Aetna Avenue Your Destination for Small Business Solutions Virginia PLAN GUIDE PLANS EFFECTIVE October 1, 2010 For businesses with 2-50 eligible employees 14.02.970.1-VA A (6/10)
V i r g i n i a p l a n G U I D E Health care is a journey A e t n a Av e n u e i s t h e way I n t h i s g u i d e : 2 Small business commitment 3 Benefits for every stage of life 5 Medical overview 8 Managing health care expenses 11 Medical plan options 24 Dental overview 27 Dental plan options 32 Life & disability overview 34 Life plan options 35 Life & disability plan options 36 Underwriting guidelines 42 Limitations and exclusions As a small business owner, providing value to your customers and growing your business are your top priorities. Yet, today health care is a business issue for every entrepreneur. Small businesses need benefits and insurance plans that fit their workplace. Aetna Avenue provides employers with a choice of insurance benefits solutions. We know that choice, ease and reputation are as valuable to employers as they are to employees. Aetna offers a variety of plans for small business from medical plans, to dental, life and disability plans. 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.
C H O I C E For business owners and employees At Aetna, we provide employers a choice of insurance benefits plans. Within these benefits programs, employers can choose specific plan designs that fit business and employee needs. And, employees have access to a wide network of doctors and other providers ensuring that they have a choice in how they receive their health care. Medical plans supporting members on their health care journey Traditional plans Consumer-directed (HSA/HRA) plans Dental, life and disability plans providing valuable protection DMO PPO PPO Max Freedom-of-Choice Preventive Basic term life insurance Disability plans Packaged life and disability plans E a s e Allowing you to focus on your business Employers want to focus on their customers and growing their business not the insurance benefits program. Aetna makes sure that our plan designs are easy to set-up, administer, use and provide support to ensure your success. Administration making it work for your business Aetna s plan designs automatically process health claim reimbursements, provide a password-protected website to keep track of accounts and are supported by knowledgeable service representatives. Secure and online, Aetna Enroll SM makes managing health benefits easy and eliminates time-consuming, expensive paper-based processes. Aetna Navigator our online resource for employers, members and providers DocFind to locate doctors in the neighborhood Track medical claims online Discount programs for eye, dental and other health care Personal Health Record providing a complete picture of health Temporary ID cards available for members to print as needed Aetna Health Connections SM disease management our newly redesigned capabilities offer support for over 30 conditions as well as integrated care for members with multiple conditions. R e p u tat i o n In business it s everything Your reputation is important to your business. At Aetna, our reputation is just as important. With 150 years of experience, we value our name, products and services and focus on delivering the right solution for your small business our reputation depends upon it. Our account executives, underwriters and customer service representatives are committed to providing your small business the valuable service it deserves. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 1
V i r g i n i a p l a n G U I D E A e t n a Av e n u e s c o m m i t m e n t t o s m a l l b u s i n e s s e m p l o y e r s We know that small business owners insurance benefits needs are often different than a larger employer. Aetna Avenue focuses on employers with 2-50 employees and our insurance benefits programs are designed to work for this size group. We ll work with you to determine the right plans for your business and assist you through implementation. A e t n a s m a r k e t m a p Guiding your small business health care journey Aetna s market map is a resource for brokers and employers to help determine the right insurance benefits plan for their business. The market map asks specific questions related to the business and employee need in order to narrow the field of plan design choices. Basic benefits for your employees Limiting the expense to your business Allowing employees to buy-up and share more of the cost You might be a Basic buyer These plans fit Basic plans VA HMO No-Referral 4.4 ($25/30%) VA PPO Consumer Directed 1.4 ($1,000 Ded) Employee responsibility These plans fit D o y o u va l u e Consumerism s ability to make a difference Tools and resources to support consumerism Innovative plan design You might be a Value seeker Consumer-directed health plans VA HMO No-Referral HSA Compatible 1.4 ($1,500 Ded) VA Health Network Option AHF HRA 1.4 ($2,500 Ded) VA PPO HSA Compatible 1.4 ($1,500 Ded) Traditional benefits plans Limiting the financial impact on employees You might be a Traditionalist These plans fit Traditional plans VA HMO No-Referral 1.4 ($20/$500) VA PPO 1.4 ($20/$500) 2
Y o u n g S i n g l e s Consumer-directed (HSA/HRA plans) Y o u n g Fa m i l i e s Traditional plans E s ta b l i s h e d Fa m i l i e s Traditional plans E m p t y N e s t e r s Consumer-directed (HSA/HRA plans) H e a lt h i n s u r a n c e b e n e f i t s f o r e v e ry s ta g e o f l i f e Y o u n g s i n g l e s Includes singles and couples without children Ready to conquer the world? Thinking big thoughts? Well, one of those thoughts should be about health coverage. Since they re probably on a budget, they might want an affordable policy with lower monthly payments and modest out-ofpocket costs that also provides for quality preventive care, prescription drug coverage and financial protection to help safeguard their assets. Y o u n g fa m i l i e s Includes married couples and single parents with young children and teens Children tend to get sick more than adults which means employees and their pediatricians get to know each other quite well. It also means they re probably looking for health coverage with lower fees for office visits, lower monthly payments and caps on their out-of-pocket expenses. And, of course, they can benefit from quality preventive care for the entire family. Established families Includes married couples and single parents with teens and college-aged children As the children get older, the entire family s needs change. Time management is important for active parents and children. Teenagers still need checkups and care for injuries and illness, while parents need to start thinking about their own needs, like plan designs that cover preventive care and screenings and promote a healthy lifestyle. And college brings financial concerns to the forefront, as well as the need for a national network. E m p t y n e s t e r s Includes men and women age 55 and over with no children at home The kids are leaving home. It s a wistful time, but also an exciting one. What are the plans? Travel? Leisure? Reassessing health coverage needs? These employees are probably looking for a policy that combines financial security with quality coverage for prescriptions, hospital inpatient/outpatient services and emergency care. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 3
V i r g i n i a p l a n G U I D E V i r g i n i a P r o v i d e r N e t w o r k * * G r e at c o v e r a g e b e g i n s w i t h a s o l i d n e t w o r k We offer a large and diverse network of health care professionals that provide quality and cost-effective care. Our pharmacy participation includes leading chains like Rite Aid, CVS, Eckerd, Wal-Mart, and many supermarket pharmacies. Throughout the Capitol Region,* our provider network is comprised of: More than 9,000 primary care physicians, including internists, family practitioners and pediatricians More than 31,000 specialists, including 2,000 obstetricians and gynecologists More than 5,400 dental providers Over 130 hospitals County HMO & PPO PPO Albemarle Alexandria City Alleghany Amelia Amherst Appomattox Arlington Bedford Bedford City Bland Botetourt Bristol City Buchanan Buckingham Campbell Caroline Carroll Charles City Charlotte Charlottesville City Chesapeake City Chesterfield Colonial Heights City Clarke Clifton Forge City Covington City Craig Culpeper Cumberland Danville City Dickenson Dinwiddie Essex Fairfax Fairfax City Falls Church City Fauquier Floyd Fluvanna Franklin City Franklin County Frederick Fredericksburg City Galax City Giles Gloucester Goochland Grayson Hampton City Hanover Henrico Henry Hopewell City Isle of Wight James City King and Queen King George County HMO & PPO PPO King William Lancaster Lee Loudon Louisa Lunenburg Lynchburg City Manassas City Manassas Park City Martinsville City Mathews Middlesex Montgomery Nelson New Kent Newport News City Norfolk City Northumberland Norton City Nottoway Orange Patrick Petersburg City Pittsylvania Poquoson City Portsmouth City Powhatan Prince Edward Prince George Prince William Pulaski Radford City Richmond City Roanoke Roanoke City Russell Salem City Scott Shenandoah Smyth Southampton Spotsylvania Stafford Suffolk City Surry Sussex Tazewell Virginia Beach City Warren Washington Westmoreland Winchester City Williamsburg City Wise Wythe York *Data as of 4/08. Actual provider count is dependent on specific network participation. **Network subject to change. 4
Aetna Avenue M e d i c a l O v e r v i e w Product Name Aetna HMO Aetna HMO No-Referral* Aetna POS No-Referral Aetna Health Network Option (SM) (Aetna HealthFund ) Aetna PPO* Aetna Indemnity Product Description A health maintenance organization (HMO) uses a network of participating providers. Each family member selects a primary care physician (PCP) participating in the Aetna network. The PCP provides routine and preventive care and helps coordinate the member s total health care. The PCP refers members to participating specialists and facilities for medically necessary specialty care. Only services provided or referred by the PCP are covered, except for emergency, urgently needed care or direct-access benefits, unless approved by the HMO in advance of receiving services. The Aetna HMO No-Referral plan uses a network of participating providers. Each family member may select a primary care physician (PCP) participating in the Aetna network to provide routine and preventive care and help coordinate the member s total health care. Members never need a referral when visiting a participating specialist for covered services. Only services rendered by a participating provider are covered, except for emergency or urgently needed care The Aetna POS No-Referral plan is a two-tiered product that allows members to access care in or out-ofnetwork. Members have lower out of pocket costs when they use the in-network tier of the plan. Member cost sharing increases if members decide to go out-of-network. Members may go to their PCP or directly to a participating specialist without a referral. It is their choice, each time they seek care. The HealthFund plan blends traditional health coverage with a fund benefit to help pay for eligible medical expenses. This health insurance plan offers members the freedom to seek care from any licensed health care professional without a referral, and a fund to help pay for services that are covered under the plan. Members can stretch their fund by seeking the most cost-effective care and services. The HealthFund plan provides: An opportunity to build the fund and apply it toward future medical expenses. Traditional coverage for eligible expenses over the fund amount. A cap that limits the total amount a member pays annually for eligible expenses. How it works: Use the health fund to pay for medical expenses. Unused fund balance rolls over to next year s fund balance, as long as the member remains in the plan and with his or her current employer. If the fund is depleted, the member pays for remaining or future expenses until the deductible is met. If the fund is depleted and the deductible is met, the base medical benefits plan begins meaning the member pays a coinsurance and/or copayment for remaining covered expenses. 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-ofpocket 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 PCP Required Referrals Required Network Yes Yes HMO Yes/ Optional Yes/ Optional Yes/ Optional No No No HMO (Open Access) Aetna Choice POS (Open Access) Aetna Health Network Option (SM) (Aetna HealthFund) No No Open Choice PPO No No N/A M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 5
V i r g i n i a p l a n G U I D E A E T N A H I G H D E D U C T I B L E H S A C O M PAT I B L E H M O N O - R E F E R R A L / P P O P L A N S * Aetna High Deductible HSA Compatible HMO No-Referral and PPO Health Plans are compatible with a Health Savings Account (HSA). HSA-compatible plans provide integrated medical and pharmacy benefits. Preventive care services are waived from the deductible. 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 assist in covering their future medical and dental expenses. HSA accounts can be funded by the employer or employee and are portable. Fund contributions may be tax-deductible (limits apply). When funds are used to cover qualified out-of-pocket medical and dental expenses, they are not taxed. Note: Employers and employees should consult with their tax advisor to determine eligibility requirements and tax advantages for participation in the HSA plan. S M A L L G R O U P S I T U S Aetna Small Group benefits and rates are based on the group/s headquarter location, subject to applicable small group reform laws. Eligible employees who live or work in CT, DC, DE, MD, NJ, NY, PA, and VA (the situs region) will receive the same rates and benefits as the headquarter location. A E T N A S M A L L G R O U P M U LT I - S TAT E S O L U T I O N As part of Aetna s commitment to make it easier for small businesses to do business with us, and bring more consistency across benefit offerings to employers with employees in multiple locations, Aetna offers a multi-state solution. VA domiciled employers can offer a VA PPO plan to their employees who live and work outside the situs region. The situs region is comprised of the following eight states CT, DC, DE, MD, NJ, NY, PA, and VA. The rates and benefits will match those offered in Virginia. If the out-of-situs employee resides in a non-network area, the employee will be enrolled in an indemnity plan. Plan sponsors will need to continue to meet small group underwriting guidelines, and the majority of eligible employees must be in Virginia. 6
In all instances, extraterritorial benefits that may apply on any of the out-of-state employees will be implemented to the extent these are more comprehensive than the domiciled state benefits. These benefits will only apply to the out-ofstate employees in the states where required. For dental products, an out-ofstate dental plan will be offered to employees who live and work outside the situs region defined above. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 7
V i r g i n i a p l a n G U I D E A way t o m a n a g e h e a lt h a n d h e a lt h c a r e e x p e n s e s Health Savings Account (HSA) No set-up or administrative fees The Aetna HealthFund HSA, when coupled with a HSA-compatible high-deductible 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. M e m b e r s H S A P l a n H S A A c c o u n t You own your HSA Contribute tax free You choose how and when to use your dollars Roll it over each year and let it grow Earns interest, tax free T o d ay Use for qualified expenses with tax-free dollars F u t u r e Plan for future and retiree health-related costs H i g h - d e d u c t i b l e h e a lt h p l a n Eligible in-network preventive care services will not be subject to the deductible You pay 100% until deductible is met, then only pay a share of the cost Meet out-of-pocket maximum, then plan pays 100% Aetna HealthFund HRAs are subject to employer-defined use and forfeiture rules, and are unfunded liabilities of your employer. Fund balances are not vested benefits. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Information subject to change. Aetna reserves the right to change any of the above fees and to impose additional fees upon prior written notice. 8
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. Aetna s 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. 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. 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. COBRA administration Aetna COBRA administration offers a full range of notification, documentation and record-keeping processes that can assist employers with managing the complex billing and notification processes that are required for COBRA compliance, while also helping to save them time and money. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 9
T R A D I T I O N A L H M O N O - R E F E R R A L P L A N O P T I O N S Plan Options VA HMO NO-REFERRAL 1.4 VA HMO NO-REFERRAL 2.4 ($20/$500) +,*,(3) ($25/10%) +,*,(3) Member Benefits In-Network No Referral Needed Member Coinsurance N/A N/A Plan Year Deductible N/A N/A Plan Year Out-of-Pocket Maximum 1 (Prescription drugs do not apply toward the Out-of-Pocket Maximum.) $1,500 per member $3,000 family Lifetime Maximum Benefit Unlimited Unlimited Preventive Care Well-Baby/Child Exams (Age and frequency schedules apply.) Adult Physical Exams (Limited to one exam per plan year.) Routine GYN Exams (Limited to a routine exam, pap smear and other appropriate tests using any FDA-approved gynecologic cytology screening technologies, once every 365 days.) $0 Copay $0 Copay $0 Copay $0 Copay $0 Copay $0 Copay In-Network No Referral Needed $2,500 per member $5,000 family Routine Mammograms $0 Copay $0 Copay Routine Eye Exam $0 Copay $0 Copay (One exam per 24 months.) Aetna Vision SM Discount Program Included Included Primary Physician Office Visit $20 Copay $25 Copay Specialist Office Visit $40 Copay $50 Copay Outpatient Services Lab $0 Copay $0 Copay Outpatient Services X-Ray $40 Copay $50 Copay Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) $200 Copay $200 Copay Chiropractic Services (20 visits per plan year) Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per plan year) Outpatient Speech Therapy (30 visits per plan year) Durable Medical Equipment ($2,500 Plan Year Maximum) $40 Copay $50 Copay $40 Copay $50 Copay $40 Copay $50 Copay 50% 50% Inpatient Hospital $500 Copay per Admission 10% Outpatient Surgery $300 Copay 10% Emergency Room (Copay waived if admitted.) $200 Copay $200 Copay Urgent Care $75 Copay $75 Copay Mental Health/Substance Abuse Inpatient (Biological: Unlimited days. Non-Biological: 30 days per plan year. Combined Inpatient Mental Health and Substance Abuse Rehab.) $500 Copay per Admission 10% Prescription Drugs Prescription Drug Deductible N/A N/A Prescription Drugs Retail: 30-day supply $10/$35/$60 $10/$35/$60 Prescription Drugs Mail Order: 31-90-day supply $20/$70/$120 $20/$70/$120 Contraceptives and Diabetic Supplies Included Included 90 Day Transition of Coverage (TOC) for Prior Authorization 2 Included Included Aetna Specialty CareRx SM Drugs $200 Copay $200 Copay *Optional Features: Morbid Obesity Morbid Obesity See pages 22-23 for important plan provisions. 10
T R A D I T I O N A L H M O N O - R E F E R R A L P L A N O P T I O N S Plan Options VA HMO NO-REFERRAL 3.4 VA HMO NO-REFERRAL 4.4 ($25/20%) +,*,(3) ($25/30%) +,*,(3) Member Benefits In-Network No Referral Needed Member Coinsurance N/A N/A Plan Year Deductible N/A N/A Plan Year Out-of-Pocket Maximum 1 (Prescription drugs do not apply toward the Out-of-Pocket Maximum.) $3,000 per member $6,000 family Lifetime Maximum Benefit Unlimited Unlimited Preventive Care Well-Baby/Child Exams (Age and frequency schedules apply.) Adult Physical Exams (Limited to one exam per plan year.) Routine GYN Exams (Limited to a routine exam, pap smear and other appropriate tests using any FDA-approved gynecologic cytology screening technologies, once every 365 days.) $0 Copay $0 Copay $0 Copay $0 Copay $0 Copay $0 Copay In-Network No Referral Needed $3,000 per member $6,000 family Routine Mammograms $0 Copay $0 Copay Routine Eye Exam $0 Copay $0 Copay (One exam per 24 months.) Aetna Vision SM Discount Program Included Included Primary Physician Office Visit $25 Copay $25 Copay Specialist Office Visit $50 Copay $50 Copay Outpatient Services Lab $0 Copay $0 Copay Outpatient Services X-Ray $50 Copay $50 Copay Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) $200 Copay $200 Copay Chiropractic Services (20 visits per plan year) Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per plan year) Outpatient Speech Therapy (30 visits per plan year) Durable Medical Equipment ($2,500 Plan Year Maximum) $50 Copay $50 Copay $50 Copay $50 Copay $50 Copay $50 Copay 50% 50% Inpatient Hospital 20% 30% Outpatient Surgery 20% 30% Emergency Room (Copay waived if admitted.) $200 Copay $200 Copay Urgent Care $75 Copay $75 Copay Mental Health/Substance Abuse Inpatient (Biological: Unlimited days. Non-Biological: 30 days per plan year. Combined Inpatient Mental Health and Substance Abuse Rehab.) 20% 30% Prescription Drugs Prescription Drug Deductible N/A N/A Prescription Drugs Retail: 30-day supply $10/$35/$60 $10/$35/$60 Prescription Drugs Mail Order: 31-90-day supply $20/$70/$120 $20/$70/$120 Contraceptives and Diabetic Supplies Included Included 90 Day Transition of Coverage (TOC) for Prior Authorization 2 Included Included Aetna Specialty CareRx SM Drugs $200 Copay $200 Copay *Optional Features: Morbid Obesity Morbid Obesity See pages 22-23 for important plan provisions. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 11
V i r g i n i a p l a n G U I D E T R A D I T I O N A L P O S N O - R E F E R R A L P L A N O P T I O N S Plan Options VA POS NO-REFERRAL 1.4 ($20/$500) +,*,(4) VA POS NO-REFERRAL 2.4 ($25/10%) +,*,(4) Member Benefits In-Network No Referral Needed Out-of-Network 5 No Referral Needed In-Network No Referral Needed Out-of-Network 5 No Referral Needed Member Coinsurance N/A 30% after deductible N/A 30% after deductible Plan Year Deductible 1 N/A $500 per member N/A $1,000 per member $1,000 family $2,000 family Plan Year Out-of-Pocket Maximum 2 (Deductible applies to the Out-of-Pocket Maximum. Prescription drugs do not apply toward the Out-of-Pocket Maximum.) $1,500 per member $3,000 family $3,500 per member $7,000 family $2,500 per member $5,000 family $4,000 per member $8,000 family Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Preventive Care Well-Baby/Child Exams $0 Copay 0%; deductible waived $0 Copay 0%; deductible waived (Age and frequency schedules apply. In-network and out-of-network combined.) Adult Physical Exams $0 Copay 30% after deductible $0 Copay 30% after deductible (Limited to one exam per plan year. In-network and out-of-network combined.) Routine GYN Exams $0 Copay 30% after deductible $0 Copay 30% after deductible (Limited to a routine exam, pap smear and other appropriate tests using any FDA-approved gynecologic cytology screening technologies, once every 365 days. In-network and out-of-network combined.) Routine Mammograms $0 Copay 30% after deductible $0 Copay 30% after deductible Routine Eye Exam $0 Copay 30% after deductible $0 Copay 30% after deductible (One exam per 24 months. In-network and out-of-network combined.) Aetna Vision SM Discount Program Included Not Covered Included Not Covered Primary Physician Office Visit $20 Copay 30% after deductible $25 Copay 30% after deductible Specialist Office Visit $40 Copay 30% after deductible $50 Copay 30% after deductible Outpatient Services Lab $0 Copay 30% after deductible $0 Copay 30% after deductible Outpatient Services X-Ray $40 Copay 30% after deductible $50 Copay 30% after deductible Outpatient Complex Imaging $200 Copay 30% after deductible $200 Copay 30% after deductible (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services $40 Copay 30% after deductible $50 Copay 30% after deductible (20 visits per plan year. In-network and out-of-network combined.) Outpatient Physical/Occupational Therapy $40 Copay 30% after deductible $50 Copay 30% after deductible (Physical and occupational therapy combined, 30 visits per plan year. In-network and out-of-network combined.) Outpatient Speech Therapy $40 Copay 30% after deductible $50 Copay 30% after deductible (30 visits per plan year. In-network and out-of-network combined.) Durable Medical Equipment 50% 50% after deductible 50% 50% after deductible ($2,500 Plan Year Maximum. In-network and out-of-network combined.) Inpatient Hospital $500 Copay per 30% after deductible 10% 30% after deductible Admission Outpatient Surgery $300 Copay 30% after deductible 10% 30% after deductible Emergency Room (Copay waived if admitted.) $200 Copay $200 Copay $200 Copay $200 Copay Urgent Care $75 Copay 30% after deductible $75 Copay 30% after deductible Mental Health/Substance Abuse Inpatient $500 Copay per 30% after deductible 10% 30% after deductible (Biological: Unlimited days. Non-Biological: 30 days per plan year. Combined Inpatient Mental Health and Substance Abuse Rehab. In-network and out-of-network combined.) Admission Prescription Drugs Prescription Drug Deductible N/A N/A N/A N/A Prescription Drugs Retail: $10/$35/$60 Not Covered $10/$35/$60 Not Covered 30-day supply Prescription Drugs Mail Order: $20/$70/$120 Not Covered $20/$70/$120 Not Covered 31-90-day supply Contraceptives and Diabetic Supplies Included Not Covered Included Not Covered 90 Day Transition of Coverage (TOC) for Prior Included Not Covered Included Not Covered Authorization 3 Aetna Specialty CareRx SM Drugs $200 Copay Not Covered $200 Copay Not Covered *Optional Features: Morbid Obesity Morbid Obesity See pages 22-23 for important plan provisions. 12
T R A D I T I O N A L P P O P L A N O P T I O N S Plan Options VA PPO 1.4 ($20/$500) +,* VA PPO 2.4 ($25/10%) +,* Member Benefits In-Network No Referral Needed Out-of-Network 4 No Referral Needed In-Network No Referral Needed Out-of-Network 4 No Referral Needed Member Coinsurance 0% 30% after deductible 10% 30% after deductible Plan Year Deductible 1 N/A $500 per member N/A $1,000 per member $1,000 family $2,000 family Plan Year Out-of-Pocket Maximum 2 (Deductible applies to the Out-of-Pocket Maximum. Prescription drugs do not apply toward the Out-of-Pocket Maximum.) $1,500 per member $3,000 family $3,500 per member $7,000 family $2,500 per member $5,000 family $4,000 per member $8,000 family Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Preventive Care Well-Baby/Child Exams $0 Copay 0%; deductible waived $0 Copay 0%; deductible waived (Age and frequency schedules apply. In-network and out-of-network combined.) Adult Physical Exams $0 Copay 30% after deductible $0 Copay 30% after deductible (Limited to one exam per 12 months. In-network and out-ofnetwork combined.) Routine GYN Exams $0 Copay 30% after deductible $0 Copay 30% after deductible (Limited to a routine exam, pap smear and other appropriate tests using any FDA-approved gynecologic cytology screening technologies, once every plan year. In-network and out-ofnetwork combined.) Routine Mammograms $0 Copay 30% after deductible $0 Copay 30% after deductible Routine Eye Exam $0 Copay 30% after deductible $0 Copay 30% after deductible (One exam per 24 months. In-network and out-of-network combined.) Aetna Vision SM Discount Program Included Not Covered Included Not Covered Primary Physician Office Visit $20 Copay 30% after deductible $25 Copay 30% after deductible Specialist Office Visit $40 Copay 30% after deductible $50 Copay 30% after deductible Outpatient Services Lab $40 Copay 30% after deductible $50 Copay 30% after deductible Outpatient Services X-Ray $40 Copay 30% after deductible $50 Copay 30% after deductible Outpatient Complex Imaging $200 Copay 30% after deductible $200 Copay 30% after deductible (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services $40 Copay 30% after deductible $50 Copay 30% after deductible (20 visits per plan year. In-network and out-of-network combined.) Outpatient Physical/Occupational Therapy $40 Copay 30% after deductible $50 Copay 30% after deductible (Physical and occupational therapy combined, 30 visits per plan year. In-network and out-of-network combined.) Outpatient Speech Therapy $40 Copay 30% after deductible $50 Copay 30% after deductible (30 visits per plan year. In-network and out-of-network combined.) Durable Medical Equipment 50% 50% after deductible 50% 50% after deductible ($2,500 Plan Year Maximum. In-network and out-of-network combined.) Inpatient Hospital $500 Copay per 30% after deductible 10% 30% after deductible Admission Outpatient Surgery $300 Copay 30% after deductible 10% 30% after deductible Emergency Room (Copay waived if admitted.) $200 Copay $200 Copay $200 Copay $200 Copay Urgent Care $75 Copay 30% after deductible $75 Copay 30% after deductible Mental Health/Substance Abuse Inpatient $500 Copay per 30% after deductible 10% 30% after deductible (Biological Mental Health and Substance Abuse: Unlimited days. Non-Biological Mental Health: 30 days per plan year. In-network and out-of-network combined.) Admission Prescription Drugs Prescription Drug Deductible N/A N/A N/A N/A Prescription Drugs Retail: $10/$35/$60 $10/$35/$60 + 30% $10/$35/$60 $10/$35/$60 + 30% 30-day supply Prescription Drugs Mail Order: $20/$70/$120 Not Covered $20/$70/$120 Not Covered 31-90-day supply Contraceptives and Diabetic Supplies Included Included Included Included 90 Day Transition of Coverage (TOC) for Prior Included Included Included Included Authorization 3 Aetna Specialty CareRx SM Drugs $200 Copay Not Covered $200 Copay Not Covered *Optional Features: Morbid Obesity Morbid Obesity See pages 22-23 for important plan provisions. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 13
V i r g i n i a p l a n G U I D E T R A D I T I O N A L P P O P L A N O P T I O N S Plan Options VA PPO 3.4 ($25/20%) +,* Member Benefits In-Network No Referral Needed Out-of-Network 4 No Referral Needed Member Coinsurance 20% 50% after deductible Plan Year Deductible 1 N/A $2,000 per member $4,000 family Plan Year Out-of-Pocket Maximum 2 (Deductible applies to the Out-of-Pocket Maximum. Prescription drugs do not apply toward the Out-of-Pocket Maximum.) $3,000 per member $6,000 family $5,000 per member $10,000 family Lifetime Maximum Benefit Unlimited Unlimited Preventive Care Well-Baby/Child Exams $0 Copay 0%; deductible waived (Age and frequency schedules apply. In-network and out-of-network combined.) Adult Physical Exams $0 Copay 50% after deductible (Limited to one exam per 12 months. In-network and out-of-network combined.) Routine GYN Exams $0 Copay 50% after deductible (Limited to a routine exam, pap smear and other appropriate tests using any FDA-approved gynecologic cytology screening technologies, once every plan year. In-network and out-of-network combined.) Routine Mammograms $0 Copay 50% after deductible Routine Eye Exam $0 Copay 50% after deductible (One exam per 24 months. In-network and out-of-network combined.) Aetna Vision SM Discount Program Included Not Covered Primary Physician Office Visit $25 Copay 50% after deductible Specialist Office Visit $50 Copay 50% after deductible Outpatient Services Lab $50 Copay 50% after deductible Outpatient Services X-Ray $50 Copay 50% after deductible Outpatient Complex Imaging $200 Copay 50% after deductible (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services $50 Copay 50% after deductible (20 visits per plan year. In-network and out-of-network combined.) Outpatient Physical/Occupational Therapy $50 Copay 50% after deductible (Physical and occupational therapy combined, 30 visits per plan year. In-network and out-of-network combined.) Outpatient Speech Therapy $50 Copay 50% after deductible (30 visits per plan year. In-network and out-of-network combined.) Durable Medical Equipment 50% 50% after deductible ($2,500 Plan Year Maximum. In-network and out-of-network combined.) Inpatient Hospital 20% 50% after deductible Outpatient Surgery 20% 50% after deductible Emergency Room (Copay waived if admitted.) $200 Copay $200 Copay Urgent Care $75 Copay 50% after deductible Mental Health/Substance Abuse Inpatient 20% 50% after deductible (Biological Mental Health and Substance Abuse: Unlimited days. Non-Biological Mental Health: 30 days per plan year. In-network and out-of-network combined.) Prescription Drugs Prescription Drug Deductible N/A N/A Prescription Drugs Retail: $10/$35/$60 $10/$35/$60 + 30% 30-day supply Prescription Drugs Mail Order: $20/$70/$120 Not Covered 31-90-day supply Contraceptives and Diabetic Supplies Included Included 90 Day Transition of Coverage (TOC) for Prior Authorization 3 Included Included Aetna Specialty CareRx SM Drugs $200 Copay Not Covered *Optional Features: Morbid Obesity See pages 22-23 for important plan provisions. 14
C O N S U M E R D I R E C T E D P P O C O N S U M E R D I R E C T E D P L A N O P T I O N S Plan Options VA PPO CONSUMER DIRECTED PLAN 1.4 ($1,000 Ded) +,* Member Benefits In-Network No Referral Needed Out-of-Network 4 No Referral Needed Member Coinsurance 20% after deductible 50% after deductible Plan Year Deductible 1 $1,000 per member $5,000 per member $2,000 family $10,000 family Plan Year Out-of-Pocket Maximum 2 (Deductible applies to the Out-of-Pocket Maximum. Prescription drugs do not apply toward the Out-of-Pocket Maximum.) $3,000 per member $6,000 family $15,000 per member $30,000 family Lifetime Maximum Benefit Unlimited Unlimited Preventive Care Well-Baby/Child Exams $0 Copay; deductible waived 0%; deductible waived (Age and frequency schedules apply. In-network and out-of-network combined.) Adult Physical Exams $0 Copay; deductible waived 50% after deductible (Limited to one exam per 12 months. In-network and out-of-network combined.) Routine GYN Exams $0 Copay; deductible waived 50% after deductible (Limited to a routine exam, pap smear and other appropriate tests using any FDA-approved gynecologic cytology screening technologies, once every plan year. In-network and out-of-network combined.) Routine Mammograms $0 Copay; deductible waived 50% after deductible Routine Eye Exam $0 Copay; deductible waived 50% after deductible (One exam per 24 months. In-network and out-of-network combined.) Aetna Vision SM Discount Program Included Not Covered Primary Physician Office Visit $25 Copay, deductible waived 50% after deductible Specialist Office Visit $50 Copay, deductible waived 50% after deductible Outpatient Services Lab $50 Copay, deductible waived 50% after deductible Outpatient Services X-Ray $50 Copay, deductible waived 50% after deductible Outpatient Complex Imaging $200 Copay after deductible 50% after deductible (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services $50 Copay after deductible 50% after deductible (20 visits per plan year. In-network and out-of-network combined.) Outpatient Physical/Occupational Therapy $50 Copay after deductible 50% after deductible (Physical and occupational therapy combined, 30 visits per plan year. In-network and out-of-network combined.) Outpatient Speech Therapy $50 Copay after deductible 50% after deductible (30 visits per plan year. In-network and out-of-network combined.) Durable Medical Equipment 50% after deductible 50% after deductible ($2,500 Plan Year Maximum. In-network and out-of-network combined.) Inpatient Hospital 20% after deductible 50% after deductible Outpatient Surgery 20% after deductible 50% after deductible Emergency Room (Copay waived if admitted.) $200 Copay after deductible $200 Copay after deductible Urgent Care $75 Copay after deductible 50% after deductible Mental Health/Substance Abuse Inpatient 20% after deductible 50% after deductible (Biological Mental Health and Substance Abuse: Unlimited days. Non-Biological Mental Health: 30 days per plan year. In-network and out-of-network combined.) Prescription Drugs Prescription Drug Deductible N/A N/A Prescription Drugs Retail: $10/$35/$60 $10/$35/$60 + 30% 30-day supply Prescription Drugs Mail Order: $20/$70/$120 Not Covered 31-90-day supply Contraceptives and Diabetic Supplies Included Included 90 Day Transition of Coverage (TOC) for Prior Authorization 3 Included Included Aetna Specialty CareRx SM Drugs $200 Copay Not Covered *Optional Features: Morbid Obesity See pages 22-23 for important plan provisions. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 15
V i r g i n i a p l a n G U I D E CONSUMER DIRECTED HMO NO-REFERRAL HSA COMPATIBLE PLAN OPTIONS Plan Options Member Benefits VA HMO NO-REFERRAL HSA COMPATIBLE 1.4 ($1,500 Ded) +,*,(4) In-Network No Referral Needed Member Coinsurance N/A N/A Plan Year Deductible 1 (All covered prescription drug and medical expenses, except in-network preventive care services, apply to the deductible.) Plan Year Out-of-Pocket Maximum 2 (All amounts paid as deductible, copayments, or coinsurance for covered services and supplies apply toward the Out-of-Pocket Maximum.) $1,500 Individual $3,000 Family $3,000 Individual $6,000 Family VA HMO NO-REFERRAL HSA COMPATIBLE 2.4 ($2,500 Ded) +,*,(4) In-Network No Referral Needed $2,500 Individual $5,000 Family $5,000 Individual $10,000 Family Lifetime Maximum Benefit Unlimited Unlimited Preventive Care Well-Baby/Child Exams $0 Copay; deductible waived $0 Copay; deductible waived (Age and frequency schedules apply.) Adult Physical Exams $0 Copay; deductible waived $0 Copay; deductible waived (Limited to one exam per plan year.) Routine GYN Exams $0 Copay; deductible waived $0 Copay; deductible waived (Limited to a routine exam, pap smear and other appropriate tests using any FDA-approved gynecologic cytology screening technologies, once every 365 days.) Routine Mammograms $0 Copay; deductible waived $0 Copay; deductible waived Routine Eye Exam $0 Copay; deductible waived $0 Copay; deductible waived (One exam per 24 months.) Aetna Vision SM Discount Program Included Included Primary Physician Office Visit $20 Copay after deductible $30 Copay after deductible Specialist Office Visit $40 Copay after deductible $50 Copay after deductible Outpatient Services Lab $40 Copay after deductible $50 Copay after deductible Outpatient Services X-Ray $40 Copay after deductible $50 Copay after deductible Outpatient Complex Imaging $200 Copay after deductible $200 Copay after deductible (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services $40 Copay after deductible $50 Copay after deductible (20 visits per plan year) Outpatient Physical/Occupational Therapy $40 Copay after deductible $50 Copay after deductible (Physical and occupational therapy combined, 30 visits per plan year) Outpatient Speech Therapy $40 Copay after deductible $50 Copay after deductible (30 visits per plan year) Durable Medical Equipment 50% after deductible 50% after deductible ($2,500 Plan Year Maximum) Inpatient Hospital $500 Copay per Admission after deductible $300 Copay per Day, 5 Day Copay Maximum per Admission, after deductible Outpatient Surgery $200 copay after deductible $200 Copay after deductible Emergency Room (Copay waived if admitted.) $200 Copay after deductible $200 Copay after deductible Urgent Care $75 Copay after deductible $75 Copay after deductible Mental Health/Substance Abuse Inpatient (Biological: Unlimited days. Non-Biological: 30 days per plan year. Combined Inpatient Mental Health and Substance Abuse Rehab.) Prescription Drugs Prescription Drug Deductible Prescription Drugs Retail: 30-day supply Prescription Drugs Mail Order: 31-90-day supply $500 Copay per Admission after deductible Integrated medical/pharmacy deductible $10/$35/$60 after integrated deductible $20/$70/$120 after integrated deductible $300 Copay per Day, 5 Day Copay Maximum per Admission, after deductible Integrated medical/pharmacy deductible $10/$35/$60 after integrated deductible $20/$70/$120 after integrated deductible Contraceptives and Diabetic Supplies Included Included 90 Day Transition of Coverage (TOC) for Prior Authorization 3 Included Included Aetna Specialty CareRx SM Drugs $200 Copay after integrated deductible $200 Copay after integrated deductible *Optional Features: Morbid Obesity Morbid Obesity See pages 22-23 for important plan provisions. 16
C O N S U M E R D I R E C T E D P P O H S A C O M PAT I B L E P L A N O P T I O N S Plan Options VA PPO HSA COMPATIBLE 1.4 ($1,500 Ded) +,* Member Benefits In-Network No Referral Needed Out-of-Network 4 No Referral Needed Member Coinsurance 0% after deductible 30% after deductible Plan Year Deductible 1 (All covered prescription drug and medical expenses, except in-network preventive care services, apply to the deductible.) Plan Year Out-of-Pocket Maximum 2 (All amounts paid as deductible, copayments, or coinsurance for covered services and supplies apply toward the Out-of-Pocket Maximum.) $1,500 Individual $3,000 Family $3,000 Individual $6,000 Family $3,000 Individual $6,000 Family $6,000 Individual $12,000 Family Lifetime Maximum Benefit Unlimited Unlimited Preventive Care Well-Baby/Child Exams $0 Copay; deductible waived 0%; deductible waived (Age and frequency schedules apply. In-network and out-of-network combined.) Adult Physical Exams $0 Copay; deductible waived 30% after deductible (Limited to one exam per 12 months. In-network and out-of-network combined.) Routine GYN Exams $0 Copay; deductible waived 30% after deductible (Limited to a routine exam, pap smear and other appropriate tests using any FDA-approved gynecologic cytology screening technologies, once every plan year. In-network and out-of-network combined.) Routine Mammograms $0 Copay; deductible waived 30% after deductible Routine Eye Exam $0 Copay; deductible waived 30% after deductible (One exam per 24 months. In-network and out-of-network combined.) Aetna Vision SM Discount Program Included Not Covered Primary Physician Office Visit $20 Copay after deductible 30% after deductible Specialist Office Visit $40 Copay after deductible 30% after deductible Outpatient Services Lab $40 Copay after deductible 30% after deductible Outpatient Services X-Ray $40 Copay after deductible 30% after deductible Outpatient Complex Imaging $200 Copay after deductible 30% after deductible (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services $40 Copay after deductible 30% after deductible (20 visits per plan year. In-network and out-of-network combined.) Outpatient Physical/Occupational Therapy $40 Copay after deductible 30% after deductible (Physical and occupational therapy combined, 30 visits per plan year. In-network and out-of-network combined.) Outpatient Speech Therapy $40 Copay after deductible 30% after deductible (30 visits per plan year. In-network and out-of-network combined.) Durable Medical Equipment 50% after deductible 50% after deductible ($2,500 Plan Year Maximum. In-network and out-of-network combined.) Inpatient Hospital $500 Copay per Admission 30% after deductible after deductible Outpatient Surgery $300 copay after deductible 30% after deductible Emergency Room (Copay waived if admitted.) $200 Copay after deductible $200 Copay after deductible Urgent Care $75 Copay after deductible 30% after deductible Mental Health/Substance Abuse Inpatient $500 Copay per Admission 30% after deductible (Biological Mental Health and Substance Abuse: Unlimited days. Non-Biological Mental Health: 30 days per plan year. In-network and out-of-network combined.) after deductible Prescription Drugs Prescription Drug Deductible Integrated medical/pharmacy deductible Prescription Drugs Retail: 30-day supply Prescription Drugs Mail Order: 31-90-day supply $10/$35/$60 after integrated deductible $20/$70/$120 after integrated deductible Contraceptives and Diabetic Supplies Included Included 90 Day Transition of Coverage (TOC) for Prior Authorization 3 Included Included Aetna Specialty CareRx SM Drugs $200 Copay Not Covered after integrated deductible *Optional Features: Morbid Obesity See pages 22-23 for important plan provisions. $10/$35/$60 + 30% after integrated deductible Not Covered M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 17
V i r g i n i a p l a n G U I D E C O N S U M E R D I R E C T E D P P O H S A C O M PAT I B L E P L A N O P T I O N S Plan Options VA PPO HSA COMPATIBLE 2.4 ($2,500 Ded) +,* Member Benefits In-Network No Referral Needed Out-of-Network 4 No Referral Needed Member Coinsurance 0% after deductible 30% after deductible Plan Year Deductible 1 (All covered prescription drug and medical expenses, except in-network preventive care services, apply to the deductible.) Plan Year Out-of-Pocket Maximum 2 (All amounts paid as deductible, copayments, or coinsurance for covered services and supplies apply toward the Out-of-Pocket Maximum.) $2,500 Individual $5,000 Family $5,000 Individual $10,000 Family $5,000 Individual $10,000 Family $10,000 Individual $20,000 Family Lifetime Maximum Benefit Unlimited Unlimited Preventive Care Well-Baby/Child Exams $0 Copay; deductible waived 0%; deductible waived (Age and frequency schedules apply. In-network and out-of-network combined.) Adult Physical Exams $0 Copay; deductible waived 30% after deductible (Limited to one exam per 12 months. In-network and out-of-network combined.) Routine GYN Exams $0 Copay; deductible waived 30% after deductible (Limited to a routine exam, pap smear and other appropriate tests using any FDA-approved gynecologic cytology screening technologies, once every plan year. In-network and out-of-network combined.) Routine Mammograms $0 Copay; deductible waived 30% after deductible Routine Eye Exam $0 Copay; deductible waived 30% after deductible (One exam per 24 months. In-network and out-of-network combined.) Aetna Vision SM Discount Program Included Not Covered Primary Physician Office Visit $30 Copay after deductible 30% after deductible Specialist Office Visit $50 Copay after deductible 30% after deductible Outpatient Services Lab $50 Copay after deductible 30% after deductible Outpatient Services X-Ray $50 Copay after deductible 30% after deductible Outpatient Complex Imaging $200 Copay after deductible 30% after deductible (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services $50 Copay after deductible 30% after deductible (20 visits per plan year. In-network and out-of-network combined.) Outpatient Physical/Occupational Therapy $50 Copay after deductible 30% after deductible (Physical and occupational therapy combined, 30 visits per plan year. In-network and out-of-network combined.) Outpatient Speech Therapy $50 Copay after deductible 30% after deductible (30 visits per plan year. In-network and out-of-network combined.) Durable Medical Equipment 50% after deductible 50% after deductible ($2,500 Plan Year Maximum. In-network and out-of-network combined.) Inpatient Hospital $300 Copay per Day, 30% after deductible 5 Day Copay Maximum per Admission, after deductible Outpatient Surgery $200 Copay after deductible 30% after deductible Emergency Room (Copay waived if admitted.) $200 Copay after deductible $200 Copay after deductible Urgent Care $75 Copay after deductible 30% after deductible Mental Health/Substance Abuse Inpatient $300 Copay per Day, 30% after deductible (Biological Mental Health and Substance Abuse: Unlimited days. Non-Biological Mental Health: 30 days per plan year. In-network and out-of-network combined.) 5 Day Copay Maximum per Admission, after deductible Prescription Drugs Prescription Drug Deductible Integrated medical/pharmacy deductible Prescription Drugs Retail: 30-day supply Prescription Drugs Mail Order: 31-90-day supply $10/$35/$60 after integrated deductible $20/$70/$120 after integrated deductible Contraceptives and Diabetic Supplies Included Included 90 Day Transition of Coverage (TOC) for Prior Authorization 3 Included Included Aetna Specialty CareRx SM Drugs $200 Copay Not Covered after integrated deductible *Optional Features: Morbid Obesity $10/$35/$60 + 30% after integrated deductible Not Covered See pages 22-23 for important plan provisions. 18