CA Group Business 2-50 Employees
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1 PLAN FEATURES Network Primary Care Physician Selection Deductible (per calendar year) Member Coinsurance Copay Maximum (per calendar year) Lifetime Maximum Referral Requirement PHYSICIAN SERVICES Primary Care Physician Visits Aetna Value Network HMO Required None Not applicable $3,000 per Individual $6,000 per Family All member copays accumulate toward the Copay Maximum, excluding member cost share for Prescription Drugs. No individual can contribute more than the Individual Copay Maximum toward satisfaction of the Family Copay Maximum. Once the Family Copay Maximum is met, all family members will be considered as having met their Copay Maximum for the remainder of the calendar year. Unlimited except where otherwise indicated. Required for all non-emergency, non-urgent and non-primary Care Physician services, except direct access services. Office Hours: $30 copay Specialist Office Visits E-Visits - Primary Care and Specialist Physicians Walk-In-Clinics Maternity/OB Visits Allergy Testing & Treatment PREVENTIVE CARE Same as Specialist Office Visit for initial visit only; thereafter covered at 100%. Routine Adult Physical Exams / Immunizations Limited to 1 exam every 12 months for members age 18 and older. Well Child Exams / Immunizations Provides coverage for 9 exams from birth up to age 3; 1 exam per 12 months from age 3 through age 17. Routine Gynecological Exams** Includes pap smear, HPV screening and related lab fees. Limited to one visit per 365-day period, unless otherwise recommended by a physician. Routine Mammograms One baseline mammogram for females age 35-39; and one annual mammogram for females age 40 and over. Routine Digital Rectal Exams/Prostate Specific Antigen Test For covered males age 40 and over Page 1
2 Colorectal Cancer Screening (includes routine sigmoidoscopy and preventive colonoscopy) For all members age 50 and over. Frequency schedule applies. Colonoscopy See Outpatient Surgery Benefit (non-preventive) Routine Eye and Hearing Screenings Paid as part of a routine physical exam. Routine Eye Exam (Refraction)** Limited to 1 exam every 24 months. DIAGNOSTIC PROCEDURES Diagnostic Laboratory Diagnostic X-ray (except for Complex Imaging Services) Diagnostic X-ray for Complex Imaging Services (MRI, MRA, PET and CT Scans) EMERGENCY/URGENT MEDICAL CARE Urgent Care Provider (benefit availability may vary by location) Non-Urgent use of Urgent Care Provider Emergency Room Non-Emergency care in an Emergency Room Ambulance HOSPITAL CARE Inpatient Coverage (including maternity & transplants) Outpatient Surgery Performed in a Hospital Outpatient Facility Outpatient Surgery Performed in a Facility Other than a Hospital Outpatient Facility MENTAL HEALTH SERVICES Inpatient Serious Mental Illness & Serious Emotional Outpatient Serious Mental Illness & Serious Emotional Inpatient Other than Serious Mental Illness & Serious Emotional Outpatient Other than Serious Mental Illness & Serious Emotional ALCOHOL/DRUG ABUSE SERVICES Inpatient Detoxification Outpatient Detoxification $30 copay $100 copay $50 copay $150 copay $100 copay $400 copay $300 copay Page 2
3 Inpatient Rehabilitation Outpatient Rehabilitation OTHER SERVICES Transplant - Facility Expense Services Coverage provided for transplants that are not experimental and noninvestigational at approved facilities generally Institutes of Excellence contracted facilities only. Precertification required. Skilled Nursing Facility Limited to 100 days per member per calendar year Home Health Care Limited to 100 visits per member per calendar year; 1 visit equals a period of 4 hours or less. Infusion Therapy Provided at Home or in the Physician's Office Infusion Therapy Provided in OP Hospital or Facility Hospice Care - Inpatient Hospice Care - Outpatient Outpatient Rehabilitation Therapy Includes physical and occupational therapy. Limited to 20 visits per member per calendar year. Outpatient Speech Therapy Subluxation (Chiropractic)** Durable Medical Equipment Maximum benefit of $2,000 per member per calendar year. Limit does not apply to prosthetics or orthotics. FAMILY PLANNING $30 copay $0 copay $15 copay 50% per item Infertility Treatment Coverage for only the diagnosis and surgical treatment of the underlying medical cause. Voluntary Sterilization Including tubal ligation and vasectomy. PHARMACY-PRESCRIPTION DRUG BENEFITS Brand Name Prescription drug calendar year deductible (must be satisfied before any brand name prescription drug benefits are paid) Member cost sharing is based on the type of service performed and the place rendered. Member cost sharing is based on the type of service performed and the place rendered. PARTICIPATING PHARMACIES $150 per member Page 3
4 Retail $20 copay for generic formulary drugs, $40 Up to a 30-day supply copay for brand name formulary drugs, and $60 copay for brand name and generic nonformulary drugs Mail Order Up to a 90-day supply 2x retail Mandatory Generic with DAW override (MG W/DAW Override) - The member pays the applicable copay only, if the physician requires brand. If the member requests brand when a generic is available, the member pays the applicable copay plus the difference between the generic and the brand price. Plan includes lifestyle/performance drugs (limited to 4 pills per month), contraceptive drugs, devices obtainable from a pharmacy and diabetic supplies. Precertification included. HMO, or its contracted organization, may use prior authorizations and ongoing reviews to limit the number of outpatient Mental or Substance Abuse visits to the maximum it deems to be Covered that are Medically Necessary independent of the maximum number of visits shown in this Schedule of Benefits. This means the Member may not receive the maximum number of outpatient visits shown in this Schedule of Benefits or the number of outpatient visits the Member and the treating Provider believe to be appropriate for a single course of treatment or episode. *For this plan, "Participating Providers" refers to the Aetna Value Network participating providers. For any questions or concerns about accessing and obtaining services from Aetna Value Network physicians, please call Member Services at AETNA ( ). **Members may directly access participating providers for certain services as outlined in the plan documents. What's This plan does not cover all health care expenses and includes exclusions and limitations. Members should refer to their plan documents to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, your plan documents may contain exceptions to this list based on state mandates or the plan design or rider(s) purchased. All medical or hospital services not specifically covered in, or which are limited or excluded by your plan documents, including costs of services before coverage begins and after coverage terminates. Cosmetic surgery. Custodial care. Dental care and x-rays. Donor egg retrieval. Experimental and investigational procedures, except for coverage for medically necessary routine patient care costs for Members participating in a cancer clinical trial). Hearing aids. Home births. Immunizations for travel or work. Implantable drugs and certain injectable drugs including injectable infertility drugs. Infertility services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services unless specifically listed as covered in your plan documents. Page 4
5 Non-medically necessary services or supplies. Orthotics. NOTE: Some states require coverage for diabetes related care and/or congenital defects. Over-the-counter medications and supplies. NOTE: Some states require coverage for certain covered diabetic drugs and supplies and/or certain contraceptives. Reversal of sterilization. Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies, counseling and prescription drugs. Special duty nursing. Therapy or rehabilitation other than those listed as covered in the plan documents. Treatment of behavioral disorders. This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee results or outcomes. Consult the plan documents (i.e. Schedule of Benefits, Certificate of Coverage, Evidence of Coverage, Group Agreement, Group Insurance Certificate and/or Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitation relating to the plan. The availability of a plan or program may vary by geographic service area. Some benefits are subject to limitations or visit maximums. Participating physicians, hospitals and other health care providers are independent contractors and are neither agents nor employees of Aetna. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change. Notice of the change shall be provided in accordance with applicable state law. If your plan covers outpatient prescription drugs, your plan may include a drug formulary (preferred drug list). A formulary is a list of prescription drugs generally covered under your prescription drug benefits plan on a preferred basis subject to applicable limitations and conditions. Your pharmacy benefit is generally not limited to the drugs listed on the formulary. The medications listed on the formulary are subject to change in accordance with applicable state law. For information regarding how medications are reviewed and selected for the formulary, formulary information, and information about other pharmacy programs such as precertification and step-therapy, please refer to Aetna's website at Aetna.com, or the Aetna Medication Formulary Guide. Many drugs, including many of those listed on the formulary, are subject to rebate arrangements between Aetna and the manufacturer of the drugs. Rebates received by Aetna from drug manufacturers are not reflected in the cost paid by a member for a prescription drug. In addition, in circumstances where your prescription plan utilizes copayments or coinsurance calculated on a percentage basis or a deductible, use of formulary drugs may not necessarily result in lower costs for the member. Members should consult with their treating physicians regarding questions about specific medications. Refer to your plan documents or contact Member Services for information regarding the terms and limitations of coverage. Aetna Rx Home Delivery refers to Aetna Rx Home Delivery, LLC, a subsidiary of Aetna, Inc., that is a licensed pharmacy providing mail-order pharmacy services. Aetna's negotiated charge with Aetna Rx Home Delivery may be higher than Aetna Rx Home Delivery's cost of purchasing drugs and providing mail-order pharmacy services. Plans are offered by: Aetna Health of California, Inc. While this information is believed to be accurate as of the print date, it is subject to change. Page 5
PARTICIPATING PROVIDERS / REFERRED Deductible (per calendar year)
Your HMO Plan Primary Care Physician - You choose a Primary Care Physician. The Aetna HMO Deductible provider network gives you access to a wide selection of Primary Care Physicians ( PCP's) and Specialists
California PCP Selected* Not Applicable
PLAN FEATURES Deductible (per calendar ) Member Coinsurance * Not Applicable ** Not Applicable Copay Maximum (per calendar ) $3,000 per Individual $6,000 per Family All member copays accumulate toward
PLAN DESIGN AND BENEFITS Basic HMO Copay Plan 1-10
PLAN FEATURES Deductible (per calendar year) Member Coinsurance Not Applicable Not Applicable Out-of-Pocket Maximum $5,000 Individual (per calendar year) $10,000 Family Once the Family Out-of-Pocket Maximum
PLAN DESIGN AND BENEFITS POS Open Access Plan 1944
PLAN FEATURES PARTICIPATING Deductible (per calendar year) $3,000 Individual $9,000 Family $4,000 Individual $12,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being
Bates College Effective date: 01-01-2010 HMO - Maine PLAN DESIGN AND BENEFITS PROVIDED BY AETNA HEALTH INC. - FULL RISK PLAN FEATURES
PLAN FEATURES Deductible (per calendar year) $500 Individual $1,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Once Family Deductible is met, all family
California Small Group MC Aetna Life Insurance Company
PLAN FEATURES Deductible (per calendar year) $1,000 per member $1,000 per member Unless otherwise indicated, the Deductible must be met prior to benefits being payable. All covered expenses accumulate
PLAN DESIGN AND BENEFITS AETNA LIFE INSURANCE COMPANY - Insured
PLAN FEATURES Deductible (per calendar year) Individual $750 Individual $1,500 Family $2,250 Family $4,500 All covered expenses accumulate simultaneously toward both the preferred and non-preferred Deductible.
PLAN DESIGN AND BENEFITS Georgia 2-100 HNOption 13-1000-80
Georgia Health Network Option (POS Open Access) PLAN DESIGN AND BENEFITS Georgia 2-100 HNOption 13-1000-80 PLAN FEATURES PARTICIPATING PROVIDERS NON-PARTICIPATING PROVIDERS Deductible (per calendar year)
PLAN DESIGN AND BENEFITS - PA Health Network Option AHF HRA 1.3. Fund Pays Member Responsibility
HEALTHFUND PLAN FEATURES HealthFund Amount (Per plan year. Fund changes between tiers requires a life status change qualifying event.) Fund Coinsurance (Percentage at which the Fund will reimburse) Fund
PLAN DESIGN AND BENEFITS - Tx OAMC 2500 08 PREFERRED CARE
PLAN FEATURES Deductible (per calendar year) $2,500 Individual $5,000 Individual $7,500 3 Individuals per $15,000 3 Individuals per Unless otherwise indicated, the Deductible must be met prior to benefits
SMALL GROUP PLAN DESIGN AND BENEFITS OPEN CHOICE OUT-OF-STATE PPO PLAN - $1,000
PLAN FEATURES PREFERRED CARE NON-PREFERRED CARE Deductible (per calendar year; applies to all covered services) $1,000 Individual $3,000 Family $2,000 Individual $6,000 Family Plan Coinsurance ** 80% 60%
IL Small Group MC Open Access Aetna Life Insurance Company Plan Effective Date: 10/01/2010 PLAN DESIGN AND BENEFITS- MC CDHP $2,500 90/70 (10/10)
PLAN FEATURES Deductible (per calendar ) $2,500 Individual $5,000 Individual $7,500 Family $15,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. All covered
Business Life Insurance - Health & Medical Billing Requirements
PLAN FEATURES Deductible (per plan year) $2,000 Employee $2,000 Employee $3,000 Employee + Spouse $3,000 Employee + Spouse $3,000 Employee + Child(ren) $3,000 Employee + Child(ren) $4,000 Family $4,000
IL Small Group PPO Aetna Life Insurance Company Plan Effective Date: 04/01/2009 PLAN DESIGN AND BENEFITS- PPO HSA HDHP $2,500 100/80 (04/09)
PLAN FEATURES OUT-OF- Deductible (per calendar ) $2,500 Individual $5,000 Individual $5,000 Family $10,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable.
100% Percentage at which the Fund will reimburse Fund Administration
FUND FEATURES HealthFund Amount $500 Employee $1,000 Employee + 1 Dependent $1,000 Employee + 2 Dependents $1,000 Family Amount contributed to the Fund by the employer Fund amount reflected is on a per
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18 Medical Plan - Healthfund Oklahoma City Community College Effective Date: 07-01-2010 Aetna HealthFund Open Choice (PPO) - Oklahoma PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY -
PLAN DESIGN AND BENEFITS - Tx OAMC Basic 2500-10 PREFERRED CARE
PLAN FEATURES Deductible (per calendar year) $2,500 Individual $4,000 Individual $7,500 Family $12,000 Family 3 Individuals per Family 3 Individuals per Family Unless otherwise indicated, the Deductible
New York Small Group Indemnity Aetna Life Insurance Company Plan Effective Date: 10/01/2010. PLAN DESIGN AND BENEFITS - NY Indemnity 1-10/10*
PLAN FEATURES Deductible (per calendar year) $2,500 Individual $7,500 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Member cost sharing for certain services,
100% Fund Administration
FUND FEATURES HealthFund Amount $500 Employee $750 Employee + Spouse $750 Employee + Child(ren) $1,000 Family Amount contributed to the Fund by the employer Fund Coinsurance Percentage at which the Fund
PREFERRED CARE. All covered expenses, including prescription drugs, accumulate toward both the preferred and non-preferred Payment Limit.
PLAN FEATURES Deductible (per plan year) $300 Individual $300 Individual None Family None Family All covered expenses, excluding prescription drugs, accumulate toward both the preferred and non-preferred
PLAN DESIGN AND BENEFITS - Tx OAMC 1500-10 PREFERRED CARE
PLAN FEATURES Deductible (per calendar year) $1,500 Individual $3,000 Individual $4,500 Family $9,000 Family 3 Individuals per Family 3 Individuals per Family Unless otherwise indicated, the Deductible
Employee + 2 Dependents
FUND FEATURES HealthFund Amount $500 Individual $1,000 Employee + 1 Dependent $1,000 Employee + 2 Dependents $1,000 Family Amount contributed to the Fund by the employer Fund Coinsurance Percentage at
Unlimited except where otherwise indicated.
PLAN FEATURES Deductible (per calendar year) $1,250 Individual $5,000 Individual $2,500 Family $10,000 Family All covered expenses including prescription drugs accumulate separately toward both the preferred
PDS Tech, Inc Proposed Effective Date: 01-01-2012 Aetna HealthFund Aetna Choice POS ll - ASC
FUND FEATURES HealthFund Amount $500 Individual $1,000 Employee + 1 Dependent $1,000 Employee + 2 Dependents $1,000 Family Amount contributed to the Fund by the employer Fund Coinsurance 100% Percentage
$6,350 Individual $12,700 Individual
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible $5,000 Individual $10,000 Individual $10,000 Family $20,000 Family All covered expenses accumulate separately toward the preferred or non-preferred Deductible.
1 exam every 12 months for members age 22 to age 65; 1 exam every 12 months for adults age 65 and older. Routine Well Child
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PLAN FEATURES NON-* Deductible (per calendar year) $2,500 Individual $3,000 Individual $5,000 Family $6,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable.
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Prepared: 04/06/2012 04:19 PM
PLAN FEATURES NON- Deductible (per calendar year) $2,000 Individual $4,000 Individual $6,000 Family $12,000 Family All covered expenses accumulate simultaneously toward both the preferred and non-preferred
THE CITY OF HOPE Proposed Effective Date: 01-01-2012 HMO - California PLAN DESIGN & BENEFITS PROVIDED BY AETNA HEALTH OF CALIFORNIA INC.
PLAN FEATURES Deductible (per calendar year) Out-of-Pocket Maximum (per calendar year) None Individual None Family $1,500 Individual $3,000 Family Member cost sharing for certain services may not apply
$20 office visit copay; deductible 20%; after deductible. $30 office visit copay; deductible Not Covered. $30 office visit copay; deductible waived
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $300 Individual $600 Individual $600 Family $1,200 Family All covered expenses, accumulate separately toward the preferred or non-preferred
$25 copay. One routine GYN visit and pap smear per 365 days. Direct access to participating providers.
HMO-1 Primary Care Physician Visits Office Hours After-Hours/Home Specialty Care Office Visits Diagnostic OP Lab/X Ray Testing (at facility) with PCP referral. Diagnostic OP Lab/X Ray Testing (at specialist)
SPIN Effective Date: 01-01-2013 Aetna HealthFund Aetna Choice POS ll - ASC PLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY
HealthFund Amount $1,500 Employee $1,500 Employee + 1 Dependent $1,500 Employee + 2 Dependents $1,500 Family Amount contributed to Fund by employer Fund Coinsurance 100% Percentage at which Fund will reimburse
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