Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Arizona 2 100 plan guide The health of business, well planned. Plans effective December 1, 2012 For businesses with 2-100 eligible employees www.aetna.com 14.02.970.1-AZ L (2/13)
Team with Aetna for the health of your business Introducing a new suite of products and services designed specifically for companies with 2 to 100 employees. You can count on Aetna to provide health plans that help simplify decision making and plan administration so you can focus on the health of your business. Aetna is committed to helping employers build healthy businesses. In today s rapidly changing economy, we recognize the need for less expensive, less complex health plan choices. Now, Aetna offers a variety of newly streamlined medical and dental benefits and insurance plans to provide more affordable options and to help simplify plan selection and administration. In this guide: 5 Small business commitment 5 Benefits for every stage of life 6 Medical overview 10 Medical plan options 22 Savings Plus & Aetna Whole Health plans 28 Dental overview 30 Dental plan options 40 Life & disability overview 43 Life & disability plan options 45 Underwriting guidelines 57 Product specifications 65 Limitations and exclusions 68 Group enrollment checklist 70 Contact information 71 Member services Health benefits and health insurance, dental benefits/dental insurance, life insurance and disability insurance plans/ policies are offered, and/or underwritten and/or administered by Aetna Health Inc., Aetna Health Insurance Company and/ or Aetna Life Insurance Company (Aetna). 2
Women s preventive health benefits New changes effective August 1, 2012 As you may know, the Affordable Care Act (ACA, or Health Care Reform law) includes changes that are being phased in over a number of years. The latest set of changes includes additional benefits for certain Women s Preventive Health Services. When plans renew or are effective on or after August 1, 2012, all of the following women s health services will be considered preventive (some were already covered). These services generally will be covered at no cost share, when provided in network: Well-woman visits (annually and now including prenatal visits) Screening for gestational diabetes Human papillomavirus (HPV) DNA testing Counseling for sexually transmitted infections Counseling and screening for human immunodeficiency virus (HIV) Screening and counseling for interpersonal and domestic violence Breastfeeding support, supplies and counseling Generic formulary contraceptives are covered without member cost-share (for example, no copayment). Certain religious organizations or religious employers may be exempt from offering contraceptive services 3
Employers and their employees can benefit from Affordable plan options Online self-service tools and capabilities Enhanced services for consumer-directed health plans 24-hour access to Employee Assistance Program services Preventive care covered 100% Aetna disease management and wellness programs With Aetna, we know it s about... Options We provide a variety of health benefits and insurance plan options to help meet your employees needs, including medical, dental, disability and life insurance. And, with access to a wide network of health care providers, you can be sure that employees have options in how they access their health care. Medical plans HMO/HNO PPO Consumer-directed health plans (CDHPs) Savings Plus Aetna Whole Health Dental plans DMO PPO PPO Max Freedom-of-Choice plan design Preventive Life and disability plans Basic life Supplemental life AD&D Ultra Supplemental AD&D Ultra Dependent life Packaged life and disability plans Short-term disability Long-term disability Simplicity We know that the health of your business is your top priority. Aetna s streamlined plans and variety of services make it easier for you to focus on your business by simplifying administration and management. Aetna makes it easy to manage health insurance benefits with simplified enrollment, billing, and claims processing so you can focus on what matters most. Trust We work hard to provide health plan solutions you can trust. Our account executives, underwriters, and customer service representatives are committed to providing small businesses and their employees with service and care they can trust. Aetna resources are designed to fortify the health of your business Track medical claims and take advantage of online services with your Aetna Navigator secure member website. It features automated enrollment, personal health records, and printable temporary member ID cards. Get real cost and health information to help make the right care decision with an online cost of care estimator. Manage health records online with the Personal Health Record. Use the Aetna Health Connections SM disease management program, which provides personal support to members to help them manage their conditions. Leverage 24/7 access to a nurse to help with personal health-related questions. Help members work toward health goals with wellness initiatives, such as the Simple Steps To A Healthier Life online program. Take advantage of discount* programs for vision, dental, and general health care that encourage use of plan offerings. Employee Assistance Program (EAP)* Aetna s Employee Assistance Program is a confidential program that gives employees and members of their household access to useful services and support to help them manage the everyday challenges of work and home. The EAP is available at no charge to members and their family members and includes: Choice They ll find a range of resources to help them balance their personal and professional lives. Easy access EAP representatives can be reached anytime toll free at 1-866-672-5417 or on the web at www.aetnaeap.com. Management and human resource assistance Employers get unlimited phone consultations with workplace-trained clinicians who can provide help in dealing with complex employee issues that may arise. *Discounts are NOT insurance and are not underwritten by Aetna. 4
We are committed to the health of your business At Aetna, we understand that your business has unique needs. That s why we have streamlined our plan options for employers with 2 to 100 employees. We are committed to providing you with value and quality you can count on. Our variety of products and services allows you to focus on the health of your business. Health insurance benefits for every stage of life For young individuals and couples without children Lower monthly payments Modest out-of-pocket costs Quality preventive care Prescription drug coverage Financial protection...we offer: CDHPs Traditional plans Value plans Aetna Whole Health Savings Plus plans For married couples and single parents with teens and college-aged children Checkups and care for injuries and illness Preventive care and screenings that promote a healthy lifestyle National network of health care providers...we offer: CDHPs Traditional plans Aetna Whole Health Savings Plus plans For married couples and single parents with young children or teens Lower fees for office visits Lower monthly payments Caps on out-of-pocket expenses Quality preventive care for the entire family...we offer: Traditional plans Value plans Aetna Whole Health Savings Plus plans For men and women 55 years of age and over with no children at home Financial security Quality prescription drug coverage Hospital inpatient/outpatient services Emergency care...we offer: CDHPs Traditional plans Aetna Whole Health Savings Plus plans 5
Aetna Medical Overview At Aetna, we are committed to putting the member at the center of everything we do. You can count on Aetna to provide health plans that help simplify decision making and plan administration so you can focus on the health of your business. 6
Medical Overview Arizona Provider Network has more than 16,000 Physicians and 95 Hospitals* Aetna HMO plan Members access care through primary care physicians With this health benefits plan, members begin by selecting a primary care physician (PCP) from Aetna s participating network of providers. Members select a PCP who will coordinate their health care needs for covered benefits or services. Each covered member of the family may choose his or her own PCP. HMO Network = 16,125 doctors and 95 hospitals Aetna HNO No Referrals No need for referrals; freedom to select a provider of choice. Aetna HNO offers all the health plan benefits of a point-ofservice plan with two easy ways to access care when members need it. Members have the freedom to visit the participating doctor or hospital of their choice for covered services. Best of all, members seeking health care do not need referrals. HNO Network = 16,125 doctors and 95 hospitals Aetna PPO The Aetna PPO insurance plan offers members the freedom to go directly to any recognized provider for covered expenses, including specialists. The PPO network is suitable for in-state rural areas. No referrals are required. PPO Network = 16,318 doctors and 95 hospitals Aetna Savings Plus plans The Aetna Savings Plus plans provide Arizona members in Maricopa, Pima and Pinal counties with the same types of coverage as other Aetna medical plans, but at a lower premium cost. Savings are generated through the use of the Savings Plus network, a quality network of local health care providers. Savings Plus Network = 11,419 doctors and 46 hospitals Aetna Whole Health plans The Aetna Whole Health plans provide Arizona members in the greater Phoenix area with the same types of coverage as other Aetna medical plans, but at a lower premium cost. Savings are generated through the use of the Aetna Whole Health network, a quality network of local health care providers. AWH Network = 5,486 doctors and 17 hospitals For additional information on Savings Plus and Aetna Whole Health plans, see page 22. What is Pick-A-Plan 3?** Pick-A-Plan 3 is Aetna Small Group s suite of plans designed specifically with small businesses in mind. These plans provide choice, flexibility and simplicity. Pick-A-Plan 3 offers the following advantages: Greater employee choice Employers can offer any 3 of the 34 available plan designs. Flexibility and affordability Employers can create a customized benefits package from any of our plan types and plan designs. Aetna offers a variety of plans at different price points. Employers may designate a level of contribution that meets their budget. Total freedom Aetna offers 34 plan choices that range in price and benefits to help meet each individual employee s needs, whether they are lower premiums or lower out-of-pocket costs at the time services are received. Easy administration Setting up this program is simple: 1. The employer chooses up to 3 plans to offer on the Employer Application. 2. The employer chooses how much to contribute. 3. Each employee chooses the plan that s right for him or her. Pick-A-Plan 3 Target Audience Plan Choices Minimum Participation Every small business with 5+ enrolled employees. Up to 3 of the 34 available plans 2 4 Enrolled Employees Single or dual option 5 or More Enrolled Employees Employer Contribution Rating Options Single, dual or triple option available 50% of the employee rate or $120 2 9 employees tabular; 10 100 employees composite *According to the Aetna Enterprise Provider Database as of May 1, 2012. Network subject to change. **Available with five or more enrolled employees. 7
Consumer-directed health plans Consumer-directed health plans are high-deductible health plans (HDHPs) designed to give individuals greater flexibility and control when purchasing care. Aetna s HDHPs are paired with account-based funds that include health savings accounts (HSAs), health reimbursement accounts (HRAs) and flexible spending accounts (FSAs). HDHP s increase the flexibility and control employers and employees have by putting them in the center of their health care. In more traditional scenarios, employees may have a higher premium associated with a low-deductible plan, and never use it. With an Aetna HDHP, the employer and employee can lower their monthly premium, and create a fund to pay for the services when needed. In an HSA or HRA fund, the monies can roll over from year to year and can be used toward future medical expenses. When a HDHP is paired with an HSA, employers and their qualified employees have a tax-advantaged solution that allows them to manage their qualified medical and dental expenses. HRAs enable employers to use tax-deductible dollars to reimburse employees for predetermined types of medical expenses. While FSAs allow individuals to use pretax salary dollars to establish an account to help pay for health care and dependent care expenses. Health Savings Account (HSA) The Aetna HealthFund HSA, when coupled with an 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. Annual HSA contributions for 2013 are $3,250 per individual/ $6,450 per family. Maximums will be adjusted for the cost of living in future years. Member s HSA plan 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 Today Use for qualified expenses with tax-free dollars Future Plan for future and retiree health-related costs High-deductible health plan 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% Health Reimbursement Account (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 and fund rollover. The fund is available to an employee for qualified expenses on the plan s effective date. The HRA and the HSA provide members with financial support for higher out-of-pocket health care expenses. 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. 8
COBRA administration Aetna COBRA administration offers a full range of notification, documentation and record-keeping processes. These can help you manage the complex billing and notification processes that are required for COBRA compliance, while also helping to save you time and money. Section 125 Cafeteria Plans and Section 132 Transit Reimbursement Accounts Employees can reduce their taxable income, and employers can pay less in payroll taxes. There are three ways to save: Premium-only plans (POP) Employees can pay for their portion of the group health insurance expenses on a pretax basis. First-year POP fees with the purchase of medical and life with 5-plus enrolled employees. Flexible savings account (FSA) FSAs give employees a chance to save for health expenses with pretax money. Health care spending accounts allow employees to set aside pretax dollars to pay for out-of-pocket expenses as defined by the IRS. Dependent care spending accounts allow participants to use pretax dollars to pay child or elder care expenses. Transit reimbursement account (TRA) TRAs allow participants to use pretax dollars to pay transportation and parking expenses for the purpose of commuting to and from work. Administrative Fees Fee description Health Reimbursement Arrangement (HSA) Initial setup $0 Monthly fees $0 POP Fee Initial setup* $190 Renewal $125 Health Reimbursement Arrangement (HSA) and Flexible Spending Account (FSA)** Initial setup 2 25 Employees $360 26 50 Employees $460 51 100 Employees $560 Renewal fee 2 25 Employees $235 26 50 Employees $285 51 100 Employees $335 Monthly fees*** Additional setup fee for stacked plans (those electing an Aetna HRA and FSA simultaneously) Participation fee for stacked participants Minimum fees $5.45 per participant $150 $10.45 per participant 2 25 Employees $25 per month minimum 26 100 Employees $50 per month minimum COBRA Annual fee 20 50 Employees $165 51 100 Employees $230 Per employee per month 20 50 Employees $0.95 51 100 Employees $1.05 Initial notice fee Transit Reimbursement Account (TRA) Annual fee $350 Transit monthly fees Parking monthly fees $3.00 per notice (includes notices at time of implementation and during ongoing administration) $4.25 per participant $3.15 per participant * Non discrimination testing provided annually after open enrollment for POP and FSA only. Additional off-cycle testing available at employer request for $100 fee. Nondiscrimination testing only available for FSA and POP products. ** Aetna FSA pricing is inclusive for POP. Debit cards are available for FSA only. Contact Aetna for further information. *** For HRA, if the employer opts out of Streamline, the fee is increased $1.50 per participant. For FSA, the debit card is available for an additional $1 per participant per month. Mailing reimbursement checks direct to employee homes is an additional $1 per participant per month. Aetna HRAs are subject to employer-defined use and forfeiture rules. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Information subject to change. Aetna reserves the right to change any of the above fees and to impose additional fees upon prior written notice. 9
HMO & Health Network Option (HNO) Plans Plan Name AZ HMO $15/$30/$250 AZ Health Network Option (Open Access) $750 80/60 Network HMO Aetna Health Network Option (Open Access) NA PCP/Referrals Required Yes No NA Member Benefits Participating providers Participating providers Nonparticipating providers 1 Calendar-Year Plan Deductible None $750 per member $750 per member Out-of-Pocket Limit $2,000 Individual $3,000 per member $6,000 per member Deductible & Out-of-Pocket Limit Accumulation Two-member maximum Two-member maximum Not Included In Out-of-Pocket Limit 3 Ambulance, chiropractic, DME, emergency/ urgent care and prescription drugs (including Specialty CareRx SM ) Primary Care Physician Office Visit $15 copay $20 copay; deductible Specialist Office Visit $30 copay $40 copay; deductible Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) Amounts over allowable charges, copays, deductible, DME, failure to precertify penalty and Rx (including Specialty CareRx SM ) 40% after deductible 40% after deductible No charge No charge 40% after deductible Diagnostic Testing (X-ray, blood work) $30 copay $40 copay; deductible 40% after deductible Imaging (CT/PET scans MRI s) $100 copay 20% after deductible Prescription Drug Deductible (Applies to brand and nonformulary brand drugs) Prescription Drugs* Generic formulary/brand formulary/ Generic & brand nonformulary Retail: 30-day supply Mail order: two-times retail copay, up to 90-day supply None None NA $15/$30/$50 $20/$40/$60 Not covered Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary N/A Aetna Specialty CareRx SM Includes self-injectable, infused and oral specialty drugs (Retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit.) 20% 20% Not covered Outpatient Surgery OP Hospital Department $250 copay 30% after deductible Outpatient Surgery Freestanding Facility $150 copay 20% after deductible 40% after deductible Inpatient Hospital Facility $250 copay per day up to 3-days per admit 20% after deductible 40% after deductible Rehabilitation Services (PT/OT) (20 visits per calendar year. Participating and nonparticipating combined.) $30 copay 20% after deductible 40% after deductible Emergency Room $100 copay $250 copay; deductible Emergency Medical Transport $100 copay 20% after deductible Urgent Care $50 copay Primary & Specialist Physician E-Visit $10 copay $10 copay; deductible Walk-In Clinics $15 copay $20 copay; deductible Chiropractic $30 copay (Limited to 20-visits per member per calendar year) $40 copay; deductible (Limited to 20-visits per member per calendar year) Not covered Not covered 40% after deductible (No visit limits) See pages 26 27 for footnotes. 10
HMO & Health Network Option (HNO) Plans Plan Name AZ Health Network Option (Open Access) $1,000 80/60 AZ Health Network Option (Open Access) $1,500 70/50 Network Aetna Health Network Option (Open Access) NA Aetna Health Network Option (Open Access) PCP/Referrals Required No NA No NA Member Benefits Participating providers Nonparticipating Participating providers Nonparticipating providers 1 providers 1 Calendar-Year Plan Deductible $1,000 per member $1,000 per member $1,500 per member $1,500 per member Out-of-Pocket Limit $4,000 per member $8,000 per member $5,000 per member $10,000 per member Deductible & Out-of-Pocket Limit Accumulation Two-member maximum Two-member maximum Two-member maximum Two-member maximum Not Included In Out-of-Pocket Limit 3 Primary Care Physician Office Visit Specialist Office Visit Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) Diagnostic Testing (X-ray, blood work) Amounts over allowable charges, copays, deductible, DME, failure to precertify penalty and Rx (including Specialty CareRx SM ) $25 copay; deductible 40% after deductible $25 copay; deductible 40% after deductible NA Amounts over allowable charges, copays, deductible, DME, failure to precertify penalty and Rx (including Specialty CareRx SM ) No charge 40% after deductible No charge 40% after deductible Imaging (CT/PET scans MRI s) 20% after deductible 30% after deductible Prescription Drug Deductible (Applies to brand and nonformulary brand drugs) Prescription Drugs* Generic formulary/brand formulary/ Generic & brand nonformulary Retail: 30-day supply Mail order: two-times retail copay, up to 90-day supply None NA None NA $20/$40/$60 Not covered $20/$40/$60 Not covered Pharmacy Plan Type Four Tier Open Formulary N/A Four Tier Open Formulary N/A Aetna Specialty CareRx SM Includes self-injectable, infused and oral specialty drugs (Retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit.) 20% Not covered 20% Not covered Outpatient Surgery OP Hospital Department 30% after deductible 40% after deductible Outpatient Surgery Freestanding Facility 20% after deductible 40% after deductible 30% after deductible Inpatient Hospital Facility 20% after deductible 40% after deductible 30% after deductible Rehabilitation Services (PT/OT) (20 visits per calendar year. Participating and nonparticipating combined.) 20% after deductible 40% after deductible 30% after deductible Emergency Room $250 copay; deductible $250 copay; deductible Emergency Medical Transport 20% after deductible 30% after deductible Urgent Care Primary & Specialist Physician E-Visit Walk-In Clinics Chiropractic $10 copay; deductible $25 copay; deductible (Limited to 20-visits per member per calendar year) Not covered Not covered 40% after deductible (No visit limits) $10 copay; deductible $25 copay; deductible (Limited to 20-visits per member per calendar year) Not covered Not covered (No visit limits) See pages 26 27 for footnotes. 11
Open Choice PPO Plan Options Plan Name AZ PPO $500 80/60 $15/$30 AZ PPO $750 80/60 $20/$40 Network Open Choice PPO NA Open Choice PPO NA PCP/Referrals Required No NA No NA Member Benefits Participating providers Nonparticipating Participating providers Nonparticipating providers 1 providers 1 Calendar-Year Plan Deductible $500 per member $500 per member $750 per member $750 per member Out-of-Pocket Limit $2,500 per member $5,000 per member $3,000 per member $6,000 per member Deductible & Out-of-Pocket Limit Accumulation Two-member maximum Two-member maximum Not Included In Out-of-Pocket Limit 3 Primary Care Physician Office Visit Specialist Office Visit Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) Diagnostic Testing (X-ray, blood work) Amounts over allowable charges, copays, deductible, DME, failure to precertify penalty and Rx (including Specialty CareRx SM ) $15 copay; deductible $30 copay; deductible 40% after deductible $20 copay; deductible 40% after deductible $40 copay; deductible Amounts over allowable charges, copays, deductible, DME, failure to precertify penalty and Rx (including Specialty CareRx SM ) 40% after deductible 40% after deductible No charge 40% after deductible No charge 40% after deductible $30 copay; deductible 40% after deductible $40 copay; deductible 40% after deductible Imaging (CT/PET scans MRI s) 20% after deductible 20% after deductible Prescription Drug Deductible (Applies to brand and nonformulary brand drugs) Prescription Drugs* Generic formulary/brand formulary/brand nonformulary Retail: 30-day supply Mail order: two-times retail copay, up to 90-day supply None None None None $15/$30/$50 20% after $15/$30/$50 $20/$40/$60 20% after $20/$40/$60 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx SM Includes self-injectable, infused and oral specialty drugs (Retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit.) 20% 40% 20% 40% Outpatient Surgery OP Hospital Department 30% after deductible 30% after deductible Outpatient Surgery Freestanding Facility 20% after deductible 40% after deductible 20% after deductible 40% after deductible Inpatient Hospital Facility 20% after deductible 40% after deductible 20% after deductible 40% after deductible Rehabilitation Services (PT/OT) (20 visits per calendar year. Participating and nonparticipating combined.) 20% after deductible 40% after deductible 20% after deductible 40% after deductible Emergency Room $250 copay; deductible $250 copay; deductible Emergency Medical Transport 20% after deductible 20% after deductible Urgent Care Primary & Specialist Physician E-Visit Walk-In Clinics Chiropractic (No visit limits) $10 copay; deductible $15 copay; deductible $30 copay; deductible 40% after deductible $10 copay; deductible 40% after deductible $20 copay; deductible 40% after deductible $40 copay; deductible 40% after deductible 40% after deductible 40% after deductible See pages 26 27 for footnotes. 12
Open Choice PPO Plan Options Plan Name AZ PPO $1,000 80/60 $20/$40 AZ PPO $1,000 70/50 $25/$50 Network Open Choice PPO NA Open Choice PPO NA PCP/Referrals Required No NA No NA Member Benefits Participating providers Nonparticipating Participating providers Nonparticipating providers 1 providers 1 Calendar-Year Plan Deductible $1,000 per member $1,000 per member $1,000 per member $1,000 per member Out-of-Pocket Limit $4,000 per member $8,000 per member $4,000 per member $8,000 per member Deductible & Out-of-Pocket Limit Accumulation Two-member maximum Two-member maximum Not Included In Out-of-Pocket Limit 3 Primary Care Physician Office Visit Specialist Office Visit Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) Diagnostic Testing (X-ray, blood work) Amounts over allowable charges, copays, deductible, DME, failure to precertify penalty and Rx (including Specialty CareRx SM ) $20 copay; deductible $40 copay; deductible 40% after deductible $25 copay; deductible 40% after deductible Amounts over allowable charges, copays, deductible, DME, failure to precertify penalty and Rx (including Specialty CareRx SM ) No charge 40% after deductible No charge $40 copay; deductible 40% after deductible Imaging (CT/PET scans MRI s) 20% after deductible 30% after deductible Prescription Drug Deductible (Applies to brand and nonformulary brand drugs) Prescription Drugs* Generic formulary/brand formulary/brand nonformulary Retail: 30-day supply Mail order: two-times retail copay, up to 90-day supply None None None None $20/$40/$60 20% after $20/$40/$60 $20/$40/$60 20% after $20/$40/$60 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx SM Includes self-injectable, infused and oral specialty drugs (Retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit.) 20% 40% 20% 50% Outpatient Surgery OP Hospital Department 30% after deductible 40% after deductible Outpatient Surgery Freestanding Facility 20% after deductible 40% after deductible 30% after deductible Inpatient Hospital Facility 20% after deductible 40% after deductible 30% after deductible Rehabilitation Services (PT/OT) (20 visits per calendar year. Participating and nonparticipating combined.) 20% after deductible 40% after deductible 30% after deductible Emergency Room $250 copay; deductible $250 copay; deductible Emergency Medical Transport 20% after deductible 30% after deductible Urgent Care Primary & Specialist Physician E-Visit Walk-In Clinics Chiropractic (No visit limits) $10 copay; deductible $20 copay; deductible $40 copay; deductible 40% after deductible $10 copay; deductible 40% after deductible $25 copay; deductible 40% after deductible See pages 26 27 for footnotes. 13
Open Choice PPO Plan Options Plan Name AZ PPO $2,000 70/50 $25/$50 AZ PPO $2,500 80/60 $25/$50 Network Open Choice PPO NA Open Choice PPO NA PCP/Referrals Required No NA No NA Member Benefits Participating providers Nonparticipating Participating providers Nonparticipating providers 1 providers 1 Calendar-Year Plan Deductible $2,000 per member $2,000 per member $2,500 per member $2,500 per member Out-of-Pocket Limit $4,500 per member $9,000 per member $5,000 per member $10,000 per member Deductible & Out-of-Pocket Limit Accumulation Two-member maximum Two-member maximum Not Included In Out-of-Pocket Limit 3 Primary Care Physician Office Visit Specialist Office Visit Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) Diagnostic Testing (X-ray, blood work) Amounts over allowable charges, copays, deductible, DME, failure to precertify penalty and Rx (including Specialty CareRx SM ) $25 copay; deductible $25 copay; deductible Amounts over allowable charges, copays, deductible, DME, failure to precertify penalty and Rx (including Specialty CareRx SM ) 40% after deductible 40% after deductible No charge No charge 40% after deductible 40% after deductible Imaging (CT/PET scans MRI s) 30% after deductible 20% after deductible Prescription Drug Deductible (Applies to brand and nonformulary brand drugs) Prescription Drugs* Generic formulary/brand formulary/brand nonformulary Retail: 30-day supply Mail order: two-times retail copay, up to 90-day supply None None None None $20/$40/$60 20% after $20/$40/$60 $20/$40/$60 20% after $20/$40/$60 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx SM Includes self-injectable, infused and oral specialty drugs (Retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit.) 20% 50% 20% 40% Outpatient Surgery OP Hospital Department 40% after deductible 30% after deductible Outpatient Surgery Freestanding Facility 30% after deductible 20% after deductible 40% after deductible Inpatient Hospital Facility 30% after deductible 20% after deductible 40% after deductible Rehabilitation Services (PT/OT) (20 visits per calendar year. Participating and nonparticipating combined.) 30% after deductible $25 copay after deductible 40% after deductible Emergency Room $250 copay; deductible $250 copay; deductible Emergency Medical Transport 30% after deductible 20% after deductible Urgent Care Primary & Specialist Physician E-Visit Walk-In Clinics Chiropractic (No visit limits) $10 copay; deductible $25 copay; deductible $10 copay; deductible $25 copay; deductible 40% after deductible 40% after deductible 40% after deductible See pages 26 27 for footnotes. 14
Open Choice PPO & Indemnity Plan Options Plan Name AZ PPO $5,000 80/60 $30/$60 AZ Indemnity $500 80% Network Open Choice PPO NA NA PCP/Referrals Required No NA NA Member Benefits Participating providers Nonparticipating providers 1 Nonparticipating providers 2 Calendar-Year Plan Deductible $5,000 per member $5,000 per member $500 per member Out-of-Pocket Limit $5,000 per member $10,000 per member $3,000 per member Deductible & Out-of-Pocket Limit Accumulation Two-member maximum Per member Not Included In Out-of-Pocket Limit 3 Primary Care Physician Office Visit Specialist Office Visit Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) Diagnostic Testing (X-ray, blood work) Amounts over allowable charges, copays, deductible, DME, failure to precertify penalty and Rx (including Specialty CareRx SM ) $30 copay; deductible $60 copay; deductible 40% after deductible 20% after deductible 40% after deductible 20% after deductible No charge 40% after deductible 0%; deductible $60 copay; deductible 40% after deductible 20% after deductible Imaging (CT/PET scans MRI s) 20% after deductible 20% after deductible Prescription Drug Deductible (Applies to brand and nonformulary brand drugs) Prescription Drugs* Generic formulary/brand formulary/brand nonformulary Retail: 30-day supply Mail order: two-times retail copay, up to 90-day supply None None None Amounts over allowable charges, ambulance, deductible, DME, emergency/urgent care, failure to precertify penalty, payments for mental disorders (2-50), substance abuse (2-50), Rx (including Specialty CareRx SM ) $20/$40/$60 20% after $20/$40/$60 Participating: $20/$40/$60 Nonparticipating: 20% after $20/$40/$60 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx SM Includes self-injectable, infused and oral specialty drugs (Retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit.) 20% 40% 20% Outpatient Surgery OP Hospital Department 30% after deductible 20% after deductible Outpatient Surgery Freestanding Facility 20% after deductible 40% after deductible 20% after deductible Inpatient Hospital Facility 20% after deductible 40% after deductible 20% after deductible Rehabilitation Services (PT/OT) (20 visits per calendar year. Participating and nonparticipating combined.) $30 copay after deductible 40% after deductible 20% after deductible Emergency Room $250 copay; deductible 20% after deductible Emergency Medical Transport 20% after deductible 20% after deductible Urgent Care Primary & Specialist Physician E-Visit Walk-In Clinics Chiropractic (No visit limits) $10 copay; deductible $30 copay; deductible $60 copay; deductible 20% after deductible 40% after deductible Not covered 40% after deductible Not covered 40% after deductible 20% after deductible See pages 26 27 for footnotes. 15
Open Choice PPO 100% Plans Plan Name AZ PPO $2,500 100/50 $20/$40 AZ PPO $3,500 100/50 $25/$50 Network Open Choice PPO NA Open Choice PPO NA PCP/Referrals Required No NA No NA Member Benefits Participating providers Nonparticipating Participating providers Nonparticipating providers 1 providers 1 Calendar-Year Plan Deductible Out-of-Pocket Limit $2,500 Individual $5,000 Family $0 Individual $0 Family $5,000 Individual $10,000 Family $5,000 Individual $10,000 Family $3,500 Individual $7,000 Family $0 Individual $0 Family $7,000 Individual $14,000 Family $7,000 Individual $14,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 4 Embedded aggregate 4 Not Included In Out-of-Pocket Limit 3 Primary Care Physician Office Visit Specialist Office Visit Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) Diagnostic Testing (X-ray, blood work) Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including Specialty CareRx SM ) $20 copay; deductible $40 copay; deductible $25 copay; deductible Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including Specialty CareRx SM ) No charge No charge $40 copay; deductible Imaging (CT/PET scans MRI s) 0% after deductible 0% after deductible Prescription Drug Deductible (Applies to brand and nonformulary brand drugs) Prescription Drugs* Generic formulary/brand formulary/brand nonformulary Retail: 30-day supply Mail order: two-times retail copay, up to 90-day supply None None None None $20/$40/$60 20% after $20/$40/$60 $20/$40/$60 20% after $20/$40/$60 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx SM Includes self-injectable, infused and oral specialty drugs (Retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit.) 20% 50% 20% 50% Outpatient Surgery OP Hospital Department 0% after deductible 0% after deductible Outpatient Surgery Freestanding Facility 0% after deductible 0% after deductible Inpatient Hospital Facility 0% after deductible 0% after deductible Rehabilitation Services (PT/OT) (20 visits per calendar year. Participating and nonparticipating combined.) 0% after deductible 0% after deductible Emergency Room $250 copay; deductible $250 copay; deductible Emergency Medical Transport 0% after deductible 0% after deductible Urgent Care Primary & Specialist Physician E-Visit Walk-In Clinics Chiropractic (No visit limits) $10 copay; deductible $20 copay; deductible $40 copay; deductible $10 copay; deductible $25 copay; deductible See pages 26 27 for footnotes. 16
Open Choice PPO 100% Plans Plan Name AZ PPO $5,000 100/50 $25/$50 Network Open Choice PPO NA PCP/Referrals Required No NA Member Benefits Participating providers Nonparticipating providers 1 Calendar-Year Plan Deductible Out-of-Pocket Limit $5,000 Individual $10,000 Family $0 Individual $0 Family $10,000 Individual $20,000 Family $10,000 Individual $20,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 4 Not Included In Out-of-Pocket Limit 3 Primary Care Physician Office Visit Specialist Office Visit Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) Diagnostic Testing (X-ray, blood work) Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including Specialty CareRx SM ) $25 copay; deductible No charge Imaging (CT/PET scans MRI s) 0% after deductible Prescription Drug Deductible (Applies to brand and nonformulary brand drugs) Prescription Drugs* Generic formulary/brand formulary/brand nonformulary Retail: 30-day supply Mail order: two-times retail copay, up to 90-day supply None None $20/$40/$60 20% after $20/$40/$60 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx SM Includes self-injectable, infused and oral specialty drugs (Retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit.) 20% 50% Outpatient Surgery OP Hospital Department 0% after deductible Outpatient Surgery Freestanding Facility 0% after deductible Inpatient Hospital Facility 0% after deductible Rehabilitation Services (PT/OT) (20 visits per calendar year. Participating and nonparticipating combined.) Emergency Room Emergency Medical Transport Urgent Care Primary & Specialist Physician E-Visit Walk-In Clinics Chiropractic (No visit limits) 0% after deductible $250 copay; deductible $10 copay; deductible $25 copay; deductible 0% after deductible See pages 26 27 for footnotes. 17
Open Choice PPO Value & Value Saver Plans Plan Name AZ PPO Value $2,500 80/50 AZ PPO Value Saver $7,500 100/50 Network Open Choice PPO NA Open Choice PPO NA PCP/Referrals Required No NA No NA Member Benefits Participating providers Nonparticipating Participating providers Nonparticipating providers 1 providers 1 Calendar-Year Plan Deductible $2,500 per member $2,500 per member $7,500 Individual $10,000 Family Out-of-Pocket Limit $5,000 per member $10,000 per member $0 Individual $0 Family See pages 26 27 for footnotes. 18 $7,500 Individual $10,000 Family Unlimited Individual Unlimited Family Deductible & Out-of-Pocket Limit Accumulation Per member Embedded aggregate 4 Not Included In Out-of-Pocket Limit 3 Primary Care Physician Office Visit Specialist Office Visit Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) Diagnostic Testing (X-ray, blood work) Imaging (CT/PET scans MRI s) Prescription Drug Deductible (Applies to brand and nonformulary brand drugs) Prescription Drugs* Generic formulary/brand formulary/brand nonformulary Retail: 30-day supply Mail order: two-times retail copay, up to 90-day supply Amounts over allowable charges, copays, deductible, DME, failure to precertify penalty and Rx (including Specialty CareRx SM ) $25 copay 5 ; deductible (office visit limit applies; see footnote for details) $25 copay 5 ; deductible (office visit limit applies; see footnote for details) 5 (office visit limit applies; see footnote for details) 5 (office visit limit applies; see footnote for details) Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including Specialty CareRx SM ) $20 copay; deductible 0%; after deductible No charge No charge $500 copay after deductible $40 copay; deductible for the first $1,000 per member, thereafter covered at 0% after deductible 0% after deductible $500 per member None None $20/$40/$60 20% after $20/$40/$60 $20/$40/$60 20% after $20/$40/$60 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx SM Includes self-injectable, infused and oral specialty drugs (Retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit.) 50% 50% 30% 50% Outpatient Surgery OP Hospital Department 30% after deductible 0% after deductible Outpatient Surgery Freestanding Facility 20% after deductible 0% after deductible Inpatient Hospital Facility 20% after deductible 0% after deductible Rehabilitation Services (PT/OT) (20 visits per calendar year. Participating and nonparticipating combined.) See office visit benefit See office visit benefit 0% after deductible Emergency Room $250 copay after deductible 0% after deductible Emergency Medical Transport 20% after deductible 0% after deductible Urgent Care Primary & Specialist Physician E-Visit $100 copay; deductible $10 copay; deductible 0% after deductible 0% after deductible $10 copay; deductible Walk-In Clinics See office visit benefit $20 copay; deductible Chiropractic (No visit limits) $25 copay; deductible 0% after deductible
Open Choice PPO Value Saver Plans Plan Name AZ PPO Value Saver $10,000 100/50 Network Open Choice PPO NA PCP/Referrals Required No NA Member Benefits Participating providers Nonparticipating providers 1 Calendar-Year Plan Deductible Out-of-Pocket Limit $10,000 Individual $10,000 Family $0 Individual $0 Family $10,000 Individual $10,000 Family Unlimited Individual Unlimited Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 4 Not Included In Out-of-Pocket Limit 3 Primary Care Physician Office Visit Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including Specialty CareRx SM ) $15 copay; deductible Specialist Office Visit 0%; after deductible Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) Diagnostic Testing (X-ray, blood work) No charge $30 copay; deductible for the first $1,000 per member, thereafter covered at 0% after deductible Imaging (CT/PET scans MRI s) 0% after deductible Prescription Drug Deductible (Applies to brand and nonformulary brand drugs) Prescription Drugs* Generic formulary/brand formulary/brand nonformulary Retail: 30-day supply Mail order: two-times retail copay, up to 90-day supply None None $20/$40/$60 20% after $20/$40/$60 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx SM Includes self-injectable, infused and oral specialty drugs (Retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit.) 30% 50% Outpatient Surgery OP Hospital Department 0% after deductible Outpatient Surgery Freestanding Facility 0% after deductible Inpatient Hospital Facility 0% after deductible Rehabilitation Services (PT/OT) (20 visits per calendar year. Participating and nonparticipating combined.) Emergency Room Emergency Medical Transport 0% after deductible 0% after deductible 0% after deductible Urgent Care 0% after deductible 0% after deductible Primary & Specialist Physician E-Visit Walk-In Clinics $10 copay; deductible $15 copay; deductible Chiropractic (No visit limits) 0% after deductible See pages 26 27 for footnotes. 19
Open Choice PPO HSA-Compatible HDHP Plans Plan Name AZ PPO HSA HDHP $2,500 100/50 AZ PPO HSA HDHP $5,000 100/50 Network Open Choice PPO NA Open Choice PPO NA PCP/Referrals Required No NA No NA Member Benefits Participating providers Nonparticipating Participating providers Nonparticipating providers 1 providers 1 Calendar-Year Plan Deductible Out-of-Pocket Limit $2,500 Individual $5,000 Family $3,450 Individual $6,900 Family $2,500 Individual $5,000 Family $3,450 Individual $6,900 Family $5,000 Individual $10,000 Family $950 Individual $1,900 Family $5,000 Individual $10,000 Family $950 Individual $1,900 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 4 Embedded aggregate 4 Not Included In Out-of-Pocket Limit 3 Amounts over allowable charges, deductible and failure to precertify penalty. Amounts over allowable charges, deductible and failure to precertify penalty. Primary Care Physician Office Visit 0% after deductible 0% after deductible Specialist Office Visit 0% after deductible 0% after deductible Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) No charge No charge Diagnostic Testing (X-ray, blood work) 0% after deductible 0% after deductible Imaging (CT/PET scans MRI s) 0% after deductible 0% after deductible Prescription Drug Deductible (Applies to brand and nonformulary brand drugs) Prescription Drugs* Generic formulary/brand formulary/brand nonformulary Retail: 30-day supply Mail order: two-times retail copay, up to 90-day supply Pharmacy Plan Type Aetna Specialty CareRx SM Includes self-injectable, infused and oral specialty drugs (Retail and mail order up to a 30-day supply, excludes insulin, does accumulate toward out-of-pocket payment limit.) Integrated medical/rx deductible Integrated medical/rx deductible Integrated medical/rx deductible Integrated medical/rx deductible $20/$40/$60 20% after $20/$40/$60 $20/$40/$60 20% after $20/$40/$60 Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary 20% 50% 20% 50% Four Tier Open Formulary Outpatient Surgery OP Hospital Department 0% after deductible 0% after deductible Outpatient Surgery Freestanding Facility 0% after deductible 0% after deductible Inpatient Hospital Facility 0% after deductible 0% after deductible Rehabilitation Services (PT/OT) (20 visits per calendar year. Participating and nonparticipating combined.) 0% after deductible 0% after deductible Emergency Room $250 copay after deductible $250 copay after deductible Emergency Medical Transport 0% after deductible 0% after deductible Urgent Care 0% after deductible 0% after deductible 0% after deductible 0% after deductible Primary & Specialist Physician E-Visit 0% after deductible 0% after deductible Walk-In Clinics 0% after deductible 0% after deductible Chiropractic (No visit limits) 0% after deductible 0% after deductible See pages 26 27 for footnotes. 20
Open Choice PPO HSA-Compatible HDHP Plans Plan Name AZ PPO HSA HDHP $2,500 90/50 AZ PPO HSA HDHP $4,000 80/50 Network Open Choice PPO NA Open Choice PPO NA PCP/Referrals Required No NA No NA Member Benefits Participating providers Nonparticipating Participating providers Nonparticipating providers 1 providers 1 Calendar-Year Plan Deductible Out-of-Pocket Limit $2,500 Individual $5,000 Family $3,000 Individual $6,000 Family $2,500 Individual $5,000 Family $3,000 Individual $6,000 Family $4,000 Individual $8,000 Family $1,500 Individual $3,000 Family $4,000 Individual $8,000 Family $1,500 Individual $3,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 4 Embedded aggregate 4 Not Included In Out-of-Pocket Limit 3 Amounts over allowable charges, deductible and failure to precertify penalty. Amounts over allowable charges, deductible and failure to precertify penalty. Primary Care Physician Office Visit 10% after deductible 20% after deductible Specialist Office Visit 10% after deductible 20% after deductible Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) No charge No charge Diagnostic Testing (X-ray, blood work) 10% after deductible 20% after deductible Imaging (CT/PET scans MRI s) 10% after deductible 20% after deductible Prescription Drug Deductible (Applies to brand and nonformulary brand drugs) Prescription Drugs* Generic formulary/brand formulary/brand nonformulary Retail: 30-day supply Mail order: two-times retail copay, up to 90-day supply Pharmacy Plan Type Aetna Specialty CareRx SM Includes self-injectable, infused and oral specialty drugs (Retail and mail order up to a 30-day supply, excludes insulin, does accumulate toward out-of-pocket payment limit.) Integrated medical/rx deductible Integrated medical/rx deductible Integrated medical/rx deductible Integrated medical/rx deductible $20/$40/$60 20% after $20/$40/$60 $20/$40/$60 20% after $20/$40/$60 Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary 20% 50% 20% 50% Four Tier Open Formulary Outpatient Surgery OP Hospital Department 10% after deductible 20% after deductible Outpatient Surgery Freestanding Facility 10% after deductible 20% after deductible Inpatient Hospital Facility 10% after deductible 20% after deductible Rehabilitation Services (PT/OT) (20 visits per calendar year. Participating and nonparticipating combined.) 10% after deductible 20% after deductible Emergency Room $250 copay after deductible $250 copay after deductible Emergency Medical Transport 10% after deductible 20% after deductible Urgent Care 10% after deductible 10% after deductible 20% after deductible 20% after deductible Primary & Specialist Physician E-Visit 10% after deductible 20% after deductible Walk-In Clinics 10% after deductible 20% after deductible Chiropractic (No visit limits) 10% after deductible 20% after deductible See pages 26 27 for footnotes. 21