HEALTH SAVINGS PPO PLAN (WITH HSA) - COLUMBUS PROVIDED BY AETNA LIFE INSURANCE COMPANY EFFECTIVE JANUARY 1, 2016 AETNA INC. CPOS II DEDUCTIBLE, COPAYS/COINSURANCE AND DOLLAR MAXIMUMS and Aligned Deductible - per calendar year* Employer Contribution $1,300 per member $2,600 per family $2,500 per member $5,000 per family $650 single $1,300 family *amount prorated based upon date of eligibility $3,500 per member $7,000 per family Copays/Coinsurance Fixed Dollar Copays No copays $100 copay Outpatient surgery facility fee only $500 copay Inpatient admissions $200 copay Outpatient surgery facility fee only $1,000 copay Inpatient admissions Percent Coinsurance 10% 20% 40% of R&C Out-of-Pocket Maximum per calendar year* Includes Prescription drugs,, coinsurance and copays $2,600 per member $5,200 per family $5,000 per member $10,000 per family $7,000 per member $14,000 per family Lifetime Maximum Includes Prescription Drugs * FULL INTEGRATION (DOLLARS ACCUMULATE TOWARDS ALL TIERS) If any individual in the plan reaches the single out-of-pocket expenses before the family out-of-pocket maximum is met, the cost of that individual s in-network, eligible care will be covered for the rest of the plan year. None FACILITY OUTPATIENT DIAGNOSTIC SERVICES and Aligned MRI, MRA, PET and CAT Scans and Nuclear Medicine Other Diagnostic Tests, X-rays, Laboratory & Pathology Radiation Therapy EMERGENCY MEDICAL CARE and Aligned Hospital Emergency Room Qualified Medical Emergency & First Aid Services Non-Emergency use of the Emergency Room Covered 60% after
Facility Based Urgent Care Centers Ambulance Services medically necessary transport Covered 80% of R&C after INPATIENT HOSPITAL CARE and Aligned Semi-Private Room, General Nursing Care, Hospital Services and Supplies Covered - 90% after Covered - $500 per confinement copay, then 80% after Unlimited days Covered $1,000 per confinement copay, then 60% of R&C after ALTERNATIVES TO INPATIENT HOSPITAL CARE and Aligned Skilled Nursing Facility Covered $500 copay, then 80% after 120 days per calendar years Hospice Care after after Unlimited days Home Health Care 120 visits per calendar year Covered $1,000 copay, then 60% of R&C after OUTPATIENT SURGICAL SERVICES (FACILITY FEE) and Aligned Surgery includes related surgical services Covered - 90% after Covered $100 copay, then 80% after Covered $200 copay, then 60% of R&C after OUTPATIENT THERAPY and Aligned Outpatient Physical, Speech and Occupational Therapy Limited to 60 visits each type of therapy per calendar year. Services are covered when performed in the outpatient department of the hospital, or approved freestanding facility. Cardiac Rehabilitation Maximum of 36 visits in a 12 week period Chemotherapy
HUMAN ORGAN TRANSPLANTS and Aligned Specified Organ Transplants coordinated through the Aetna Transplant Program (1-877-212-8811) Covered 90% waived No coverage for services rendered at a non-ioe Transplant facility INPATIENT MENTAL HEALTH CARE AND SUBSTANCE ABUSE TREATMENT and Aligned Inpatient Mental Health and Substance Abuse Care * Covered $1,000 copay, then 60% of R&C after * DEDUCTIBLE OTHER SERVICES and Aligned Durable Medical Equipment/Medical Supplies Prosthetic and Orthotic Appliances Private Duty Nursing after after after PREVENTIVE SERVICES AS PER HEALTH CARE REFORM, PREVENTIVE SERVICES AS DEFINED BY THE U.S. PREVENTIVE SERVICES TASK FORCE PERFORMED BY AN IN-NETWORK PROVIDER WILL BE AT NO COST TO THE ASSOCIATE Health Maintenance Exam age 18 and over; includes related chest X-rays, EKG, and lab procedures performed as part of the exam and Aligned waived Annual Gynecological Exam - one per calendar year waived Pap Smear and related lab fees one per calendar year waived Mammography Screening One baseline for ages 35-39, then waived one annual mammogram age 40 and over Prostate Specific Antigen (PSA) and DRE-One Screening - one per calendar year for males 40 and over Colonoscopy Screening Exam one every 10 years after age 50 Sigmoidoscopy Screening Exam one per calendar year age 40 and over waived waived waived waived waived waived waived waived waived waived after after after after after after after
Well-Baby and Child Care through age 17 7 exams in the first 12 months of life waived 3 visits in the second 12 months of life 3 visits in the third 12 months of life 1 exam per year thereafter Immunizations - pediatric and adult waived waived waived after after PHYSICIAN OFFICE SERVICES and Aligned Office Visits Includes: Primary care and specialist physicians Presurgical consultations Initial visit to determine pregnancy Covered 80% after after PROFESSIONAL DIAGNOSTIC SERVICES and Aligned MRI, MRA, PET and CAT Scans and Nuclear Medicine Other Diagnostic Tests, X-rays, Laboratory & Pathology Radiation Therapy after after after MATERNITY SERVICES and Aligned Pre-Natal and Post-Natal Care for physician office visits including the initial and subsequent history and physical exams of the pregnant woman (maternal weight, blood pressure, and fetal heart rate check) waived waived Delivery and Nursery Care High Risk Specialist Visits Ultrasounds and Pregnancy Diagnostic Lab Tests Anemia Screening and Gestational Diabetes Screening waived waived Amniocentesis (Professional Charges) Amniocentesis (Facility Charges) after $100 copay after $200 copay *Mom and Baby s claims are processed separately under their own files and both may be subject to the and OOP Max.
OUTPATIENT MENTAL HEALTH CARE AND SUBSTANCE ABUSE TREATMENT and Aligned Outpatient Mental Health Care * Outpatient Substance Abuse Care * *Tier 1 OTHER PROFESSIONAL SERVICE and Aligned Inpatient Medical Care (Physician visits) Allergy Testing and Therapy Injections Chiropractic Care (20 visits per calendar year) Physical Therapy -Independent Physical Therapist (Limited to 60 visits per calendar year combined with outpatient physical therapy) OTHER MISC SERVICES Non Surgical Weight Management Program of billed eligible expenses up to $500 COVERAGE UNDER THE MEDICAL PLAN FOR DEPENDENTS THAT RESIDE OUTSIDE THE SERVICE AREA Colleagues with dependents who reside outside of the service area are eligible to expand their Tier 2 network coverage to include more providers in their local area. Colleagues who are enrolled in the medical plan and have dependents residing outside the service area, need to contact Customer Service Aetna with the dependent's name and address to have their contract updated and for claims to process correctly. Note: Cancer Treatment Centers of America (CTCA) There is no Network or Out-Of-Network coverage for both health care services provided by the facility; and health care services provided by physicians and other health care professionals at the facility. BEGINNING RIGHT MATERNITY PROGRAM There s a lot of information on pregnancy. Using the Beginning Right program will make it easier for you (or your enrolled spouse/eligible adult) to find the information you need, by sharing materials to help you throughout your pregnancy and even after your baby is born. If enrolled by the 16th week of pregnancy, participants will receive the book, "What to Expect When You're Expecting." It s easy to sign up for the program: 1. Call toll-free at 1-800-CRADLE-1 (1-800-272-3531), weekdays from 8 a.m. to 7 p.m. ET.
2. Or log in to Aetna Navigator at www.aetna.com and look under Health Programs. Important Information: Certification for certain non-preferred must be obtained in order to avoid a reduction in benefits for that care. Certification required for Hospital, Treatment Facility, and Convalescent Facility Admissions. In addition, certification is required for Home Health Care and Hospice Care. Plan limits and maximums are combined for in-network and out-of-network care. This plan does not cover all healthcare expenses and excludes or limits coverage for some medical services. Members should refer to their plan documents to determine which medical services are covered and to what extent. This chart displays only a general description of your benefits. Should there be a conflict between the benefits shown on the chart and those in the legal plan documents, the terms of the plan documents will be used to determine coverage and benefits.
Prescription Drugs Administered directly by CVS Caremark CVS CAREMARK MEMBER SERVICES 1-877-876-6877 Retail 34-day supply Generic Formulary Brand Name Non-formulary Brand Name Mail Order 90 day supply Generic Formulary Brand Name Non-Formulary Brand Name Ministry owned on-site pharmacies 34-day supply Generic Formulary Brand Name Non-Formulary Brand Name 80% subject to (Deductible and out-of-pocket maximum based on "Trinity Health" / Tier 1 benefit level) * Generic preventive drugs are covered at 100% (no ) 80% subject to (Deductible and out-of-pocket maximum based on "Trinity Health" / Tier 1 benefit level) Ministry owned on-site pharmacies 90 day supply Generic Formulary Brand Name Non-Formulary Brand Name * Generic preventive drugs are covered at 100% (no ) 50% coinsurance for infertility drugs dispensed through pharmacy (no maximum) If the brand drug has a specific equivalent generic drug available and the plan participant receives the brand, then in addition to the copay, the plan participant must also pay the difference between the ingredient cost of the brand drug and the generic drug. Specialty medications must be filled at a Trinity Health pharmacy or through the CVS Caremark Specialty program; prescriptions limited to a 30 day supply. Mandatory Maintenance is required for each maintenance medication after an initial retail prescription and two refills. Pharmacy copays and coinsurance will track to Tier 1 out-of-pocket max. Coverage of Preventive Services Medications (under the Patient Protection and Affordable Care Act (No copay): Prescription required - Iron supplements (Ages 6 months through 12 months), Oral Fluorides (Ages 5 and younger), Aspirin (ages 45 and older, male and female; age 12 and older, female), Folic Acid (women age 55 and younger), Immunizations, Vitamin D (Ages 65+), Bowel Preparation Medications Prescription only (ages 50 through 74), and Breast Cancer Drugs (female age 35+) Prescription required (total 168-day supply) - Tobacco Cessation - Nicotine replacement products, including Nicotine patch, gum & lozenges. Also covers generic Zyban or Chantix Exclusions: Cosmetic medication Anti-wrinkle agents, Hair growth / removal, etc Erectile Dysfunction (ED) Medications Non-Sedating Antihistamine (NSA) Drugs Compound pain patches and bulk powders Hypoactive Sexual Desire Disorder (Addyi) The following is a list of the drugs that need prior authorization to be covered (not intended to be an allinclusive list): (Your physician must call 1-800-626-3046 to obtain approval for a period of up to one year) Topical acne Oral contraceptives Compounds $300 an greater Specialty medications Anti-obesity agents Narcolepsy Anabolic steroids The following is a list of most but not all of the drugs that have a quantity limit imposed:
Flu medication Migraine medication Due to the large number of available medicines, this list is not all inclusive. Please note that this list does not guarantee coverage and is subject to change. Your prescription benefit plan may not cover certain products or categories, regardless of their appearance on this list. This document is only an educational tool and should not be relied upon as legal or compliance advice. Additionally, some PPACA requirements may differ for particular members enrolled in certain programs, and those members should consult with their plan administrators for specific details. This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply. For a complete description of benefits please see the applicable summary plan descriptions. If there is a discrepancy between this summary and any applicable plan document, the plan document will control. More information is available through Caremark.com to help you manage your prescription drug program. You will be able to locate a pharmacy, order mail service refills, track mail service orders, and ask questions. For additional information contact Caremark at 800-966-5772