:Aetna Leap Everyday Value Plan

1 : aetna Leap Everyday Value plan 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: HMO. 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: You must pay all the costs up to the deductible amount before this plan begins In-network: Individual $6,075 / Family to pay for covered services you use. Check your policy or plan document to see What is the overall $12,150. Does not apply to certain office visits, when the deductible starts over (usually, but not always, January 1st). See the deductible? preventive care and urgent care in-network. chart starting on page 2 for how much you pay for covered services after you meet the deductible.

2 Are there other You don't have to meet deductibles for specific services, but see the chart deductibles for specific No. starting on page 2 for other costs for services this plan covers. services? The out-of-pocket limit is the most you could pay during a coverage period Is there an out-of-pocket Yes. In-network: Individual $6,075 / Family (usually one year) for your share of the cost of covered services. This limit helps limit on my expenses? $12,150. you plan for health care expenses. What is not included in Premiums and health care this plan does not Even though you pay these expenses, they don't count toward the out-of the out-of-pocket limit? cover. pocket limit. 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.

3 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 Yes. A written referral is required for most This plan will pay some or all of the costs to see a specialist for covered services a specialist? specialist visits. but only if you have the plan 's permission before you see the specialist. Are there services this Some of the services this plan doesn't cover are listed on page 5.

4 See your policy Yes. plan doesn't cover? or plan document for additional information about excluded services. Questions: Call 1-844-241-0208 or visit us at 072900-080020-061691. 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 Leap Everyday Value plan 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: HMO. 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.

5 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. 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 Primary care visit to treat an injury or $10 copay/visit, none . Not covered illness deductible waived 0% coinsurance, after none.

6 Specialist visit Not covered If you visit a health deductible care provider's office 0% coinsurance, after Coverage is limited to 25 visits for or clinic Other practitioner office visit deductible for Not covered Chiropractic care. Chiropractic care Preventive care /screening Age and frequency schedules may apply. No charge Not covered /immunization Lab: $10 copay/visit, none . deductible waived;. Diagnostic test (x-ray, blood work) X-ray: 0% Not covered If you have a test coinsurance, after deductible 0% coinsurance, after none . Imaging (CT/PET scans, MRIs) Not covered deductible Questions: Call 1-844-241-0208 or visit us at 072900-080020-061691. 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 Leap Everyday Value plan Coverage Period: 01/01/2017 - 12/31/2017.

7 Summary of Benefits and Coverage: What this plan Covers & What it Costs Coverage for: Individual + Family| plan Type: HMO. 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 $5 copay for up to a Covers up to a 90 day supply (retail & mail If you need drugs to 30 day supply, $10 order prescription). Applicable cost share Preferred/Non-preferred generic drugs copay for up to a 90 Not covered plus difference (brand minus generic cost). treat your illness or day supply, deductible applies for brand when generic available. condition waived No charge for preferred generic 0% coinsurance, after FDA-approved women's contraceptives More information in-network. Precertification and step Preferred brand drugs deductible for up to a Not covered about prescription therapy required.

8 90 day supply drug coverage is 0% coinsurance, after available at Non-preferred brand drugs deductible for up to a Not covered 90 day supply All specialty prescription drug fills on x?siteCode=5758788519. initial fill must be filled at a network 0% coinsurance, after specialty pharmacy except for urgent Four Tier Closed Preferred/non-preferred specialty drugs deductible for up to a Not covered situations. Your plan may include access to Individual Formulary 30 day supply CVS retail pharmacies for certain specialty drugs. Facility fee ( , ambulatory surgery 0% coinsurance, after none . Not covered If you have outpatient center) deductible surgery 0% coinsurance, after none . Physician/surgeon fees Not covered deductible Out-of-network emergency room services 0% coinsurance, after 0% coinsurance, Emergency room services cost-share same as in-network.

9 No deductible after deductible If you need coverage for non-emergency care. immediate medical 0% coinsurance, after 0% coinsurance, Out-of-network cost-share same as Emergency medical transportation attention deductible after deductible in-network. $10 copay/visit, No coverage for non-urgent use. Urgent care Not covered deductible waived Questions: Call 1-844-241-0208 or visit us at 072900-080020-061691. 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. : aetna Leap Everyday Value plan 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: HMO. 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 0% coinsurance, after none.

10 Facility fee ( , hospital room) Not covered If you have a hospital deductible stay 0% coinsurance, after none . Physician/surgeon fee Not covered deductible Mental/Behavioral health outpatient 0% coinsurance, after none . Not covered services deductible If you have mental Mental/Behavioral health inpatient 0% coinsurance, after none . Not covered health, behavioral services deductible health, or substance Substance use disorder outpatient 0% coinsurance, after none . abuse needs Not covered services deductible Substance use disorder inpatient 0% coinsurance, after none . Not covered services deductible Prenatal: No charge; none . Postnatal: 0%. Prenatal and postnatal care Not covered coinsurance, after If you are pregnant deductible 0% coinsurance, after none . Delivery and all inpatient services Not covered deductible 0% coinsurance, after none.