Pennsylvania Plan guide

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Quality health plans & benefits

Healthier living

Financial well-being

Intelligent solutions

The health of business,

well planned.

Pennsylvania 2–100

Plan guide

Plans effective August 1, 2012

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Health benefits and health insurance, dental benefits/dental insurance, life insurance, and disability insurance plans/policies are offered, underwritten,

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 eligible employees.

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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

8 Managing health care expenses 10 Medical plan options

35 Dental overview 36 Dental plan options 47 Life & disability overview 49 Life & disability plan options 51 Underwriting guidelines 60 Product specifications 69 Limitations and exclusions

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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 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 • Cost-sharing plans • Consumer-directed plans • Traditional plans Dental plans • DMO® • PPO • PPO Max

• Freedom-of-Choice plan design option

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 ConnectionsSM_{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.

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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.

Aetna’s health plan options are designed with the

health of your business in mind

Basic plans

• Basic benefits for your employees • Limit the expense to your business

• Allow employees to buy up and share more of the cost - PA POS 5.7 CY (30/400D)

- PA POS CS 2.7 CY (1000 Ded) - PA POS CS 1.7 CY (500 Ded)

Value plans

• Encourage employee responsibility in their health care decisions • Tools and resources to support consumerism

• Innovative plan design - PA POS CS 4.7 CY (2000 Ded)

- PA POS HSA Comp NR 1.7 PY (1500 Ded)

- PA Health Network Option AHF HRA 2.7 PY (2500 Ded)

Traditional plans

• Traditional benefits plans

• Limit the financial impact on employees - PA POS 2.7 CY (10/500A)

- PA POS 3.7 CY (15/200D)

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 Consumer-directed 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

Cost-sharing 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 Traditional 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

Cost-sharing plans Consumer-directed plans

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Product Information

Plan Name Product Description PCP Required Referrals Required Network

Aetna POS The Aetna POS plan is a two-tiered product that allows members to access care in one of two ways:

• PCP-referred, in network or • Self-referred, in or out of network

Members have lower out-of-pocket costs when they use the HMO (referred) tier of the plan and follow the PCP referral process. Member cost sharing increases if members decide to self-refer in or out of network.

Yes Yes for

PCP-referred care. No for self-referred care. QPOS® Aetna POS No-Referral

The Aetna POS No-Referral plan is a two-tiered product that allows members to access care in or out of network. 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.

Yes/ Optional No Aetna Choice®_POS (Open Access)

Medical

Overview

At Aetna, we are committed to putting the employee 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.

Pennsylvania provider network*

POS, Health Network Option & PPO Plans PPO Plans Only

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Product Information (continued)

Plan Name Product Description PCP Required Referrals Required Network

Aetna Health Network OptionSM (Aetna HealthFund®₎

The Aetna 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 Aetna 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.

Yes/ Optional No Aetna HealthFund® Aetna Health Network OptionSM (Open Access)

Aetna PPO 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-of-pocket costs, or non-network providers at higher out-of-pocket costs.

No No Open

Choice®_PPO

Aetna Indemnity

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.

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Administrative Fees

Fee description Fee

HSA Initial set-up $0 Monthly fees $0 POP* Initial set-up $175 Renewal $100

HRA and FSA** Initial set-up 2–25 employees $350 26–50 employees $450 51–100 employees $550 Renewal fee 1–25 employees $225 26–50 employees $275 51–100 employees $325

Monthly fees*** $5.25 per participant

Additional set-up fee for “stacked” plans (those electing an Aetna HRA

and FSA simultaneously)

$150

Participation fee for “stacked” participants $10.25 per participant Minimum fees

1–25 employees $25 per month minimum

26–100 employees $50 per month minimum

TRA

Annual fee $350

Transit monthly fees $4.25 per participant

Parking monthly fees $3.15 per participant

COBRA Annual fee

20–50 employees $100

51–100 employees $175

Per employee per month

20 – 50 employees $0.88

51 – 100 employees $1.02

Initial notice fee $1.50 per notice

(includes notices at time of implementation and during ongoing administration)

Monthly fee $0.88 per employee

Aetna High-Deductible HSA-Compatible Health

Network Option (Open Access)/PPO plans

Aetna high-deductible HSA-compatible health network option (open access) 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 exempt 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 help cover their future medical and dental expenses. HSAs 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.

Group situs

Medical and dental benefits and rates are based on the group’s headquarters location, subject to applicable state 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 headquarters location.

Multi-State Solution

We offer a multi-state solution to make it easier for businesses like yours to do business with us. We believe it brings more consistency across medical benefits offerings to employers with employees in multiple locations.

Employers based in Pennsylvania can offer PA PPO plans to their employees who live and work outside of the “situs” region. The situs region comprises the following eight states - CT, DC, DE, MD, NJ, NY, PA and VA.

The rates and benefits will match those offered in Pennsylvania. If the out-of-situs employee lives in a non-network area, the employee will be enrolled in an indemnity plan. Plan sponsors will need to continue to meet underwriting guidelines, subject to all applicable state laws.

In all instances, extraterritorial benefits that may apply on any of the out-of-situs employees will be implemented where required.

* Non-discrimination testing provided annually after open enrollment for POP and FSA only. Additional off-cycle testing available at employer request for $100 fee. Non-discrimination 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.

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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.

Member’s HSA plan

HSA Advantages • 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 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.

COBRA administration

Aetna COBRA administration offers a full range of notification, documentation and record-keeping processes that can help employers manage the complex billing and notification processes required for COBRA compliance, while also helping to save them 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.

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)

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Traditional - POS Plan Options

Plan Options PA POS 1.7 CY (10/0A)+_* _{PA POS 2.7 CY (10/500A)}+_*

# Member Benefits In-network Out-of-network1 _In-network _{Out-of-network}1

PCP coordinated No-referral needed PCP coordinated No-referral needed

1 Benefit/Plan Administration Calendar year Calendar year Calendar year Calendar year

2 Member Coinsurance N/A 20% after ded N/A 20% after ded

3 Calendar Year Deductible2 _N/A _{$1,000 per member}

$3,000 family N/A $1,000 per member $3,000 family 4 Calendar Year Out-of-Pocket Maximum3 _{$3,000 per member}

$6,000 family $5,000 per member $15,000 family $3,000 per member $6,000 family $5,000 per member $15,000 family

5 Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited

6 Preventive Care

7 Well-Baby/Child/Adult Physical Exams (Age and frequency schedules apply. In-network and out-of-network combined)

$0 copay 20%, ded waived $0 copay 20%, ded waived

8 Routine Gyn Exams (One exam and pap smear per 365 days. In-network and out-of-network combined))

9 Routine Mammograms (One annual mammogram for females age 40 and over. In-network and out-of-network combined)

$0 copay 20% after ded $0 copay 20% after ded

10 Routine Eye Exam (One exam per 24 months.

In-network and out-of-network combined) $0 copay 20% after ded $0 copay 20% after ded

11 Glasses and Contact Lens Reimbursement $100/24-month period. In-network and out-of-network combined.

12 Aetna VisionSM_{Discount Program} _Included _{Not covered} _Included _{Not covered}

13 Primary Physician Office Visit $10 copay 20% after ded $10 copay 20% after ded

14 Specialist Office Visit $20 copay 20% after ded $20 copay 20% after ded

15 Outpatient Services - Lab / X-ray $0 copay / $20 copay 20% after ded $0 copay / $20 copay 20% after ded 16 Outpatient Complex Imaging (MRA/MRS, MRI,

PET and CAT scans) $200 copay 20% after ded $200 copay 20% after ded

17 Chiropractic Services (20 visits per calendar year.

18 Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per calendar year. In-network and out-of-network combined)

19 Outpatient Speech Therapy (30 visits per calendar

year. In-network and out-of-network combined) $20 copay 20% after ded $20 copay 20% after ded

20 Durable Medical Equipment ($2,500 calendar year

maximum. In-network and out-of-network combined) 50% 50% after ded 50% 50% after ded

21 Inpatient Hospital $0 copay per admission 20% after ded $500 copay per

admission

20% after ded

22 Outpatient Surgery $0 copay 20% after ded $500 copay 20% after ded

23 Emergency Room (Copay waived if admitted) $100 copay $100 copay, ded waived $150 copay $150 copay, ded waived

24 Urgent Care $50 copay 20% after ded $50 copay 20% after ded

25 Prescription Drugs◊_{(Includes 90-day transition of coverage (TOC) for prior authorization and step-therapy}4₎

26 Prescription Drugs: 30-day supply5 _{Option 1: $10/$25/$50}

Option 2: $10/$35/$60 Option 3: $15/$45/$75

Not covered Option 1: $10/$25/$50 Option 2: $10/$35/$60 Option 3: $15/$45/$75

Not covered

27 Prescription Drugs: 31- to 90-day supply5 _{Option 1: $20/$50/$100}

Option 2: $20/$70/$120 Option 3: $30/$90/$150

Not covered

28 Aetna Specialty CareRxSM_{Drugs: 30-day supply} _{$250 copay} _{Not covered} _{$250 copay} _{Not covered}

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Traditional - POS Plan Options

Plan Options PA POS 3.7 CY (15/200D)+_* _{PA POS 4.7 CY (20/300D)}+_*

8 Routine Gyn Exams (One exam and pap smear per 365 days. In-network and out-of-network combined)

21 Inpatient Hospital $200 copay per day,

5-day copay max per admission

30% after ded $300 copay per day, 5-day copay max per admission

50% after ded

Option 2: $10/$35/$60 Option 3: $15/$45/$75

Not covered

Option 2: $20/$70/$120 Option 3: $30/$90/$150

Not covered

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Traditional - POS Plan Options

Plan Options PA POS 5.7 CY (30/400D)+_* _{PA POS 6.7 CY (40/500D)}+_*

8 Routine Gyn Exams (One exam and pap smear per 365 days. In-network and out-of-network combined)

21 Inpatient Hospital $400 copay per day,

5-day copay max per admission

50% after ded $500 copay per day, 5-day copay max per admission

50% after ded

Option 2: $10/$35/$60 Option 3: $15/$45/$75

Not covered

Option 2: $20/$70/$120 Option 3: $30/$90/$150

Not covered

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Traditional - POS Plan Options

Plan Options PA POS 7.7 CY (35/30%)+_*

# Member Benefits In-network Out-of-network1

PCP coordinated No-referral needed

1 Benefit/Plan Administration Calendar year Calendar year

2 Member Coinsurance N/A 50% after ded

$15,000 family 4 Calendar Year Out-of-Pocket Maximum3 _{$3,000 per member}

$6,000 family $10,000 per member $30,000 family

5 Lifetime Maximum Benefit Unlimited Unlimited

$0 copay 50%, ded waived

8 Routine Gyn Exams (One exam and pap smear per

365 days. In-network and out-of-network combined) $0 copay 50%, ded waived

$0 copay 50% after ded

10 Routine Eye Exam (One exam per 24 months. In-network and out-of-network combined)

12 Aetna VisionSM_{Discount Program} _Included _{Not covered}

13 Primary Physician Office Visit $35 copay 50% after ded

14 Specialist Office Visit $60 copay 50% after ded

15 Outpatient Services - Lab / X-ray $0 copay / $60 copay 50% after ded

16 Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans)

30% 50% after ded

17 Chiropractic Services (20 visits per calendar year. In-network and out-of-network combined)

19 Outpatient Speech Therapy (30 visits per calendar year. In-network and out-of-network combined)

20 Durable Medical Equipment ($2,500 calendar year maximum. In-network and out-of-network combined)

50% 50% after ded

21 Inpatient Hospital/Outpatient Surgery 30% 50% after ded

22 Emergency Room 30% 30%, ded waived

23 Urgent Care 30% 50% after ded

24 Prescription Drugs◊_{(Rx Options 1 and 2: 90-day transition of coverage (TOC) for prior authorization and step-therapy}4

Rx Option 3: 90-day transition of coverage (TOC) for prior authorization4₎

Option 2: $15/$45/$75

Option 3: $10 for Generic drugs. Brand-name drugs are not covered, but members may access Aetna’s negotiated discount at in-network pharmacies.

Not covered

Option 2: $30/$90/$150

Option 3: $20 for Generic drugs. Brand-name drugs are not covered, but members may access Aetna’s negotiated discount at in-network pharmacies.

Not covered

27 Aetna Specialty CareRxSM_{Drugs: 30-day supply} _{$250 copay} _{Not covered}

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Cost-Sharing - POS Cost-Sharing Plan Options

Plan Options PA POS CS 1.7 CY (500 Ded)+_* _{PA POS CS NR 1.7 PY (500 Ded)}+_*6

PCP coordinated No-referral needed No-referral needed No-referral needed

1 Benefit/Plan Administration Calendar year Calendar year Plan year Plan Year

3 Benefit Year Deductible2 _{$500 per member}

$1,000 family $5,000 per member $10,000 family $500 per member $1,000 family $5,000 per member $10,000 family 4 Benefit Year Out-of-Pocket Maximum3 _{$3,000 per member}

$0 copay, ded waived 50%, ded waived $0 copay, ded waived 50%, ded waived

365 days. In-network and out-of-network combined) $0 copay, ded waived 50%, ded waived $0 copay, ded waived 50%, ded waived 9 Routine Mammograms (One mammogram for

females age 40 and over per benefit year. In-network and out-of-network combined)

$0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded

$0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded 11 Glasses and Contact Lens Reimbursement $100/24-month period. In-network and out-of-network combined.

13 Primary Physician Office Visit $20 copay, ded waived 50% after ded $20 copay, ded waived 50% after ded

14 Specialist Office Visit $40 copay, ded waived 50% after ded $40 copay, ded waived 50% after ded

15 Outpatient Services - Lab $0 copay, ded waived 50% after ded $0 copay, ded waived 50% after ded

16 Outpatient Services - X-ray $40 copay, ded waived 50% after ded $40 copay, ded waived 50% after ded 17 Outpatient Complex Imaging

(MRA/MRS, MRI, PET and CAT scans) $200 copay, ded waived 50% after ded $200 copay, ded waived 50% after ded 18 Chiropractic Services (20 visits per benefit year.

In-network and out-of-network combined) $10 copay, ded waived 25% after ded $10 copay, ded waived 25% after ded 19 Outpatient Physical/Occupational Therapy

(Physical and occupational therapy combined, 30 visits per benefit year. In-network and out-of-network combined)

20 Outpatient Speech Therapy (30 visits per benefit year.

In-network and out-of-network combined) $40 copay, ded waived 50% after ded $40 copay, ded waived 50% after ded 21 Durable Medical Equipment ($2,500 benefit year

maximum. In-network and out-of-network combined)

50%, ded waived 50% after ded 50%, ded waived 50% after ded

22 Inpatient Hospital $0 copay per admission

after ded

50% after ded $0 copay per admission after ded

50% after ded

23 Outpatient Surgery $0 copay after ded 50% after ded $0 copay after ded 50% after ded

24 Emergency Room (Copay waived if admitted) $200 copay, ded waived $200 copay, ded waived $150 copay, ded waived $150 copay, ded waived

25 Urgent Care $50 copay, ded waived 50% after ded $50 copay, ded waived 50% after ded

Option 2: $10/$35/$60 Option 3: $15/$45/$75

Not covered

Option 2: $20/$70/$120 Option 3: $30/$90/$150

Not covered

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Cost-Sharing - POS Cost-Sharing Plan Options

1 Benefit/Plan Administration Calendar year Calendar year Plan year Plan year

3 Benefit Year Deductible2 _{$1,000 per member}

$2,000 family $5,000 per member $10,000 family $1,000 per member $2,000 family $5,000 per member $10,000 family 4 Benefit Year Out-of-Pocket Maximum3 _{$3,000 per member}

after ded

50% after ded

Option 2: $10/$35/$60 Option 3: $15/$45/$75

Not covered

Option 2: $20/$70/$120 Option 3: $30/$90/$150

Not covered

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Cost-Sharing - POS Cost-Sharing Plan Options

after ded

50% after ded

Option 2: $10/$35/$60 Option 3: $15/$45/$75

Not covered

Option 2: $20/$70/$120 Option 3: $30/$90/$150

Not covered

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Cost-Sharing - POS Cost-Sharing Plan Options

after ded

50% after ded

Option 2: $10/$35/$60 Option 3: $15/$45/$75

Not covered

Option 2: $20/$70/$120 Option 3: $30/$90/$150

Not covered

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Cost-Sharing - POS Cost-Sharing Plan Options

1 Benefit/Plan Administration Calendar year Calendar Year Plan year Plan year

after ded

50% after ded

Option 2: $10/$35/$60 Option 3: $15/$45/$75

Not covered

Option 2: $20/$70/$120 Option 3: $30/$90/$150

Not covered

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Cost-Sharing - POS Cost-Sharing Plan Options

after ded

50% after ded

Option 2: $10/$35/$60 Option 3: $15/$45/$75

Not covered

Option 2: $20/$70/$120 Option 3: $30/$90/$150

Not covered

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Cost-Sharing - POS Cost-Sharing Plan Options

after ded

50% after ded

Option 2: $10/$35/$60 Option 3: $15/$45/$75

Not covered

Option 2: $20/$70/$120 Option 3: $30/$90/$150

Not covered

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Consumer-Directed - POS HSA-Compatible Plan Options

Plan Options PA POS HSA Comp NR 1.7 PY (1500 Ded)+6 PA POS HSA Comp NR 2.7 PY _{(2500 Ded)}+6

No-referral needed No-referral needed No-referral needed No-referral needed

1 Benefit/Plan Administration Plan year Plan year Plan year Plan year

2 Member Coinsurance 10% after ded 50% after ded 10% after ded 50% after ded

3 Plan Year Deductible2 _{$1,500 individual}

$3,000 family $5,000 individual $10,000 family $2,500 individual $5,000 family $5,000 individual $10,000 family 4 Plan Year Out-of-Pocket Maximum3 _{$3,000 individual}

$6,000 family $10,000 individual $20,000 family $5,000 individual $10,000 family $10,000 individual $20,000 family

0%, ded waived 0%, ded waived 0%, ded waived 0%, ded waived

365 days. In-network and out-of-network combined) 0%, ded waived 0%, ded waived 0%, ded waived 0%, ded waived 9 Routine Mammograms (One mammogram per

plan year for females age 40 and over. In-network and out-of-network combined)

13 Primary Physician Office Visit 10% after ded 50% after ded 10% after ded 50% after ded

14 Specialist Office Visit 10% after ded 50% after ded 10% after ded 50% after ded

15 Outpatient Services - Lab / X-ray 10% after ded 50% after ded 10% after ded 50% after ded

16 Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT scans)

10% after ded 50% after ded 10% after ded 50% after ded

17 Chiropractic Services (20 visits per plan year. In-network and out-of-network combined)

18 Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per plan year. In-network and out-of-network combined)

19 Outpatient Speech Therapy (30 visits per plan year. In-network and out-of-network combined)

20 Durable Medical Equipment ($2,500 plan year maximum. In-network and out-of-network combined)

21 Inpatient Hospital 10% after ded 50% after ded 10% after ded 50% after ded

22 Outpatient Surgery 10% after ded 50% after ded 10% after ded 50% after ded

23 Emergency Room 10% after ded 10% after ded 10% after ded 10% after ded

24 Urgent Care 10% after ded 50% after ded 10% after ded 50% after ded

25 Prescription Drugs◊_{(Includes 90-day transition of coverage (TOC) for prior authorization}4₎

26 Prescription Drugs: 30-day supply5 _{$15/$45/$75 after ded} _{Not covered} _{$15/$45/$75 after ded} _{Not covered}

27 Prescription Drugs: 31- to 90-day supply5 _{$30/$90/$150 after ded Not covered} _{$30/$90/$150 after ded Not covered}