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% Coinsurance Limits (per calendar year, excludes ) $2,500 Individual $7,500 Family $5,000 Individual $15,000 Family Certain member cost sharing elements may not apply toward the Coinsurance Limits, including amounts over Usual and Customary, copays, failure to pre-certify penalty, payments for chiropractic, mental health, substance abuse and DME continue to be payable after the maximum coinsurance limit is reached. Lifetime maximum Unlimited unless noted otherwise Unlimited unless noted otherwise Payment for Non-Preferred Care Not Applicable Usual and Customary* Primary Care Physician Selection Not Required Not Applicable Referral Requirement None None Precertification Requirements Precertification for certain types of non-preferred care must be obtained to avoid a reduction in benefits paid for that care. Precertification for Hospital Admissions, Treatment Facility Admissions, Skilled Nursing Facility Admissions, Home Health Care and Hospice Care and Private Duty Nursing is required. Benefits will be reduced by $400 per occurrence if Precertification is not obtained. PREVENTIVE CARE PREFERRED CARE NON-PREFERRED CARE Routine Adult Physical Exams / Immunizations 1 exam every 24 months up to age 65 and 1 exam every 12 months for adults age 65 and older. $25 copay; no 60%; after Well Child Exams / Immunizations 6 exams in first 12 months of life, 2 exams in the 13th 24th months of life, 1 exam every 12 months of life thereafter up to age 18, 1 exam every 24 months for children age 18 and older. Routine Gynecological Care Exams Includes Pap smears and related lab fees. One Routine exam per calendar year. Routine Mammograms Includes coverage for routine mammograms with no age or frequency limitation. Routine Digital Rectal Exams/ Prostate Specific Antigen Test For covered males age 40 and over. One digital rectal exam and prostate specific antigen test per calendar year. Colorectal Cancer Screening For all members age 50 and over. Includes coverage for an annual fecal occult blood test (3 specimens), 1 flexible sigmoidoscopy every 5 years, 1 colonoscopy every 10 years and 1 double contrast barium enema every 5 years. Routine Eye Exams $25 copay; no 60%; after $40 copay; no 60%; after $0 copay; no 60%; after the type of service and where it is performed the place where is rendered Not covered (except as part of routine physical) 60%; after 60%; after Not covered (except as part of routine physical) PHYSICIAN SERVICES PREFERRED CARE NON-PREFERRED CARE Office Visits to Non-Specialist $25 copay; no 60%; after Includes services of an internist, general physician, family practitioner or pediatrician for routine care as well as diagnosis and treatment of an illness or injury. Specialist Office Visits $40 copay; no 60%; after OB Visit (for initial visit only) Allergy Testing $40 copay; no 60%; after Allergy Injections $40 copay; no, copay waived when office visit charge is not made. 60%; after Out-of-State Small Group PPO Plan - $1,000 Page 1 Edition: 7/05
Out-of-State Small Group PPO Plan - $1,000 Page 2 Edition: 7/05
PHARMACY PRESCRIPTION DRUG BENEFITS Retail Up to a 30 day supply Mail Order Delivery (MOD) 31 to 60 day supply PARTICIPATING PHARMACY $10 copay for generic drugs, $20 copay for formulary brandname drugs, and $35 copay for non-formulary brand-name drugs. $20 copay for generic drugs, $40 copay for formulary brand-name drugs, and $70 copay for nonformulary brand-name drugs. No Mandatory Generic (No MG) Member is responsible to pay the applicable copay and/or coinsurance. Plan includes: Contraceptive drugs and devices obtainable from a pharmacy and diabetic supplies. Prescription Drug Deductible (per calendar year) (Must be satisfied before any prescription drug benefits are paid. Combined for all preferred and non-preferred retail and mail order brand-name drugs.) NON-PARTICIPATING PHARMACY $10 copay plus 80% for generic drugs, $20 copay plus 80% for formulary brand-name drugs, and $35 copay plus 80% for nonformulary brand-name drugs. Not Covered $100 Individual $300 Family DIAGNOSTIC PROCEDURES PREFERRED CARE NON-PREFERRED CARE Outpatient Diagnostic Laboratory and X-ray (If performed as a part of a physician's office visit and billed by the physician, expenses are covered subject to the member coinsurance office visit copay.) Outpatient Diagnostic X-ray for Complex Imaging Services (Including, but not limited to, MRI, MRA, PET and CAT Scans) EMERGENCY MEDICAL CARE PREFERRED CARE NON-PREFERRED CARE Urgent Care Provider 80%; after Same as Preferred Care (Benefit availability may vary by location.) Non-Urgent Use of Urgent Care Provider 50%; after 50%; after Emergency Room Copay waived if admitted. 80% after $75 Emergency Room Copay; no Same as Preferred Care Non-Emergency Care in an Emergency Room 50%; after 50%; after Ambulance HOSPITAL CARE PREFERRED CARE NON-PREFERRED CARE Inpatient Coverage (Including maternity - prenatal, delivery and postpartum) Applied per admission. 3x limit per calendar year; waived if readmitted to a hospital within 10 days of discharge; nonpreferred cannot be lower than preferred. 80% after $250 per confinement and calendar year 60% after $500 per confinement and calendar year Outpatient Surgery MENTAL HEALTH SERVICES PREFERRED CARE NON-PREFERRED CARE Inpatient Mental Disorders Limited to 30 days per calendar year. 80% after 250 per confinement and calendar year 60% after $500 per confinement and calendar year Outpatient Hospital 80%; after 50%; after Outpatient Mental Disorders $40 copay; no 50%; after Out-of-State Small Group PPO Plan - $1,000 Page 3 Edition: 7/05
ALCOHOL/DRUG ABUSE SERVICES PREFERRED CARE NON-PREFERRED CARE Inpatient Hospital/Treatment Facility Limited to 30 days per calendar year. Outpatient Hospital/Treatment Facility/Physician Limited to 20 visits per calendar year. 80% after $250 per confinement and calendar year 60% after $500 per confinement and calendar year 80%; after 50%; after OTHER SERVICES AND PLAN DETAILS PREFERRED CARE NON-PREFERRED CARE Skilled Nursing Facility Limited to 120 days per member per calendar year, 3 day prior hospital confinement required. Home Health Care Limited to 120 visits per member per calendar year. Hospice Care Inpatient Limited to 30 days. Hospice Care Outpatient Up to a Maximum benefit of $5,000. Private Duty Nursing (Outpatient) Limited to 70 eight-hours shifts per calendar year. Benefits will not be paid during a calendar year for private duty nursing for any shifts in excess of the Private Duty Nursing Care maximum shifts. Each period of up to 8-hours will be deemed to be one private duty nursing shift. Outpatient Speech Therapy Outpatient Physical and Occupational Therapy Chiropractic Services Spinal Disorder $1,000 maximum per member per calendar year. This calendar year limit will not apply if the insured is confined in a hospital; is receiving treatment of scoliosis or fracture care; or for surgery (including pre/post surgical care given or ordered by the operating physician). Durable Medical Equipment Diabetic Supplies not obtainable at a pharmacy Contraceptive drugs and devices not obtainable at a pharmacy Transplants FAMILY PLANNING PREFERRED CARE NON-PREFERRED CARE Infertility Treatment Coverage only for the diagnosis and treatment of the underlying medical condition Voluntary Sterilization Including tubal ligation and vasectomy. SPECIAL PROGRAMS/SERVICES Certain Special programs and Services may be included in your plan: Aetna Navigator, Fitness, Healthy Outlook, Moms-to-Babies Maternity Management, National Advantage, National Medical Excellence, Natural Alternatives, Natural Products, Vision One, and Vitamin Advantage. * Payment for Non-Preferred care is determined based upon the lowest of: the provider s usual charge for furnishing it; or the charge Aetna determines to be appropriate, based on factors such as the cost of providing the same or a similar service or supply and the manner in which charges for the service or supply are made. These charges are referred to in your plan documents as "reasonable" or recognized charges. ** The dollar amount copayments indicate what the member is required to pay and the percentage copayments indicate what Aetna is required to pay. Out-of-State Small Group PPO Plan - $1,000 Page 4 Edition: 7/05
Items not covered under the office visit copay. X-rays/lab bills are not covered under office visit copay when the x-rays/lab charges are billed and submitted separately from the Preferred Provider office visit charge. Employees should ask their Preferred Provider how he/she bills for x-rays/lab facilities. It may be that the facility submits its charges directly to Aetna and not through the office visit charge; if this is the case, these benefits will be subject to the and paid under the provisions of the plan indicated under "Other Charges. Surgery performed in a Preferred Provider's office is not considered routine office visit. Benefits are subject to the and paid at the Preferred coinsurance level (e.g., 20% after ). Maternity: A PPO provider will normally bill an initial office visit, which is subject to your co-pay. Subsequent pre-natal office visits are billed as part of the global fee at the time of delivery. The global fee and any laboratory or testing expenses are subject to your and then payable at the Preferred coinsurance level. Allergy shots during an office visit are not considered a routine office visit when the Preferred Provider is not seen during the visit. Benefits are subject to the and paid at the Preferred Provider coinsurance level (e.g., $8.00 allergy shot is paid at 20% after ). If a Preferred Provider is seen, shots and office visits are covered under single office visit co-pay (e.g., $20 copay). 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. All medical or hospital services not specifically covered in, or which are limited or excluded in the plan documents; Charges related to any eye surgery mainly to correct refractive errors; Cosmetic surgery, including breast reduction; Custodial care; Dental care and X-rays; Donor egg retrieval; Experimental and investigational procedures; Hearing aids; Immunizations for travel or work; Infertility services, including, but not limited to, 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; Treatment of those for or related to treatment of obesity or for diet or weight control; Non-medically necessary services or supplies; Orthotics except as specified in the plan; Over-the-counter medications and supplies; Reversal of sterilization; Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies, or counseling; and Special duty nursing. Pre-Existing Conditions Exclusion Provision This plan imposes a pre-existing conditions exclusion, which may be waived in some circumstances (that is, creditable coverage) and may not be applicable to you. A pre-existing condition exclusion means that if you have a medical condition before coming to our plan, you might have to wait a certain period of time before the plan will provide coverage for that condition. This exclusion applies only to conditions for which medical advice, diagnosis or treatment was recommended or received or for which the individual took prescribed drugs within 180 days. Generally, this period ends the day before your coverage becomes effective. However, if you were in a waiting period for coverage, the 180 day period ends on the day before the waiting period begins. The exclusion period, if applicable, may last up to 365 days from your first day of coverage, or, if you were in a waiting period, from the first day of your waiting period. If you had prior credible coverage within 90 days immediately before the date you enrolled under this plan, then the pre-existing conditions exclusion in your plan, if any, will be waived. If you had no prior creditable coverage within the 90 days prior to your enrollment date (either because you had no prior coverage or because there was more than a 90 day gap from the date your prior coverage terminated to your enrollment date), we will apply your plan's pre-existing conditions exclusion. In order to reduce or possibly eliminate your exclusion period based on your creditable coverage, you should provide us a copy of any Certificates of Creditable Coverage you have. Please contact your Aetna Member Services representative at 1-888-80-AETNA if you need assistance in obtaining a Certificate of Creditable Coverage from your prior carrier or if you have any questions on the information noted above. The pre-existing condition exclusion does not apply to pregnancy nor to a child who is enrolled in the plan within 31 days after birth, adoption, or placement for adoption. Note: For late enrollees, coverage will be delayed until the plan's next open enrollment; the preexisting exclusion will be applied from the individual's effective date of coverage. 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 any results or outcomes. Consult the plan documents (i.e. Booklet, Booklet-Certificate and/or Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitations relating to the plan. The availability of a plan or program may vary by geographic service area. With the exception of Aetna Rx Home Delivery, LLC, participating providers and vendors are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Aetna Rx Home Out-of-State Small Group PPO Plan - $1,000 Page 5 Edition: 7/05
Delivery, LLC is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change without notice. Some benefits are subject to limitations or visit maximums. Certain services require pre-certification or prior approval of coverage. Failure to pre-certify for these services may lead to substantially reduced benefits or denial of coverage. Some of the benefits requiring precertification may include, but are not limited to, inpatient hospital, inpatient mental health, inpatient skilled nursing, and outpatient surgery, substance abuse (detoxification, inpatient and outpatient rehabilitation). When the Member s preferred provider is coordinating care, the preferred provider will obtain the pre-certification. When the member utilizes a non-preferred provider, Member must obtain the precertification. Pre-certification requirements may vary. Depending on the plan selected, new prescription drugs not yet reviewed by our medication review committee are either available at the highest copayment under plans with an open formulary, or excluded from coverage unless a medical exception is obtained under plans that use a closed formulary. They may also be subject to pre-certification or step-therapy. Non-prescription drugs and drugs in the Limitations and Exclusions section of the plan documents (received after enrollment) are not covered, and medical exceptions are not available for them. Aetna Rx Home Delivery, LLC, is a licensed pharmacy providing mail-order pharmacy services. Aetna's negotiated reimbursement rates with Aetna Rx Home Delivery may be higher than Aetna Rx Home Delivery's cost of purchasing drugs and providing mail-order pharmacy services. In prescription plans with copayment or coinsurance tiers, use of formulary drugs generally will result in lower costs to members. However, where the prescription plan utilizes copayments or coinsurance calculated on a percentage basis, there could be some circumstances in which a formulary drug would cost the member more than a non-formulary drug because (i) the negotiated pharmacy payment rate for the formulary drug may be more than the negotiated pharmacy payment rate for the non-formulary drug, and (ii) rebates received by Aetna from drug manufacturers are not reflected in the cost of a prescription drug obtained by a member. Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. The Aetna Company that underwrites or administers benefits coverage includes Aetna Life Insurance Company. Plans are offered by Aetna Life Insurance Company. While this material is believed to be accurate as of the print date, it is subject to change. Out-of-State Small Group PPO Plan - $1,000 Page 6 Edition: 7/05