: Aetna Gold $10 Copay PPO

1 : Aetna gold $10 Copay PPO Coverage Period: 01/01/ 2017 - 12/31/ 2017 . summary of benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family|Plan Type: PPO. This is only a summary . If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling 1-844-241-0208. Important Questions Answers Why this Matters: In-network: Individual $1,400 / Family $2,800. You must pay all the costs up to the deductible amount before this plan begins Out-of-network: Individual $6,750 / Family to pay for covered services you use. Check your policy or plan document to see What is the overall $13,500. Does not apply to certain office visits, when the deductible starts over (usually, but not always, January 1st). See the deductible? preventive care, urgent care and prescription chart starting on page 2 for how much you pay for covered services after you drugs in-network. meet the deductible.

2 Yes. For prescription drug expenses per Are there other member - In-network: $250 / Out-of-network: You must pay all of the costs for these services up to the specific deductible deductibles for specific $500. Does not apply to in-network for amount before this plan begins to pay for these services. services? preferred generic drugs. There are no other specific deductibles. Yes. In-network: Individual $5,200 / Family The out-of-pocket limit is the most you could pay during a coverage period Is there an out-of-pocket $10,400. Out-of-network: Individual (usually one year) for your share of the cost of covered services. This limit helps limit on my expenses? Unlimited / Family Unlimited. you plan for health care expenses. Premiums, balance-billed charges, penalties for What is not included in Even though you pay these expenses, they don't count toward the out-of failure to obtain pre-authorization for services, the out-of-pocket limit? pocket limit. and health care this plan does not cover.

3 Is there an overall annual The chart starting on page 2 describes any limits on what the plan will pay for limit on what the plan No. specific covered services, such as office visits. pays? If you use an in-network doctor or other health care provider, this plan will pay Yes. See or call some or all of the costs of covered services. Be aware, your in-network doctor Does this plan use a 1-844-241-0208 for a list of in-network or hospital may use an out-of-network provider for some services. Plans use the network of providers? providers. term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. Do I need a referral to see No. You can see the specialist you choose without permission from this plan. a specialist? Are there services this Some of the services this plan doesn't cover are listed on page 6. See your policy Yes. plan doesn't cover? or plan document for additional information about excluded services.

4 Questions: Call 1-844-241-0208 or visit us at 071500-090020-481642. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at 1 of 8. or call 1-844-241-0208 to request a copy. : Aetna gold $10 Copay PPO Coverage Period: 01/01/ 2017 - 12/31/ 2017 . summary of benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family|Plan Type: PPO. Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan's allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven't met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference.

5 For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.). This plan may encourage you to use in-network providers by charging you lower deductibles, copayments, and coinsurance amounts. Your Cost If Your Cost If Common You Use an You Use an Services You May Need Limitations & Exceptions Medical Event In-Network Out of Network Provider Provider $10 Copay /visit, none . Primary care visit to treat an injury or 50% coinsurance, deductible does not illness after deductible apply $45 Copay /visit, none . 50% coinsurance, Specialist visit deductible does not after deductible apply If you visit a health 20% coinsurance, 25% coinsurance, Coverage is limited to 30 visits for care provider's office Other practitioner office visit after deductible for after deductible for Chiropractic care. or clinic Chiropractic care Chiropractic care 50% coinsurance, Age and frequency schedules may apply.

6 After deductible;. Preventive care /screening except deductible No charge /immunization does not apply for childhood immunizations 20% coinsurance, 50% coinsurance, none . Diagnostic test (x-ray, blood work). after deductible after deductible If you have a test 20% coinsurance, 50% coinsurance, Out-of-network precertification required or Imaging (CT/PET scans, MRIs). after deductible after deductible $400 penalty applies per occurrence. Questions: Call 1-844-241-0208 or visit us at 071500-090020-481642. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at 2 of 8. or call 1-844-241-0208 to request a copy. : Aetna gold $10 Copay PPO Coverage Period: 01/01/ 2017 - 12/31/ 2017 . summary of benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family|Plan Type: PPO. Your Cost If Your Cost If Common You Use an You Use an Services You May Need Limitations & Exceptions Medical Event In-Network Out of Network Provider Provider Tier 1A: $3 Copay for Covers up to a 30 day supply (retail up to a 30 day supply, prescription), 31-90 day supply (retail &.)

7 $9 Copay for up to a 50% coinsurance for mail order prescription). Applicable cost 90 day supply; Tier 1: up to a 30 day share plus difference (brand minus generic Preferred generic drugs $10 Copay for up to a supply, deductible cost) applies for brand when generic 30 day supply, $30 does not apply available. No charge for preferred generic If you need drugs to Copay for up to a 90 FDA-approved women's contraceptives treat your illness or day supply in-network. Precertification and step condition $45 Copay for up to a therapy required. No coverage for mail 30 day supply, $135 50% coinsurance, order prescriptions out-of-network. Preferred brand drugs Copay for up to a 90 after deductible for More information day supply, after up to a 30 day supply about prescription deductible drug coverage is $75 Copay for up to a available at 30 day supply, $225 50% coinsurance, Non-preferred generic/brand drugs Copay for up to a 90 after deductible for day supply, after up to a 30 day supply x?

8 SiteCode=5644738991 deductible Preferred: 40% All specialty prescription drug fills on Five Tier Closed coinsurance up to a initial fill must be filled at a network Individual Formulary $150 maximum for up specialty pharmacy except for urgent to a 30 day supply; situations. Your plan may include access to Preferred specialty drugs, non-preferred Non-preferred: 50% Not covered CVS retail pharmacies for certain specialty specialty drugs coinsurance up to a drugs. $150 maximum for up to a 30 day supply, after deductible Facility fee ( , ambulatory surgery 20% coinsurance, 50% coinsurance, none . If you have outpatient center) after deductible after deductible surgery 20% coinsurance, 50% coinsurance, none . Physician/surgeon fees after deductible after deductible Questions: Call 1-844-241-0208 or visit us at 071500-090020-481642. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at 3 of 8. or call 1-844-241-0208 to request a copy.

9 : Aetna gold $10 Copay PPO Coverage Period: 01/01/ 2017 - 12/31/ 2017 . summary of benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family|Plan Type: PPO. Your Cost If Your Cost If Common You Use an You Use an Services You May Need Limitations & Exceptions Medical Event In-Network Out of Network Provider Provider Out-of-network emergency room services 20% coinsurance, 20% coinsurance, Emergency room services cost-share same as in-network. No after deductible after deductible coverage for non-emergency care. If you need 20% coinsurance, 20% coinsurance, Out-of-network cost-share same as immediate medical Emergency medical transportation after deductible after deductible in-network. attention $45 Copay /visit, No coverage for non-urgent use. 50% coinsurance, Urgent care deductible does not after deductible apply 20% coinsurance, 50% coinsurance, Out-of-network precertification required or Facility fee ( , hospital room). If you have a hospital after deductible after deductible $400 penalty applies per occurrence.

10 Stay 20% coinsurance, 50% coinsurance, none . Physician/surgeon fee after deductible after deductible $45 Copay /visit, none . Mental/Behavioral health outpatient 50% coinsurance, deductible does not services after deductible apply If you have mental Mental/Behavioral health inpatient 20% coinsurance, 50% coinsurance, Out-of-network precertification required or health, behavioral services after deductible after deductible $400 penalty applies per occurrence. health, or substance $45 Copay /visit, none . abuse needs Substance use disorder outpatient 50% coinsurance, deductible does not services after deductible apply Substance use disorder inpatient 20% coinsurance, 50% coinsurance, Out-of-network precertification required or services after deductible after deductible $400 penalty applies per occurrence. Prenatal: No charge; none . Postnatal: 20% 50% coinsurance, Prenatal and postnatal care coinsurance, after after deductible If you are pregnant deductible 20% coinsurance, 50% coinsurance, Out-of-network precertification required or Delivery and all inpatient services after deductible after deductible $400 penalty applies per occurrence.