Colorado plan guide

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Financial well-being Intelligent solutions XX.XX.XXX.X (X/14)

www.aetna.com

Financial well-being Intelligent solutions

Colorado plan guide

Creating the right health benefits package

starts with you and your employees

www.aetna.com

Plans effective January 1, 2015

For businesses with 51 – 100 eligible employees

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Health/dental benefits and health/dental insurance plans are offered and/or underwritten by Aetna Health Inc. and/or Aetna Life Insurance Company (Aetna). Each insurer has sole financial responsibility for its own products.

Choosing the right health plan

Every company has its own particular needs, driven in part

by the health of its employees, by its commitment to health

and wellness and, of course, by its financial resources.

We believe creating the right health benefits and

insurance plan means combining these four options

to meet a company’s specific needs:

benefits,

network, cost sharing, funding.

Experience matters

We take the time to listen and learn about your needs. Our

experience allows us to share knowledge and provide tools

to help achieve the right balance of cost and coverage.

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M

D

V

L&D

U

So we’ve organized information in this easy-to-understand guide.

Health care reform

4 Plans, tools and extras

5 – 6

Network options, cost sharing and premiums

7 Health and wellness programs

8 Medical plans overview

9 Medical plan options

12 Aetna Whole Health

SM

_{-Colorado Front Range}

₁₄

Aetna Health NetworkOnly

SM

_(HNOnly)

₁₈

Aetna Open Access Managed Choice

®

_{(OAMC) plans}

₁₉

OAMC Health Savings Account (HSA) plans

26 Preferred Provider Organization (PPO) and Indemnity plans

30 Dental plans overview

32 Aetna standard and voluntary

small group dental plans 10 – 100

34 Vision plans overview

38 Aetna Vision Preferred

40 Life and Disability plans overview

43 Life: 51 – 100 Simplified Expanded plans

46 Short Term Disability: 51 – 100 Simplified Expanded plans

47 Long Term Disability: 51 – 100 Simplified Expanded plans

48 Underwriting guidelines

49 Limitations and exclusions

59

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*Prescription drugs may have a separate out-of-pocket maximum. **Note: no standalone insured behavioral health.

Signed into law in March 2010, the Affordable Care Act is the most life-changing law since the passing of Medicare in the 1960s. We are committed to following the new health care law and to helping you understand its impact.

We have outlined below key changes that may impact your health care benefits.

Essential health benefits package

Aetna plans must offer standard coverage known as “essential health benefits.” This includes all plans inside and outside of the health insurance exchanges. These benefits provide your employees with essential health benefits, and limit cost sharing.

Here are the broad categories of essential benefits that will be included in your employees’ coverage:

• Ambulatory patient services • Emergency services

• Hospitalization

• Maternity and newborn care

• Mental health and substance abuse services • Prescription drugs

• Rehabilitative and habilitative services and devices • Laboratory services

• Preventive and wellness services and chronic disease management

• Pediatric dental • Pediatric vision

Out-of-pocket (OOP) maximum mandate All cost sharing must apply toward the OOP maximum*, including in-network medical, behavioral health and pharmacy cost sharing. This does not include premiums, balances above recognized charges that non-network providers may charge, or spending for non-covered services. The out-of-pocket maximum must include:

• Copays • Deductibles • Coinsurance

Fees

These fees are included in your premium:

• Health Insurer Fee — Annual fee to offset premium

subsidies and tax credit related expenses

• Transitional Reinsurance Program Contribution —

Helps finance the cost of high-risk individuals in the individual market

• Patient-Centered Outcomes Research Fee (also known as the Comparative Effectiveness Fee) — Fee to fund

clinical outcomes effectiveness research Guaranteed issue

Guaranteed issue of health insurance coverage applies to individual, small group and large group markets. Guaranteed issue is available for:

• Group Health Plans/Insurance Coverage (insured only) • Individual Health Insurance Coverage

(including medical conversion) • Pharmacy (insured only)

• Behavioral Health (insured only)**

Please note that guaranteed issue is not available for: • Self-funded plans

• Standalone/separate dental or vision • Hospital indemnity/fixed indemnity • Medicare and Medicare Supplement • Medicaid

• Retiree-only plans • Grandfathered plans • Association/MEWA plans Waiting period

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* Estimated costs not available in all markets. The tool gives you an estimate of what you would owe for a particular service based on your plan at that very point in time. Actual costs may differ from the estimate if, for example, claims for other services are processed after you get your estimate but before the claim for this service is submitted. Or, if the doctor or facility performs a different service at the time of your visit.

** In 2011, members who used Member Payment Estimator before receiving care saved an average of $170 out of pocket on 34 common procedures, according to the Member Payment Estimator Study, Aetna Informatics and Product Development, August 2012.

Our product portfolio includes a range of coverage and cost combinations. You’ll find choices for different budgets and benefits strategies. And you’ll see that we’re more than medical. You can round out your benefits offering with dental and vision, as well as life and disability offerings.

Take a look at what’s available. Medical plans

• Aetna Whole HealthSM_(AWH)

• Health Network OnlySM_(HNOnly)

• Aetna Open Access®_{Managed Choice}®_{(OAMC) plans}

• Health savings account (HSA) compatible plans

Tools to help your employees stay healthy, informed and productive

With Aetna health plans, your employees get online tools and helpful resources that let them make the most of their benefits. Our most popular tools include:

• Secure member website. Your employees get self-service

tools, plus health plan and health information through their Aetna Navigator®_{website. Think of it as the key that unlocks}

the full value of their health benefits package. Encourage them to sign up at www.aetna.com.

• Member Payment Estimator. With an Aetna health plan,

your employees can compare and estimate costs* for office visits, tests, surgeries and more. This means they can save money** — and avoid surprises. This online tool factors in their deductible, coinsurance and copays, plus contracted rates. They can see how much they have to pay and how much the plan will pay. They can log in to their Aetna Navigator member website to use the tool.

• Online provider directory. Finding doctors, specialists,

hospitals and more in the Aetna network is easy with our DocFind®_{directory. It’s available at}_{www.aetna.com and}

the Aetna Navigator member website.

• My Life Values. Your employees get 24/7 online services

and support for managing their everyday personal and work matters.

• iTriage. This is a free mobile app that lets members research

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*For groups 51 to 100, please consult your sales representative for a plan design to meet your group needs. • Dental Maintenance Organization (DMO )

• Preferred Provider Organization (PPO) • Freedom-of-Choice (FOC) plan design option Dental plan extras

There’s extra value built into our dental portfolio:

• Dental-medical integration. Our program encourages

preventive dental care among employees who have diabetes or heart disease, or who are pregnant. This can lead to more of your employees taking steps to stay healthy.

Vision plans

• Aetna VisionSM_{Preferred Plans}

Vision plan extras

• Choice and convenience and flexibility. Members have

the choice to go to any vision provider. Plus, for added convenience, members can easily schedule an eye exam online with some participating providers. Our plans help members fit vision care in to their lifestyle and our bundled plan options provide the administrative ease of having one bill, one renewal and one trusted company to work for you. • The value of a balanced network. We offer a balanced

network of independent eye care providers as well as in-network retail providers that include five of the six most preferred national optical retail chains offering flexible evening and weekend hours.

• Discounts. Aetna Vision Preferred plan offers additional

savings on contact lenses, eyeglasses, prescription sunglasses, LASIK vision correction and more at most in-network locations. Availability varies by state.

• Basic life

• Supplemental life • AD&D Ultra®

• Supplemental AD&D Ultra®

• Dependent life • Short-term disability • Long-term disability

Life and disability plan extras

• Aetna Life EssentialsSM_{. Through our program, your}

employees get access to expert advice on legal and financial matters — at no added cost. Plus, they get discounts on health products and services, like fitness and vision care.* • Funeral planning and concierge service. Through

our collaboration with Everest, we offer our life members pre-planning and at-need services.

• Aetna Return to Work SolutionsSM_{Program. Our return}

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to fit your needs.

About our benefits

Choose from numerous, integrated benefits options that can lead to improved employee engagement and health, while helping you manage your costs. This includes medical, pharmacy, dental, life, disability and vision. Plus, online tools that help employees use their benefits wisely and get help when they need it.

About our cost sharing

Some of our cost-sharing arrangements encourage

employees to become more involved in their own health care and become better health care consumers. Employees with these plans receive more preventive care, have lower overall costs and use online tools more frequently.

Cost sharing and premiums for every budget Your focus is on lower costs. Increasingly, that means greater levels of employee cost sharing. With Aetna in your corner, you can map out a strategy based on your employee population and price point. And you can choose from the full spectrum of health plan types:

• Our fully insured portfolio, traditionally a mainstay for small businesses, provides plans with a range of robust coverage options.

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* While only your doctor can diagnose, prescribe or give medical advice, the Informed Health Line nurses can provide information on more than 5,000 health topics. Contact your doctor first with any questions or concerns regarding your health care needs. Having a happier, healthier workforce is important to you.

So is cost management. We’ve found that helping your employees get more involved in managing their health and well-being is a great way to meet these goals. Talk to your broker or Aetna representative to learn more about our programs.

Wellness on us

Wellness for employees means a healthier business for employers. As always, our health benefits and insurance plans offer $0 copays for in-network eye exams and $0 copay for in-network preventive care. It’s one more way to help employees get a step closer to better health.

Preventive care benefits with no copay:

• Immunizations • Routine physicals • Child wellness visits • Routine mammogram • Routine OB/GYN visits

No cost health incentive credit

• Step 1: Complete or update a health assessment by visiting the Aetna Navigator member website. • Step 2: Complete one online health program

consultation. Earn the incentive once the program

consultation is submitted. This thorough but easy consultation helps to create a personalized program plan. Members then receive their program plan, along with all the tools, resources and tips to get them on their way to better health.

• Step 3: Take action and get rewarded. The incentive will

be put into an account, and will be applied to the next claim that has deductible or coinsurance owed by the member.

Wellness programs can make health and fitness part of everyday living

• Women’s health and preventive health reminders • Simple Steps To A Healthier Life®_program

• Informed Health®_{24-hour nurse line*}

• Aetna discount programs • Personal health record

These services are generally 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, certain brand formulary contraceptives are covered without member copayment; certain religious organizations or religious employers may be exempt from offering contraceptive services

We make things easy for you

Health plan management and administration is our specialty, which makes it easier for you to manage health insurance benefits with:

• eEnrollment. Handle enrollments, terminations and other

changes online, with less paperwork and greater efficiency. • eBilling. Save time and simplify reconciliation and payment,

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Aetna medical overview

Medical coverage can be a deal-breaker

in recruiting and keeping talented

employees. Our medical plan portfolio

was designed with the needs of

businesses like yours in mind. You’ll

find flexible options, from traditional

indemnity to consumer-directed plans.

You can choose the plan design and

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Colorado provider networks*

Aetna Whole Health – Colorado Front Range ** = 6,766 doctors and 37 hospitals HNOnly network = 10,201 doctors and 59 hospitals

Aetna Open Access®_{Managed Choice}®_{= 12,993 doctors and 88 hospitals}

County AWH OAMC HNOnly

Adams • • • Alamosa • Arapahoe • • • Archuleta • Baca • Bent • Boulder • • • Broomfield • • • Chaffee • Cheyenne • Clear Creek • Conejos • Costilla • Crowley • Custer • Delta • Denver • • • Dolores • Douglas • • • Eagle • El Paso • • • Elbert • •

Fremont • • Garfield • Gilpin • Grand • Gunnison • Hinsdale • Huerfano • Jackson • Jefferson • • • Kiowa • Kit Carson • La Plata • Lake • Larimer • • • Las Animas • Lincoln • Logan • Mesa • • Mineral • Moffat • Montezuma • Montrose •

Morgan • Otero • Ouray • Park • Phillips • Pitkin • Prowers • Pueblo • • Rio Blanco • Rio Grande • Routt • Saguache • San Juan • San Miguel • Sedgwick • Summit • Teller • • • Washington • Weld • • • Yuma •

*According to the Aetna Enterprise Provider Database as of May 2015. Network subject to change.

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Plan type and value by price*

Plan name $ $$ $$$ OAMC HDHP $5,000 80/50 OAMC HDHP $5,000 100/50 OAMC HDHP $3,500 80/50 OAMC HDHP $4,000 100/50 OAMC HDHP $2,500 80/50 OAMC HDHP $3,000 100/50 OAMC $5,000 70/50 OAMC $3,500 80/50 OAMC HDHP $2,500 100/50 OAMC $3,000 70/50 OAMC $2,500 80/50 OAMC $4,000 100/50 OAMC $2,000 80/50 OAMC $3,500 100/50 OAMC $1,500 80/50 OAMC $3,000 100/50 OAHNO $1,000 70% $35 OAMC $1,000 80/50 OAMC $1,500 90/50 OAMC $1,000 90/50 OAMC $750 80/50 OAMC $500 80/50 OAHNO $500 90% $25

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Medical

overview

We offer the in-state portfolio (OAMC) and rating structure to out-of-state employees who live in an out-of-state network area. Out-of-state employees who do not live in an out-of-state network area will be eligible for an indemnity plan.

Product

name Product description PCP required Referrals required Plan name

Aetna Whole Health – Colorado Front Range

The Aetna Whole Health plans provide Colorado members with the same types of coverage as other Aetna medical plans, but with the advantage of a lower premium cost and a greater level of care coordination. Savings are generated through the use of the Aetna Whole Health network, a specially selected network of high-performing, high-quality local health care providers that are dedicated to delivering a coordinated patient experience. Members are strongly encouraged to designate a primary care physician who will help guide important health decisions and direct care across other specialties and facilities in the network. See pages 14-17 for more detail.

Encouraged, not required No Aetna Whole Health – Colorado Front Range Health Network Only (Open Access) or Open Access Managed Choice Health Network Only (HNOnly)

HNOnly is a health maintenance organization (HMO) that uses a network of participating providers. Each family member is encouraged but not required to select a primary care physician (PCP) participating in the Aetna network to provide routine and preventive care and help coordinate the member’s total health care. Members never need a referral when visiting a participating specialist for covered services. Only services rendered by a participating provider are covered, except for emergency or urgently needed care.

No No Aetna Health Network Only (Open Access) Aetna Open Access® Managed Choice® (OAMC)

Members can access any participating provider for covered services without a referral. Members have the freedom to choose network providers at lower out-of-pocket costs or non-network providers at higher out-of-pocket costs at any time. Members can receive emergency services at the in-network coinsurance/copay level.

No No Aetna Open Access Managed Choice

Out-of-state/Out-of-area plans

Product

name Product description PCP required Referrals required Plan name

PPO Members can access any participating provider for covered services without a referral. Members have the freedom to choose network providers at lower out-of-pocket costs or non-network providers at higher out-of-pocket costs at any time. Members can receive emergency services at the in-network coinsurance/copay level.

No No Open

Choice®_PPO

Indemnity Employees who live outside the plan’s network service area are eligible. Members coordinate their own health care and may access any licensed provider for covered services without a referral.

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Open Access Managed Choice plans

Aetna high-deductible Open Access Managed Choice 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 you and your 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. HSA accounts can be funded by you or your employees 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. Your or your employees can decide whether or not to establish an HSA.

Note: Employers and employees should consult with their tax advisor to determine eligibility requirements and tax advantages for participation in the HSA plan.

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, you and/or your employees can contribute to the account. The HSA can be used to pay for qualified expenses tax free.

Member’s HSA Plan HSA Account

• The member owns the HSA • Contribute tax free

• Members choose how and when to use HSA dollars • They can roll it over each year and let it grow • Earns interest, tax free

Today and into the future

• Use now for qualified expenses with tax-free dollars • Save for future and retiree health-related costs

High-deductible health plan

• Eligible in-network preventive care services will not be subject to the deductible

• Member pays 100 percent until deductible is met, then only pay a share of the cost

• Meet out-of-pocket maximum, then plan pays 100 percent

Aetna COBRA administration offers a full range of notification, documentation and record-keeping processes that can help you manage the complex billing and notification processes 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, while you 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 are waived with the purchase of medical with five or more 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)

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* Employers and employee must reside in an eligible area. Live/work rules apply. Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, El Paso, Jefferson, Larimer, Teller and Weld counties.

Actual results may vary since they depend on a variety of factors including Aetna Whole Health plan model.

Aetna Whole Health

plans in the Colorado Front Range*

We’re proud to offer new Aetna Whole Health plans in the Colorado Front Range.

Our Aetna Whole Health plans feature high-performing Colorado health care organizations that have teamed up with us to help improve care while decreasing cost for you and your covered employees.

The Aetna Whole Health – Colorado Front Range network features doctors and facilities from: • Banner Network Colorado

• Colorado Health Neighborhoods • Colorado Innovative Physician Solutions • New West Physicians

• Physician Health Partners

These providers have the skill, experience and compassion to help improve care, while decreasing costs for members and employers.

Key ingredients make the difference — we’ve designed Aetna Whole Health to:

• Reward doctors for improving patient care quality • Lower medical cost growth over time by reducing waste,

improving care coordination and closing care gaps • Enhance each patient’s experience with innovative care

management programs

• Support effective patient and primary care doctor relationships

Accountable care up close — better health, better care, better cost

That’s what the Aetna Whole Health product with our ACOs is designed for. It’s a member-centered approach that may differ from care your employees have had before.

Our locally based accountable care model centers on the relationship between the primary care doctor and the patient. Through that, we strive to reach members where, when and how they live. And improve the quality, efficiency and affordability of their health care.

We strongly encourage members to designate a primary care doctor to lead their ACO care team and unlock the full benefits of this coordinated-care model.

Why it matters: Every team needs a leader. And the primary

care doctor your employees pick will lead their Aetna Whole Health care team. Their doctor gets to know them and their medical history and sees them for their annual wellness exam and preventive screenings. So, if they get sick, their primary care doctor can treat them and help guide them on important health decisions, as well as direct their care across other specialties and facilities in the Aetna Whole Health – Colorado Front Range network.

• The ACO care team’s goal is to help keep your employees healthy or help improve their health, not just treat them when they’re sick or injured

• The ACO care team can better coordinate care, because we share data that allows them to see how other doctors are treating your employees, what medicine they’re taking, lab results, health history and more

• The ACO care team is up-to-date on medical guidelines and clinical information. This helps to spot problems early and develop personalized care plans for your employees • The ACO team wants your employees to take an active and

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Aetna Whole Health

–

Colorado Front Range network coverage area*

Primary care physicians

Urgent care facilities Hospitals

For illustrative purposes only.

* Network information and counts effective as of April 2015, and subject to change.

25 70 76 36 85 285 34 36 287

Weld

County

Adams

County

Arapahoe

County

Douglas

County

Jeﬀerson

County

Boulder

County

Denver

County

Larimer

County

Broomfield

County

Loveland Longmont Boulder Louisville Brighton Thornton Aurora Denver Westminster Wheat Ridge Lakewood Littleton Lone Tree Parker Castle Rock Highlands Ranch Lafayette Greeley Fort Collins Englewood

Finding an Aetna Whole Health – Colorado Front Range

network doctor is easy. Follow these simple steps:

• Visit www.aetna.com/docfind for the most up-to-date

information on doctors and facilities

• Type a name, specialty, procedure or condition in the “Who or what are you looking for?” box

• Enter your ZIP code or city and state in the “Where?” box • Choose (CO) Aetna Whole Health – Colorado Front Range

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Aetna Whole Health –

Colorado Front Range network hospitals

Always consult DocFind®_{for the most up-to-date information on doctors and facilities in the Aetna Whole Health – Colorado Front}

Range network. Network information and counts effective as of April 2015, and subject to change without notice.

Health benefits and health insurance plans are offered, underwritten and/or administered by Aetna Health Inc., Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). Each insurer has sole financial responsibility for its own products.

This material is for information only. Health benefits and health insurance plans contain exclusions and limitations. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health care services. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to www.aetna.com.

Adams County

Children’s Hospital Colorado North Suburban Medical Center Platte Valley Medical Center St. Anthony North Hospital University of Colorado Hospital

Arapahoe County

Littleton Adventist Hospital The Medical Center of Aurora – North Campus

The Medical Center of Aurora – South Campus

Swedish Medical Center

Boulder County

Avista Adventist Hospital Boulder Community Foothills Hospital

Boulder Community Hospital Good Samaritan Medical Center

Boulder County (cont’d)

Avista Adventist Hospital

Denver County

Children’s Hospital Colorado at Saint Joseph Hospital Denver Health Medical Center National Jewish Health Porter Adventist Hospital Presbyterian/St. Luke’s Medical Center

Rose Medical Center Saint Joseph Hospital

Douglas County

Castle Rock Adventist Hospital Children’s Hospital Colorado at Parker Adventist Hospital Children’s Hospital Colorado South Campus

Parker Adventist Hospital Sky Ridge Medical Center

El Paso County

Penrose Hospital

St. Francis Medical Center University of Colorado Health Memorial Hospital

University of Colorado Health Memorial Hospital North

Jefferson County

Lutheran Medical Center OrthoColorado Hospital at St. Anthony Medical Campus St. Anthony Hospital

St. Anthony North Health Campus

Larimer County

Banner Health’s McKee Medical Center

Banner Fort Collins Medical Center

Weld County

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* 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 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 reserves the right to change any of the above fees and to impose additional fees upon prior written notice.

Administrative fees

Fee description Fee

Premium-Only Plan (POP)

Initial set-up* $190

Renewal fee $125

Flexible Spending Account (FSA)**

Initial set-up Renewal fee

51 – 100 employees $560 $335

Monthly fees*** $5.45 per participant

Additional set-up fee

for “stacked” plans

(those electing an Aetna HRA and FSA simultaneously)

$150

Participation fee

for “stacked” participants $10.45 per participant

Minimum fees

26 – 100 employees $50 per month minimum

COBRA Services Annual fee

51 – 100 employees $230

Per employee per month

51 – 100 employees $1.05

Initial notice fee $3.00 per notice (includes notices at time of implementation and during ongoing administration)

Minimum fees

51 – 100 employees $50 per month minimum

Transit Reimbursement Account (TRA) Annual fee $350

Transit monthly fees $4.25 per participant

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Refer to page 31 for footnotes.

HNOnly plans

Plan name CO HNOnly 500 90% CO HNOnly 1000 70%

Networks available HNOnly, Aetna Whole Health –

Colorado Front Range HNOnly, Aetna Whole Health – Colorado Front Range

Member benefits Network care Network care

Calendar year deductible $500/$1,000 $1,000/$2,000

Calendar year out-of-pocket limit $4,000/$8,000 $5,000/$10,000

Deductible & out-of-pocket limit accumulation Embedded Embedded

Primary care physician office visit $25 copay; deductible waived $35 copay; deductible waived

Specialist office visit $50 copay; deductible waived $60 copay; deductible waived

Walk-in clinics $25 copay; deductible waived $35 copay; deductible waived

Diagnostic testing: Lab Covered in full; deductible waived Covered in full; deductible waived

Diagnostic testing: X-ray $50 copay; deductible waived $60 copay; deductible waived

Imaging (CT/PET scans MRIs) 10% after deductible 30% after deductible

Inpatient hospital facility 10% after deductible 30% after deductible

Outpatient surgery 10% after deductible 30% after deductible

Emergency room $150 copay; deductible waived $150 copay; deductible waived

Urgent care $75 copay; deductible waived $75 copay; deductible waived

Rehabilitation services (PT/OT/ST)

Coverage is limited to 40 combined visits per calendar year for PT/OT/ST, rehabilitation and habilitation visits are combined

$50 copay; deductible waived $60 copay; deductible waived

Chiropractic

Coverage is limited to 20 visits per calendar year $50 copay; deductible waived $60 copay; deductible waived

Pharmacy* Network Network

Pharmacy deductible None None

Preferred generic drugs** $10 copay $15 copay

Preferred brand drugs $30 copay $35 copay

Nonpreferred drugs*** $50 copay $60 copay

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OAMC plans

Plan name CO OAMC 3000 70/50 CO OAMC 5000 70/50

Networks available Open Access Managed Choice, Aetna Whole Health – Colorado Front Range

N/A Open Access Managed Choice, Aetna Whole Health – Colorado Front Range

N/A

Member benefits Network care Out-of-network care†† Network care Out-of-network care††

Calendar year deductible $3,000/$6,000 $6,000/$12,000 $5,000/$10,000 $7,500/$15,000

Calendar year out-of-pocket limit $6,000/$12,000 $12,000/$24,000 $6,350/$12,700 $12,500/$25,000

Deductible & out-of-pocket limit accumulation1 Embedded Embedded

Primary care physician office visit $30 copay; deductible waived

50% after deductible $30 copay; deductible waived

50% after deductible

Specialist office visit $60 copay; deductible waived

Walk-in clinics $30 copay; deductible

waived Not covered $30 copay; deductible waived Not covered

Diagnostic testing: Lab $30 copay; deductible

waived 50% after deductible $30 copay; deductible waived 50% after deductible

Diagnostic testing: X-ray $60 copay; deductible

Imaging (CT/PET scans MRIs) $300 copay; deductible

Inpatient hospital facility 30% after deductible 50% after deductible 30% after deductible 50% after deductible

Outpatient surgery 30% after deductible 50% after deductible 30% after deductible 50% after deductible

Emergency room (copay waived if admitted) $250 copay; deductible

waived Paid as network care $250 copay; deductible waived Paid as network care

Urgent care $75 copay; deductible waived

Rehabilitation services (PT/OT/ST)2

$60 copay; deductible waived

Chiropractic2

Coverage is limited to 20 visits per calendar year

Pharmacy* Network Out of network Network Out of network

Pharmacy deductible None N/A None N/A

Preferred generic drugs** $20 copay Not covered $20 copay Not covered

Preferred brand drugs $40 copay Not covered $40 copay Not covered

Nonpreferred drugs*** $70 copay Not covered $70 copay Not covered

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OAMC plans

N/A

Calendar year deductible $500/$1,000 $1,000/$2,000 $750/$1,500 $1,500/$3,000

Chiropractic2

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OAMC plans

N/A

Chiropractic2

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OAMC plans

N/A

Chiropractic2

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OAMC plans

N/A

Chiropractic2

(24)

OAMC plans

N/A

Inpatient hospital facility 10% after deductible 50% after deductible Covered in full after

deductible 50% after deductible

Outpatient surgery 10% after deductible 50% after deductible Covered in full after

Chiropractic2

(25)

OAMC plans

N/A

Inpatient hospital facility Covered in full after

deductible 50% after deductible Covered in full after deductible 50% after deductible

Outpatient surgery Covered in full after

Chiropractic2

(26)

OAMC HSA plans

Plan name CO OAMC 2600 80/50 HSA CO OAMC 3500 80/50 HSA

N/A

Primary care physician office visit 20% after deductible 50% after deductible 20% after deductible 50% after deductible

Specialist office visit 20% after deductible 50% after deductible 20% after deductible 50% after deductible

Walk-in clinics 20% after deductible Not covered 20% after deductible Not covered

Diagnostic testing: Lab 20% after deductible 50% after deductible 20% after deductible 50% after deductible

Diagnostic testing: X-ray 20% after deductible 50% after deductible 20% after deductible 50% after deductible

Imaging (CT/PET scans MRIs) 20% after deductible 50% after deductible 20% after deductible 50% after deductible

Emergency room 20% after deductible Paid as network care 20% after deductible Paid as network care

Urgent care 20% after deductible 50% after deductible 20% after deductible 50% after deductible

20% after deductible 50% after deductible 20% after deductible 50% after deductible

Chiropractic2

20% after deductible 50% after deductible 20% after deductible 50% after deductible

Pharmacy deductible Integrated with medical

deductible N/A Integrated with medical deductible N/A

Preferred generic drugs** $15 copay after

deductible Not covered $15 copay after deductible Not covered

Preferred brand drugs $35 copay after

Nonpreferred drugs*** $60 copay after

Specialty drugs† 20% up to $250 after deductible

Not covered 20% up to $250 after deductible

(27)

OAMC HSA plans

N/A

Primary care physician office visit 20% after deductible 50% after deductible Covered in full after deductible

Specialist office visit 20% after deductible 50% after deductible Covered in full after deductible

Walk-in clinics 20% after deductible Not covered Covered in full after

deductible Not covered

Diagnostic testing: Lab 20% after deductible 50% after deductible Covered in full after

Diagnostic testing: X-ray 20% after deductible 50% after deductible Covered in full after

Imaging (CT/PET scans MRIs) 20% after deductible 50% after deductible $300 copay after

Inpatient hospital facility 20% after deductible 50% after deductible Covered in full after

Outpatient surgery 20% after deductible 50% after deductible Covered in full after

Emergency room 20% after deductible Paid as network care Covered in full after

deductible Paid as network care

Urgent care 20% after deductible 50% after deductible Covered in full after deductible

20% after deductible 50% after deductible Covered in full after deductible

Chiropractic2

20% after deductible 50% after deductible Covered in full after deductible

(28)

OAMC HSA plans

N/A

Primary care physician office visit Covered in full after deductible

50% after deductible Covered in full after deductible

Specialist office visit Covered in full after deductible

Walk-in clinics Covered in full after

deductible Not covered Covered in full after deductible Not covered

Diagnostic testing: Lab Covered in full after

Diagnostic testing: X-ray Covered in full after

Imaging (CT/PET scans MRIs) $300 copay after

deductible 50% after deductible $300 copay after deductible 50% after deductible

Emergency room Covered in full after

deductible Paid as network care Covered in full after deductible Paid as network care

Urgent care Covered in full after deductible

Covered in full after deductible

Chiropractic2

(29)

OAMC HSA plans

Plan name CO OAMC 5000 100/50 HSA

N/A

Member benefits Network care Out-of-network care††

Calendar year deductible $5,000/$10,000 $10,000/$20,000

Calendar year out-of-pocket limit $6,000/$12,000 $12,000/$24,000

Deductible & out-of-pocket limit accumulation Embedded

Primary care physician office visit Covered in full after deductible

Specialist office visit Covered in full after deductible

Walk-in clinics Covered in full after

Diagnostic testing: Lab Covered in full after

Diagnostic testing: X-ray Covered in full after

Imaging (CT/PET scans MRIs) $300 copay after

Emergency room Covered in full after

deductible Paid as network care

Urgent care Covered in full after deductible

Chiropractic2

Pharmacy* Network Out of network

Pharmacy deductible Integrated with medical deductible N/A

(30)

PPO and Indemnity plans

Plan name CO PPO 1000 80/50 CO Indemnity 500 80%

Networks available Open Choice PPO N/A

Member benefits Network Care Out-of-network care††

Calendar year deductible $1,000/$2,000 $2,000/$4,000 $500/$1,000

Calendar year out-of-pocket limit $5,000/$10,000 $10,000/$20,000 $3,000/$6,000

Primary care physician office visit $25 copay; deductible

waived 50% after deductible 20% after deductible

Specialist office visit $50 copay; deductible

Walk-in clinics $25 copay; deductible waived

Not covered Not covered

Diagnostic testing: Lab $25 copay; deductible waived

50% after deductible 20% after deductible

Diagnostic testing: X-ray $50 copay; deductible waived

Imaging (CT/PET scans MRIs) $300 copay; deductible waived

Inpatient hospital facility 20% after deductible 50% after deductible 20% after deductible

Outpatient surgery 20% after deductible 50% after deductible 20% after deductible

Emergency room $250 copay; deductible waived

Paid as network care 20% after deductible

Urgent care $75 copay; deductible

$50 copay; deductible

Chiropractic2

Coverage is limited to 20 visits per calendar year $50 copay; deductible waived 50% after deductible 20% after deductible

Pharmacy deductible None N/A None None