, the Affordable Care Act is the most life-changing law since the passing of Medicare in the 1960s. We are committed to following the new health care law and to helping you understand its impact. We have outlined below key changes that may impact your health care benefits. Essential health benefits package Aetna plans must offer standard coverage known as essential health benefits. This includes all plans inside and outside of the health insurance exchanges. These benefits provide your employees with essential health benefits, and limit cost-sharing. Here are the broad categories of essential benefits that will be included in your employees coverage: Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance abuse services Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric dental Pediatric vision Out-of-pocket (OOP) maximum mandate All cost sharing must apply toward the OOP maximum*, including in-network medical, behavioral health and pharmacy cost-sharing. This does not include premiums, balance billing amounts of non-network providers or spending for non-covered services. The out-of-pocket maximum must include: Copays Deductibles Coinsurance Fees These fees are included in your premium: Health Insurer Fee Annual fee to offset premium subsidies and tax credit related expenses Transitional Reinsurance Program Contribution Helps finance the cost of high-risk individuals in the individual market Patient-Centered Outcomes Research Fee (also known as the Comparative Effectiveness Fee) Fee to fund clinical outcomes effectiveness research Guaranteed issue Guaranteed issue of health insurance coverage applies to individual, small group and large group markets. Guaranteed Issue is available for: Group health plans/insurance coverage (insured only) Individual health insurance coverage (including medical conversion) Pharmacy (insured only) Behavioral health (insured only)** Please note that guaranteed issue is not available for: Self-funded plans Standalone/separate dental or vision Hospital indemnity/fixed indemnity Medicare and Medicare supplement Medicaid Retiree-only plans Grandfathered plans Association/MEWA plans Waiting period Plans may not have any waiting periods longer than 90 days. The benefit waiting period for future employees may be the 1 st or 15 th or the month following 0 days, 30 days or 60 days. The maximum 90-day waiting period applies to fully insured and self-funded plans. We will update our policies and will work with employers that have waiting periods exceeding 90 days. Refer to Underwriting Guidelines for details. *Prescription drugs may have a separate out-of-pocket maximum. **Note: no standalone insured behavioral health. 4

5 Pediatric dental/vision (2 to 50) Pediatric dental and vision mandates are a separate essential health benefit category and are included with your medical benefits. We will cover those services in 2015 according to the benchmark plan coverage. Pediatric dental and vision is for children up to age 19. Pediatric dental* PPO/HNO plans PPO HSA plans HMO plans with no Indemnity Preferred Nonpreferred Preferred Nonpreferred Preferred No network Dental check-up (preventive/diagnostic) 0% 30% after 0% after 30% after 0% 0% Dental basic 30% after 50% after 30% after 50% after 30% 30% after Dental major 50% after 50% after 50% after 50% after 50% 50% after Dental ortho (after 24 months of continuous coverage) 50% after 50% after 50% after 50% after 50% 50% after Pediatric vision** PPO/HNO plans PPO HSA plans HMO plans with no Indemnity Preferred Nonpreferred Preferred Nonpreferred Preferred No network Vision exam (one exam per 12 months) $0 copay 50% after 0% 50% after $0 copay 0% Frames, lenses or contacts (per 12 months) Preferred:0% Nonpreferred: 50% after 50% after Preferred: 0% after Nonpreferred: 50% after 50% after Preferred: 0% Nonpreferred: 50% Preferred: 0% Nonpreferred: 50% after * These medical plans don t cover all pediatric dental care expenses and include limitations and exclusions. Please refer to your plan documents to see which services we cover. The following is a partial list of services and supplies that we generally don t cover. However, your plan documents may have exceptions to this list. We base these documents on state laws, essential health benefits, or the plan design or rider(s) you buy. --All pediatric dental services not specifically covered in, or that your plan documents limit or exclude, including costs of services before coverage begins and after coverage ends --Instructions for diet, plaque control and oral hygiene --Dental services or supplies that you may primarily use to change, improve or enhance appearance --Dental implants --Experimental or investigational drugs, devices, treatments or procedures --Services not necessary for the diagnosis, care or treatment of a condition --Orthodontic treatment that isn t medically necessary for a severe or handicapping condition --Replacement of lost or stolen appliances --Services and supplies provided where there is no evidence of pathology, dysfunction or disease ** Medically necessary glasses or contact lenses prescribed to treat an eye disease or injury are covered as prosthetics and are not covered as a pediatric vision expense. 5

6 Choosing the right plan for your business Our product portfolio includes a range of coverage and cost combinations. You ll find choices for different budgets and benefits strategies. And you ll see that we re more than medical. You can round out your benefits offering with dental as well as life and disability offerings. Take a look at what s available. Medical plans PPO plans Aetna Whole Health plans* Savings Plus plans* HMO and HNOption plans Plan levels You can choose up to four levels of health plans. These levels are named using metals bronze, silver, gold and platinum. Each level includes the same essential health benefits. But the levels differ in how much the health plan pays. Health plan levels Bronze 60% Silver 70% Gold 80% Platinum 90% Average amount the plan pays for covered services Tools to help your employees stay healthy, informed and productive With Aetna health plans, your employees get online tools and helpful resources that let them make the most of their benefits. Our most popular tools include: Secure member website. Your employees get self-service tools, plus health plan and health information through their Aetna Navigator website. Think of it as the key that unlocks the full value of their health benefits package. Encourage them to sign up at Member Payment Estimator SM tool. With an Aetna health plan, your employees can compare and estimate costs** for office visits, tests, surgeries and more. This means they can save money*** and avoid surprises. This online tool factors in their, coinsurance and copays, plus contracted rates. They can see how much they have to pay and how much the plan will pay. They can log in to their Aetna Navigator member website to use the tool. Online provider directory. Finding doctors, specialists, hospitals and more in the Aetna network is easy with our DocFind directory. It s available at and the Aetna Navigator member website. itriage. (51 to 100 employees) This is a free mobile app that lets members research symptoms and diseases, find a medical provider and even book an appointment all from the convenience of their mobile device. itriage will guide them to network doctors, hospitals and facilities based on their company health plan. It can help direct your employees to the most appropriate, cost-effective care. *May not be available in all areas. ** Estimated costs not available in all markets. The tool gives members an estimate of what they would owe for a particular service based on the plan at that point in time. Actual costs may differ from the estimate if, for example, claims for other services are processed after a member gets the estimate but before the claim for this service is submitted. Or, if the doctor or facility performs a different service at the time of the visit. *** In 2011, members who used Member Payment Estimator before receiving care saved an average of $170 out of pocket on 34 common procedures, according to the Member Payment Estimator Study, Aetna Informatics and Product Development, August

7 Dental plans Dental DMO Dental PPO Dental PPO Max Dental Freedom-of-Choice plan design Dental plan extras There s extra value built into our dental portfolio: Dental-medical integration. Our program encourages preventive dental care among employees who have diabetes or heart disease, or who are pregnant. This can lead to more of your employees taking steps to stay healthy. Vision plans Aetna Vision SM Preferred (AVP) --Basic, Plus and Premier plan designs Vision plan extras Life and disability plans* Basic life Supplemental life AD&D Ultra Supplemental AD&D Ultra Dependent life Packaged life and disability plans Short-term disability Long-term disability Life and disability plan extras Aetna Life Essentials SM. Through our program, your employees get access to expert advice on legal and financial matters at no added cost. Funeral planning and concierge service. Through our collaboration with Everest, we offer our life members pre-planning and at-need services. Routine vision care is important to overall health and wellness. With our competitive plan options, your employees will receive both in- and out-of-network coverage for exams, eyeglass lenses, frames and contact lenses. In addition, they can save up to 40 percent off the retail costs on products and services that aren t covered under the plan when they visit an in-network provider. Your employees can choose from our extensive network of over 65,000 vision providers1, including their neighborhood eye doctors, as well as their favorite retail chains. Like LensCrafters, Pearle Vision, Sears Optical, Target Optical and JCPenney Optical. *For groups 51 to 100, please consult your sales representative for a plan design to meet your group needs. 1Data as of June 2014, EyeMed network database. 7

8 You get a wide range of health care options to fit your needs. About our benefits Choose from numerous, integrated benefits options that can lead to improved employee engagement and health, while helping you manage your costs. This includes medical, pharmacy, dental, life, disability and vision. Plus, online tools that help employees use their benefits wisely and get help when they need it. About our network We have many full-network and tiered-network options to lower employer costs while still providing employees with access to quality care. Our doctor networks prioritize quality and efficiency to improve the health care experience and make it easy for individuals to get the care they need. About our cost sharing Some of our cost-sharing arrangements encourage employees to become more involved in their own health care and become better health care consumers. Employees with these plans receive more preventive care, have lower overall costs and use online tools more frequently. About our funding options We can show you how a combined network, cost sharing and benefits approach can help you manage your premium to meet your budget. We also offer a range of funding options from traditional fully insured to enhanced self-insured solutions that provide different levels of cost, plan control and information access. Network options for healthy outcomes and lower costs Our network solutions help lower your costs while providing employees with access to trusted doctors and hospitals. Your employees can still get care within the broad Aetna network. But they pay less out of pocket when they use doctors and hospitals in our special networks. The more they use health care providers in these networks, the more likely you are to see lower medical costs. We make it easier for your employees, too. They get online tools for estimating costs and finding the right doctors and hospitals. Cost sharing and premiums for every budget Your focus is on lower costs. Increasingly, that means greater levels of employee cost sharing. With Aetna in your corner, you can map out a strategy based on your employee base and price point. And you can choose from the full spectrum of health plan types: Our fully insured portfolio, traditionally a mainstay for small businesses, provides plans with a range of robust coverage options. New self-funded options for small businesses may help you manage costs while simplifying administration and making monthly expenses more predictable. Our defined contribution offering combines an attractive benefits package with more controlled costs. As well as motivation for your employees to get more involved in their health care. Our consumer-directed health plans have long offered fully featured coverage, along with lower premiums and higher s. Our research has found that members with these plans have lower overall health care costs, receive more preventive care and use online tools more frequently than members with traditional plans. 8

9 Health and wellness programs Having a happier, healthier workforce is important to you. So is cost management. We ve found that helping your employees get more involved in managing their health and well-being is a great way to meet these goals. Talk to your broker or Aetna representative to learn more about our programs. Wellness on us Wellness for employees means a healthier business for employers. As always, our health benefits and insurance plans offer $0 copays for in-network eye exams and $0 copay for in-network preventive care. It s one more way to help employees get a step closer to better health. Preventive care benefits with no copay: Immunizations Routine physicals Child wellness visits Routine mammogram Routine OB/GYN visits No -cost health incentive credit Members earn an out-of-pocket expense credit when they: Complete or update their Simple Steps To A Healthier Life health assessment, and Complete one online health program If the employee s spouse is covered under the plan, he or she is also eligible for the same incentive credit. Incentive rewards will be credited toward the and maximum out-of-pocket limit. This program is included at no additional cost on all plans except the HSA-compatible plans. Women s preventive health benefits These services are generally 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, certain brand formulary contraceptives are covered without member copayment; certain religious organizations or religious employers may be exempt from offering contraceptive services We make things easy for you Health plan management and administration is our specialty, which makes it easier for you to manage health insurance benefits with**: eenrollment. Handle enrollments, terminations and other changes online, with less paperwork and greater efficiency. ebilling. Save time and simplify reconciliation and payment, anytime, anywhere, with our secure system. It lets you get, view and pay all your medical and dental bills online. Wellness programs can make health and fitness part of everyday living Women s health and preventive health reminders Simple Steps To A Healthier Life program Informed Health Line* Aetna discount programs Personal health record * While only your doctor can diagnose, prescribe or give medical advice, the Informed Health Line nurses can provide information on more than 5,000 health topics. Contact your doctor first with any questions or concerns regarding your health care needs. **Not available for Aetna Vision Preferred. 9

10 10 Aetna medical overview Medical coverage can be a deal-breaker in recruiting and keeping talented employees. Our medical plan portfolio was designed with the needs of businesses like yours in mind. You ll find flexible options, from traditional indemnity to consumer-directed plans. You can choose the plan design and benefits level that fits your budget and achieve the right balance of cost and coverage for your business.

11 Medical overview M Aetna high- HSA-compatible health plans High- HSA-compatible plans provide integrated medical and pharmacy benefits. Preventive care services are exempt from the. HSAs provide employers and their qualified employees with an affordable tax-advantaged solution that allows them to better manage their qualified medical and dental expenses. Employees can build a savings fund to help cover their future medical and dental expenses. HSA accounts can be funded by the employer or employee and are portable. Fund contributions may be tax (limits apply). When funds are used to cover qualified out-of-pocket medical and dental expenses, they are not taxed. It is completely at the discretion of the employer or employee whether or not to establish an HSA. Note: Employers and employees should consult with their tax advisor to determine eligibility requirements and tax advantages for participation in the HSA plan. Health savings account (HSA) No set-up or administrative fees The Aetna HealthFund HSA, when coupled with a HSA-compatible high- health benefits and health insurance plan, is a tax-advantaged savings account. Once enrolled, account contributions can be made by the employee and/or employer. The HSA can be used to pay for qualified expenses tax free. Member s HSA plan Member owns the HSA Contribute tax free Member chooses how and when to use fund dollars Roll it over each year and let it grow Earns interest, tax free Today and into the future Use now for qualified expenses with tax-free dollars Save for future and retiree health-related costs High- health plan Eligible in-network preventive care services will not be subject to the Member pays 100 percent until is met, then only pays a share of the cost Meet out-of-pocket maximum, then plan pays 100 percent Health reimbursement arrangement (HRA) The Aetna HealthFund HRA combines the protection of a -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 and fund rollover. 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 lower employers costs. COBRA administration Aetna COBRA administration offers a full range of notification, documentation and record-keeping processes that can help employers manage the complex billing and notification processes required for COBRA compliance, while also helping to save them time and money. Section 125 cafeteria plans and Section 132 transit reimbursement accounts Employees can reduce their taxable income, and employers can pay less in payroll taxes. 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. First-year POP fees are with the purchase of medical with five or more enrolled employees. 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. 11

12 M Administrative fees Fee description Fee Premium-only plan (POP) Health reimbursement arrangement (HRA) and flexible spending account (FSA)** Initial set-up* $190 $125 Initial set-up 2 25 Employees $360 $ Employees $460 $ Employees $560 $335 Monthly fees*** Additional set-up fee for stacked plans (those electing an Aetna HRA and FSA simultaneously) Participation fee for stacked participants $5.45 per participant $150 $10.45 per participant Renewal fee Renewal fee 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 * Nondiscrimination testing provided annually after open enrollment for POP and FSA only. Additional off-cycle testing available at employer request for $100 fee. Nondiscrimination testing only available for FSA and POP products. **Aetna FSA pricing is inclusive for POP. Debit cards are available for FSA only. Contact us for more 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 HRAs are subject to employer-defined use and forfeiture rules. 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. We reserve the right to change any of the above fees and to impose additional fees upon prior written notice. 12

13 Arizona provider network has more than 18,000 physicians and 95 hospitals* M Aetna PPO plans The Aetna PPO insurance plan offers members the freedom to go directly to any recognized provider for covered expenses, including specialists. The PPO network is suitable for in-state rural areas. No referrals are required. PPO Network = 18,401 providers and 95 hospitals Aetna Whole Health plans Banner Health Network (BHN) and Arizona Care Network (ACN) The Aetna Whole Health plans provide Arizona members in the greater Phoenix area with the same types of coverage as other Aetna medical plans, but at a lower premium cost. Savings are generated through the use of the Aetna Whole Health network, a quality network of local health care providers. Aetna Whole Health Network featuring: Banner Health Network = 5,853 providers and 19 hospitals Arizona Care Network = 3,985 providers and 15 hospitals Aetna Savings Plus plans The Aetna Savings Plus plans provide Arizona members in Maricopa, Pima and Pinal counties with the same types of coverage as other Aetna medical plans, but at a lower premium cost. Savings are generated through the use of the Savings Plus network, a quality network of local health care providers. Savings Plus Network = 11,419 providers and 46 hospitals Aetna HMO plans Members access care through primary care physicians With this health benefits plan, members begin by selecting a primary care physician (PCP) from our participating network of providers. Members select a PCP who will coordinate their health care needs for covered benefits or services. Each covered member of the family may choose his or her own PCP. HMO Network = 18,162 providers and 95 hospitals Aetna HNOption plans No referrals No need for referrals. Aetna HNOption offers all the health plan benefits of a point-of-service plan with two easy ways to access care when members need it. Members have the freedom to visit the participating doctor or hospital of their choice for covered services. Best of all, members seeking health care do not need referrals. HNO Network = 18,162 providers and 95 hospitals For more information on Savings Plus and Aetna Whole Health plans, see pages *According to the Aetna Enterprise Provider Database as of April Network subject to change. Employers and employee must reside in an eligible area. Live/work rules apply. 13

14 M What is Pick-A-Plan 4?* Pick-A-Plan 4 is our suite of plans designed specifically with small businesses in mind. These plans provide choice, flexibility and simplicity. Pick-A-Plan 4 Target Audience Every small business with 5+ enrolled employees. Pick-A-Plan 4 offers the following advantages: Plan Choices Up to 4 available plans Greater employee choice Employers can offer any four of the available plan designs. Flexibility and affordability Employers can create a customized benefits package from any of our plan types and plan designs. We offer a variety of plans at different price points. Employers may designate a level of contribution that meets their budget. Total freedom You can choose from plans that range in price and benefits to help meet each employee s needs, whether they are lower premiums or lower out-of-pocket costs at the time services are received. Minimum Participation 2 4 Enrolled Employees Single, dual or triple 5 or More Enrolled Employees Up to four available options Employer Contribution 50% of the employee rate or $120 Rating Options 2 50 employees age banded; employees composite Easy administration Setting up this program is simple: 1. The employer chooses up to four plans to offer on the employer application. 2. The employer chooses how much to contribute. 3. Each employee chooses the plan that s right for him or her. *Available with five or more enrolled employees. 14

15 Aetna Whole Health (AWH) Options in the Phoenix Metropolitan Area M We re proud to offer two Accountable Care Organizations (ACOs) in the greater Phoenix metropolitan area for you to choose from! Both ACOs are high quality provider networks that are working with Aetna to help improve care while decreasing costs for members and employers. Your employees will find care in their own communities, with local health care providers who have skill, experience, and compassion. Both the Arizona Care Network (ACN) and the Banner Health Network (BHN) provide convenient access to an integrated network of health care providers and facilities dedicated to patient-centered team approach that delivers a better patient experience at a much lower cost. Two key ingredients make the difference in our ACOs A better health care experience enabled by doctor-driven care, technology-based information sharing, and care coordination New payment models and incentives that encourage accountability to help improve patient health Better health, better care, better cost That s what the Aetna Whole Health product with our ACOs is designed for. It s a member-centered approach that may differ from care your employees have had before The ACO care team s goal is to help keep your employees healthy or help improve their health, not just treat them when they re sick or injured The ACO care team can better coordinate care because they can see how other doctors are treating your employees, what medicine they re taking, lab results, health history and more The ACO care team is up-to-date on medical guidelines and clinical information. This helps to spot problems early and develop personalized care plans for your employees The ACO team wants your employees to take an active and informed role in their health and health care decisions Find Aetna Whole Health Arizona Care Network doctors: Visit Type a name, specialty, procedure or condition in the What are you looking for? box OR search from a list of conditions, procedures and provider types. Enter your ZIP Code or city and state. Select the Aetna Whole Health Arizona Care Network health benefits plan from the drop-down menu. Look for doctors and facilities with the Aetna Whole Health symbol. Find Aetna Whole Health Banner Health Network doctors: Visit Type a name, specialty, procedure or condition in the What are you looking for? box OR search from a list of conditions, procedures and provider types. Enter your ZIP Code or city and state. Select the Aetna Whole Health Banner Health Network OAMC health benefits plan from the drop-down menu. Look for doctors and facilities with the Aetna Whole Health symbol. All plans are designed to have two levels of benefits Level 1: When members use the designated network to coordinate all of their care, they realize maximum savings. Level 2: Use of any other providers will result in a lower level of benefits. Employers and employee must reside in an eligible area. Live/work rules apply. 15

16 M Arizona Care Network coverage area Anthem Glendale North Scottsdale Peoria Litchfield Park Scottsdale Apache Junction 60 Goodyear E Maricopa County Maricopa San Tan Valley Mesa Gilbert Pinal County Find Aetna Whole Health SM Arizona Care Network doctors: Visit Type a name, specialty, procedure or condition in the Who or what are you looking for? box Enter your ZIP Code or city and state in the Where? box Choose (AZ) Aetna Whole Health Arizona Care Network from the Select a Plan drop down menu Hospitals Primary care physicians Urgent care facilities 16 Aetna Whole Health Banner Network doctor

17 M Hospital ZIP City Address Arizona Orthopedic Surgical Hospital Chandler 2905 W Warner Rd. Chandler Regional Medical Center Chandler 1955 W Frye Rd. Mercy Gilbert Medical Center Gilbert 3555 S Val Vista Dr. Phoenix Children s Mercy Gilbert Center Specialty Care Gilbert 3555 S Val Vista Dr. Arrowhead Hospital Glendale N 67th Ave. HealthSouth Valley of the Sun Rehabilitation Hospital Glendale N 67th Ave. St. Joseph s Westgate Medical Center Glendale 7300 N 99th Ave. West Valley Hospital Medical Center Goodyear W McDowell Rd. HealthSouth East Valley Rehabilitation Hospital Mesa 5652 E Baseline Rd. Arizona Heart Hospital Phoenix 1930 E Thomas Rd. Maryvale Hospital Phoenix 5102 W Campbell Ave. OASIS Hospital Phoenix 750 N 40th St. Paradise Valley Hospital Phoenix 3929 E Bell Rd. Phoenix Baptist Hospital Phoenix 2000 W Bethany Home Rd. Phoenix Children s Hospital Phoenix 1919 E Thomas Rd. St. Joseph s Hospital and Medical Center Phoenix 350 W Thomas Rd. HealthSouth Scottsdale Rehabilitation Hospital Scottsdale 9630 E Shea Blvd. 17

18 M Banner Health Network coverage area Wickenburg Anthem 17 Glendale 60 North Scottsdale 101 Peoria Litchfield Park Scottsdale Apache Junction 60 Goodyear 202E Mesa 10 Gilbert aricopa County Maricopa San Tan Valley Pinal County Find Aetna Whole Health SM Banner Health Network doctors: Visit Type a name, specialty, procedure or condition in the Who or what are you looking for? box Enter your ZIP Code or city and state in the Where? box Choose the (AZ) Aetna Whole Health Banner Health Network plan from the Select a Plan drop down menu Hospitals Health centers Primary care physicians Urgent care facilities 18

19 M Hospital Address Health center Address Banner Goldfield Medical Center 2050 W Southern Ave. Apache Junction, Banner Health Center at Verrado W Market St. Buckeye, Banner Gateway Medical Center 1900 N Higley Rd. Gilbert, Banner Health Center in Chandler 1435 S Alma School Rd. Chandler, Banner Thunderbird Medical Center 5555 W Thunderbird Rd. Glendale, Banner Health Center in Gilbert 155 E Warner Rd. Gilbert, Banner Baywood Medical Center 6644 E Baywood Ave. Mesa, Banner Health Center at Estrella 9780 S Estrella Pkwy. Goodyear, Banner Desert Medical Center Cardon Children s Medical Center 1400 S Dobson Rd. Mesa, Banner Health Center in Maricopa Banner Health Center in East Mesa N Porter Rd. Maricopa, S Crismon Rd. Mesa, Banner Heart Hospital 6750 E Baywood Ave. Mesa, Banner Health Center in Queen Creek S Ellsworth Loop Rd. Queen Creek, Banner Estrella Medical Center 9201 W Thomas Rd. Phoenix, Banner Health Center in Surprise W Statler Blvd. Surprise, Banner Good Samaritan Medical Center 1111 E McDowell Rd. Phoenix, Banner Ironwood Medical Center N Gantzel Rd. San Tan Valley, Banner Behavioral Health Hospital 7575 E Earll Dr. Scottsdale, Banner Boswell Medical Center W Thunderbird Blvd. Sun City, Banner Del E. Webb Medical Center W Meeker Blvd. Sun City West,

20 M Savings Plus Network Map 10 Maricopa County 8 Pinal County Pima County Find Aetna Savings Plus doctors: Visit Type a name, specialty, procedure or condition in the What are you looking for? box OR search from a list of conditions, procedures and provider types. Enter your ZIP Code or city and state. Select the Savings Plus Plans: Savings Plus of Arizona from the drop down menu. Hospitals Primary care physicians Urgent care facilities 20

21 M Hospital ZIP City Address Casa Grande Regional Medical Center Casa Grande 1800 E Florence Blvd. Arizona Orthopedic Surgical Hospital Chandler 2905 W Warner Rd. Chandler Regional Medical Center Chandler 1955 W Frye Rd. Mercy Gilbert Medical Center Gilbert 3555 S Val Vista Dr. Arrowhead Hospital Glendale N 67th Ave. Banner Thunderbird Medical Center Glendale 5555 W Thunderbird Rd. St. Joseph¹s Westgate Medical Center Glendale 7300 North 99th Avenue West Valley Hospital Medical Center Goodyear W McDowell Rd. Arizona Spine and Joint Hospital Mesa 4620 E Baseline Rd. Cardon Children s Medical Center Mesa 1400 S Dobson Rd. Mountain Vista Medical Center Mesa 1301 S Crimson Rd. Oro Valley Hospital Oro Valley 1551 E Tangerine Rd. North Peoria Emergency Center Peoria N Lake Pleasant Pkwy. Arizona Heart Hospital Phoenix 1930 E Thomas Rd. Los Ninos Hospital Phoenix 2303 E Thomas Rd. Maryvale Hospital Phoenix 5102 W Campbell Ave. OASIS Hospital Phoenix 750 N 40th St. Paradise Valley Hospital Phoenix 3929 E Bell Rd. Phoenix Baptist Hospital Phoenix 2000 W Bethany Home Rd. Phoenix Children s Hospital Phoenix 1919 E Thomas Rd. Phoenix Indian Medical Center Phoenix 4212 N 16th St. St. Joseph s Hospital and Medical Center Phoenix 350 W Thomas Rd. St. Luke s Medical Center Phoenix 1800 E Van Buren Surgical Specialty Hospital of Arizona Phoenix 6501 N 19th Ave. 21

22 M Hospital ZIP City Address Scottsdale Healthcare Greenbaum Surgical Specialty Hospital Scottsdale 3535 N Scottsdale Rd. Scottsdale Healthcare Osborn Medical Center Scottsdale 7400 E Osborn Rd. Scottsdale Healthcare Shea Medical Center Scottsdale 9003 E Shea Blvd. Scottsdale Healthcare Thompson Peak Hospital Scottsdale 7400 E Thompson Peak Pkwy. Tempe St. Luke s Hospital, A Campus of St. Luke s Tempe 1500 S Mill Ave. Carondelet St. Joseph s Hospital Tucson 350 N Wilmot Rd. Carondelet St. Mary s Hospital Tucson 1601 W St. Marys Rd. Northwest Medical Center Tucson 6200 N La Cholla Blvd. Tucson Medical Center Tucson 5301 E Grant Rd. University Physicians Hospital at Kino Tucson 2800 E Ajo Way 22

23 Traditional medical plans M Plan name Gold /50 (2 50) /50 (51 100) Gold /50 (2 50) /50 (51 100) Networks available Open Choice PPO, Aetna Whole Health Arizona Care Network OAMC, Aetna Whole Health Banner Health Network OAMC, Savings Plus of AZ Open Choice PPO, Aetna Whole Health Arizona Care Network OAMC, Aetna Whole Health Banner Health Network OAMC, Savings Plus of AZ Member benefits* Network care Out-of-network care Network care Out-of-network care Calendar year $500/$1,000 $1,000/$2,000 $750/$1,500 $1,500/$3,000 Calendar year out-of-pocket limit $3,750/$7,500 $7,500/$15,000 $3,750/$7,500 $7,500/$15,000 Deductible & out-of-pocket limit accumulation1 Embedded Embedded Primary care physician office visit Specialist office visit Walk-in clinics Diagnostic testing: Lab Diagnostic testing: X-ray $20 copay; $40 copay; $20 copay; $20 copay; $40 copay; 50% after $20 copay; 50% after $40 copay; 50% after $20 copay; 50% after $20 copay; 50% after $40 copay; 50% after 50% after 50% after 50% after 50% after Imaging (CT/PET scans MRIs) 20% after 50% after 20% after 50% after Inpatient hospital facility 20% after 50% after 20% after 50% after Outpatient surgery Emergency room (copay if admitted) Urgent care Rehabilitation services (PT/OT/ST)2 Coverage is limited to 60 visits per calendar year PT/OT/ST combined. Chiropractic 20% after at ASC; 30% after at hospital $250 copay; $50 copay; 50% after 20% after at ASC; 30% after at hospital Paid as in-network $250 copay; 50% after $50 copay; 50% after Paid as in-network 50% after 20% after 50% after 20% after 50% after $40 copay; 50% after $40 copay; 50% after Pharmacy** Network Out of network Network Out of network Pharmacy None None None None Preferred generic drugs*** T1: $15 copay T1: $15 copay plus 20% T1: $15 copay T1: $15 copay plus 20% Preferred brand drugs $50 copay $50 copay plus 20% $50 copay $50 copay plus 20% Nonpreferred drugs $80 copay $80 copay plus 20% $80 copay $80 copay plus 20% Specialty drugs P: 30% up to $300; NP: 50% up to $500 P: 30% up to $300; NP: 50% up to $500 P: 30% up to $300; NP: 50% up to $500 P: 30% up to $300; NP: 50% up to $500 Refer to page 33 for footnotes. 23

24 M Traditional medical plans Plan name Gold /50 (2 50) /50 (51 100) Gold /50 (2 50) /50 (51 100) Networks available Open Choice PPO, Aetna Whole Health Arizona Care Network OAMC, Aetna Whole Health Banner Health Network OAMC, Savings Plus of AZ Open Choice PPO, Aetna Whole Health Arizona Care Network OAMC, Aetna Whole Health Banner Health Network OAMC, Savings Plus of AZ Member benefits* Network care Out-of-network care Network care Out-of-network care Calendar year $1,000/$2,000 $2,000/$4,000 $1,000/$2,000 $2,000/$4,000 Calendar year out-of-pocket limit $4,500/$9,000 $9,000/$18,000 $4,000/$8,000 $8,000/$16,000 Deductible & out-of-pocket limit accumulation1 Embedded Embedded Primary care physician office visit Specialist office visit Walk-in clinics $20 copay; $50 copay; $20 copay; 50% after $25 copay; 50% after $50 copay; 50% after $25 copay; 50% after 50% after 50% after Diagnostic testing: Lab 20% 50% after 30% 50% after Diagnostic testing: X-ray 20% 50% after 30% 50% after Imaging (CT/PET scans MRIs) 20% after 50% after 30% after 50% after Inpatient hospital facility 20% after 50% after 30% after 50% after Outpatient surgery Emergency room (copay if admitted) Urgent care Rehabilitation services (PT/OT/ST)2 Coverage is limited to 60 visits per calendar year PT/OT/ST combined. Chiropractic 20% after at ASC; 30% after at hospital $250 copay; $60 copay; 50% after 30% after at ASC; 40% after at hospital Paid as in-network $250 copay; 50% after $60 copay; 50% after Paid as in-network 50% after 20% after 50% after 30% after 50% after $50 copay; 50% after $50 copay; 50% after Pharmacy** Network Out of network Network Out of network Pharmacy None None None None Preferred generic drugs*** T1: $15 copay T1: $15 copay plus 20% T1: $15 copay T1: $15 copay plus 20% Preferred brand drugs $50 copay $50 copay plus 20% $50 copay $50 copay plus 20% Nonpreferred drugs $80 copay $80 copay plus 20% $80 copay $80 copay plus 20% Specialty drugs P: 30% up to $300; NP: 50% up to $500 P: 30% up to $300; NP: 50% up to $500 P: 30% up to $300; NP: 50% up to $500 P: 30% up to $300; NP: 50% up to $500 Refer to page 33 for footnotes. 24

25 Traditional medical plans M Plan name Silver /50 (2 50) /50 (51 100) Silver /50 (2 50) /50 (51 100) Networks available Open Choice PPO, Aetna Whole Health Arizona Care Network OAMC, Aetna Whole Health Banner Health Network OAMC, Savings Plus of AZ Open Choice PPO, Aetna Whole Health Arizona Care Network OAMC, Aetna Whole Health Banner Health Network OAMC, Savings Plus of AZ Member benefits* Network care Out-of-network care Network care Out-of-network care Calendar year $1,500/$3,000 $3,000/$6,000 $2,000/$4,000 $4,000/$8,000 Calendar year out-of-pocket limit $6,600/$13,200 $13,200/$26,400 $6,600/$13,200 $13,200/$26,400 Deductible & out-of-pocket limit accumulation1 Embedded Embedded Primary care physician office visit Specialist office visit Walk-in clinics Diagnostic testing: Lab Diagnostic testing: X-ray $30 copay; $60 copay; $30 copay; $30 copay; $60 copay; 50% after $30 copay; 50% after $60 copay; 50% after $30 copay; 50% after $30 copay; 50% after $60 copay; 50% after 50% after 50% after 50% after 50% after Imaging (CT/PET scans MRIs) 30% after 50% after 30% after 50% after Inpatient hospital facility 30% after 50% after 30% after 50% after Outpatient surgery Emergency room (copay if admitted) Urgent care Rehabilitation services (PT/OT/ST)2 Coverage is limited to 60 visits per calendar year PT/OT/ST combined. Chiropractic 30% after at ASC; 40% after at hospital $250 copay; $70 copay; 50% after 30% after at ASC; 40% after at hospital Paid as in-network $250 copay; 50% after $70 copay; 50% after Paid as in-network 50% after 30% after 50% after 30% after 50% after $60 copay; 50% after $60 copay; 50% after Pharmacy** Network Out of network Network Out of network Pharmacy None None None None Preferred generic drugs*** T1: $15 copay T1: $15 copay plus 20% T1: $15 copay T1: $15 copay plus 20% Preferred brand drugs $50 copay $50 copay plus 20% $50 copay $50 copay plus 20% Nonpreferred drugs $80 copay $80 copay plus 20% $80 copay $80 copay plus 20% Specialty drugs P: 30% up to $300; NP: 50% up to $500 P: 30% up to $300; NP: 50% up to $500 P: 30% up to $300; NP: 50% up to $500 P: 30% up to $300; NP: 50% up to $500 Refer to page 33 for footnotes. 25

26 M Traditional medical plans Plan name Silver /50 (2 50) /50 (51 100) Silver /50 (2 50) /50 (51 100) Networks available Open Choice PPO, Aetna Whole Health Arizona Care Network OAMC, Aetna Whole Health Banner Health Network OAMC, Savings Plus of AZ Open Choice PPO, Aetna Whole Health Arizona Care Network OAMC, Aetna Whole Health Banner Health Network OAMC, Savings Plus of AZ Member benefits* Network care Out-of-network care Network care Out-of-network care Calendar year $2,500/$5,000 $5,000/$10,000 $2,500/$5,000 $5,000/$10,000 Calendar year out-of-pocket limit $6,600/$13,200 $13,200/$26,400 $6,600/$13,200 $13,200/$26,400 Deductible & out-of-pocket limit accumulation1 Embedded Embedded Primary care physician office visit Specialist office visit Walk-in clinics Diagnostic testing: Lab Diagnostic testing: X-ray $25 copay; $50 copay; $25 copay; $25 copay; $50 copay; 50% after $30 copay; 50% after $55 copay; 50% after $30 copay; 50% after $30 copay; 50% after $60 copay; 50% after 50% after 50% after 50% after 50% after Imaging (CT/PET scans MRIs) 20% after 50% after 30% after 50% after Inpatient hospital facility 20% after 50% after 30% after 50% after Outpatient surgery Emergency room (copay if admitted) Urgent care Rehabilitation services (PT/OT/ST)2 Coverage is limited to 60 visits per calendar year PT/OT/ST combined. Chiropractic 20% after at ASC; 30% after at hospital $250 copay; $60 copay; 50% after 30% after at ASC; 40% after at hospital Paid as in-network $250 copay; 50% after $70 copay; 50% after Paid as in-network 50% after 20% after 50% after 30% after 50% after $50 copay; 50% after $55 copay; 50% after Pharmacy** Network Out of network Network Out of network Pharmacy None None None None Preferred generic drugs*** T1: $15 copay T1: $15 copay plus 20% T1: $15 copay T1: $15 copay plus 20% Preferred brand drugs $50 copay $50 copay plus 20% $50 copay $50 copay plus 20% Nonpreferred drugs $80 copay $80 copay plus 20% $80 copay $80 copay plus 20% Specialty drugs P: 30% up to $300; NP: 50% up to $500 P: 30% up to $300; NP: 50% up to $500 P: 30% up to $300; NP: 50% up to $500 P: 30% up to $300; NP: 50% up to $500 Refer to page 33 for footnotes. 26

27 Traditional medical plans M Plan name Bronze /50 (2 50) /50 (51 100) Silver /50 (2 50) /50 (51 100) Networks available Open Choice PPO, Aetna Whole Health Arizona Care Network OAMC, Aetna Whole Health Banner Health Network OAMC, Savings Plus of AZ Open Choice PPO, Aetna Whole Health Arizona Care Network OAMC, Aetna Whole Health Banner Health Network OAMC, Savings Plus of AZ Member benefits* Network care Out-of-network care Network care Out-of-network care Calendar year $4,500/$9,000 $9,000/$18,000 $5,000/$10,000 $10,000/$20,000 Calendar year out-of-pocket limit $6,600/$13,200 $13,200/$26,400 $6,600/$13,200 $13,200/$26,400 Deductible & out-of-pocket limit accumulation1 Embedded Embedded Primary care physician office visit $55 copay; 50% after $30 copay; Specialist office visit 50% after 50% after $55 copay; Walk-in clinics $55 copay; 50% after $30 copay; Diagnostic testing: Lab 50% after 50% after $30 copay; Diagnostic testing: X-ray 50% after 50% after $60 copay; 50% after 50% after 50% after 50% after 50% after Imaging (CT/PET scans MRIs) 50% after 50% after 30% after 50% after Inpatient hospital facility 50% after 50% after 30% after 50% after Outpatient surgery 50 % after 50% after 30% after at ASC; 40% after at hospital Emergency room (copay if admitted) 50% after Paid as in-network $250 copay; (copay if admitted) Urgent care 50% after 50% after $70 copay; Rehabilitation services (PT/OT/ST)2 Coverage is limited to 60 visits per calendar year PT/OT/ST combined. 50% after Paid as in-network 50% after 50% after 50% after 30% after 50% after Chiropractic 50% after 50% after $55 copay; 50% after Pharmacy** Network Out of network Network Out of network Pharmacy Integrated with Medical Deductible Integrated with Medical Deductible Preferred generic drugs*** T1: $15 copay T1: $15 copay plus 20% T1: $15 copay T1: $15 copay plus 20% Preferred brand drugs Nonpreferred drugs Specialty drugs $70 copay after $70 copay plus 20% after $100 copay after P: 30% up to $300 after ; NP: 50% up to $500 after $100 copay plus 20% after P: 30% up to $300 after ; NP: 50% up to $500 after None None $50 copay $50 copay plus 20% $80 copay $80 copay plus 20% P: 30% up to $300; NP: 50% up to $500 P: 30% up to $300; NP: 50% up to $500 Refer to page 33 for footnotes. 27

28 M Traditional medical plans Plan name Silver /50 (2 50) /50 (51 100) Silver /50 (2 50) /50 (51 100) Networks available Open Choice PPO, Aetna Whole Health Arizona Care Network OAMC, Aetna Whole Health Banner Health Network OAMC, Savings Plus of AZ Open Choice PPO, Aetna Whole Health Arizona Care Network OAMC, Aetna Whole Health Banner Health Network OAMC, Savings Plus of AZ Member benefits* Network care Out-of-network care Network care Out-of-network care Calendar year $3,500/$7,000 $7,000/$14,000 $5,000/$10,000 $10,000/$20,000 Calendar year out-of-pocket limit $6,600/$13,200 $13,200/$26,400 $6,600/$13,200 $13,200/$26,400 Deductible & out-of-pocket limit accumulation1 Embedded Embedded Primary care physician office visit Specialist office visit Walk-in clinics Diagnostic testing: Lab Diagnostic testing: X-ray Imaging (CT/PET scans MRIs) Inpatient hospital facility Outpatient surgery Emergency room (copay if admitted) Urgent care Rehabilitation services (PT/OT/ST)2 Coverage is limited to 60 visits per calendar year PT/OT/ST combined. Chiropractic $30 copay; $60 copay; $30 copay; $30 copay; $60 copay; Covered in full after Covered in full after Covered in full after $250 copay; $70 copay; Covered in full after $60 copay; 50% after $30 copay; 50% after $60 copay; 50% after $30 copay; 50% after $30 copay; 50% after $60 copay; 50% after Covered in full after 50% after Covered in full after 50% after Covered in full after Paid as in-network $250 copay; 50% after $70 copay; 50% after Covered in full after 50% after $60 copay; 50% after 50% after 50% after 50% after 50% after 50% after 50% after 50% after Paid as in-network 50% after 50% after 50% after Pharmacy** Network Out of network Network Out of network Pharmacy None None None None Preferred generic drugs*** T1: $15 copay T1: $15 copay plus 20% T1: $15 copay T1: $15 copay plus 20% Preferred brand drugs $50 copay $50 copay plus 20% $50 copay $50 copay plus 20% Nonpreferred drugs $80 copay $80 copay plus 20% $80 copay $80 copay plus 20% Specialty drugs P: 30% up to $300; NP: 50% up to $500 P: 30% up to $300; NP: 50% up to $500 P: 30% up to $300; NP: 50% up to $500 P: 30% up to $300; NP: 50% up to $500 Refer to page 33 for footnotes. 28