Easy steps to renew your coverage

Transcription

1 Easy steps to renew your coverage Florida renewal instructions For 2 50 eligible employees Effective March 1, FL (1/12)

2 Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. Those companies include Aetna Health Inc., Aetna Health Insurance Company and Aetna Life Insurance Company (Aetna). 2

3 It s renewal time, with Aetna Aetna makes the renewal process easy Dear Valued Employer: Thank you for choosing Aetna for your employee benefits. We value your business and appreciate your trust in us to protect you and your employees assets. This booklet is your guide for current and new plan information and outlines the renewal process. If you are pleased with your current plan(s) and would like to renew on the plan that most closely matches the in force plan(s) the renewal process is complete and your coverage will automatically renew before its effective date. In order to comply with the Patient Protection and Affordable Care Act (PPACA) as well as make improvements that drive value as your health benefits carrier, we ve modified some plans to introduce new plans that broaden your options with regard to price. Aetna The Health of 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. Now Aetna offers Consumer Flex Choice to groups with four or more eligible employees. It allows you to select as many plans from the portfolio as meets your group s specific needs. With Consumer Flex Choice, you control expenses while providing employees superior health benefits coverage. And your employees will have access to care from one of Florida s most solid provider networks. In addition, Aetna offers you corporate buying power through Aetna s Resource Connection, which features discounted goods and services. While not insurance, these discounts can help you save on office supplies, HR support, payroll, technology assistance and more. If you have questions or need additional information, please contact your broker or Aetna at We understand you have a choice of carriers. Thank you for placing your confidence with Aetna. Sincerely, Sherry Baker Florida Head of Sales Aetna 3

4 Contact information Aetna Small Group Broker and General Agents BROKER SERVICES phone fax Choose the following numbers, when prompted, to access the information you need: 1 Claims Questions 2 Billing or Eligibility 3 Products or Services 4 Underwriting or Rating Department 5 Sales Support (Broker Liaisons, supply requests, and other questions) 6 Licensing and Appointments or Commissions Supplies SESalesSupport@aetna.com New Business Quoting ProducerWorld>SmallGroupBusiness> Quoting SESG@aetna.com Fax: Prescreen Requests SEPrescreen@aetna.com Fax: Sold Case Submission SENBUnderwriting@aetna.com Overnight Delivery Aetna New Business Underwriting 841 Prudential Drive, F602 Jacksonville, FL Renewal Business Underwriting Aetna Small Group Renewal 841 Prudential Drive, F390 Jacksonville, FL SESalesSupport@aetna.com Fax: E.Technical Assistance Line Monday Friday 7 a.m. 9 p.m. ET Choose the following numbers, when prompted, to access the information you need: Aetna Navigator (Our member website) Prompt 1 1 Assistance with registration 2 Assistance with password, user name or other website or technical assistance Producer World Prompt 4 1 Assistance with password or user name 2 Assistance with registration 3 Access assistance 4 All other website or technical assistance EMPLOYER SERVICES Billing For premium remittance and lockbox information, see customer bill or please contact the Employer Services toll-free number above. Enrollment For enrollment additions, changes, terms: Fax: SoutheastEnrollment@aetna.com or mail to: Aetna Plan Sponsor Services P.O. Box Jacksonville, FL eenrollment Technical Support Brokers can access eenrollment at 4

5 Member Services For member benefit questions or claims inquiries MEDICAL For Aetna HMO or QPOS Plans Aetna P.O. Box Lexington, KY For Aetna PPO, Consumer-Directed Health or Aetna Indemnity Plans , Prompt 1 Aetna P.O. Box El Paso, TX DENTAL Prompt 1 (Dental Plan Member) Prompt 2 (Dental Care Provider) Aetna P.O. Box Lexington, KY LIFE Aetna Life Insurance P.O. Box Lexington, KY DISABILITY For Short Term Disability Only For Short Term Disability with FMLA Fax Aetna Life Insurance P.O. Box Lexington, KY PHARMACY AETNA RX ( ) Prompt 2 (Member or calling on behalf of a member) Aetna Pharmacy Management P.O. Box Minneapolis, MN Mail-Order Drug Ordering Address Aetna Rx Home Delivery P.O. Box Kansas City, MO To track and order Rx refills: OTHER PROGRAMS Aetna Vision SM discount program Call for closest eye care provider Informed Health Line Hour Nurse Help Line Aetna Behavioral Health For Aetna Natural Products and Services SM, Aetna Fitness SM program, DocFind directory, member website and other information, visit Visit your personal self-service member website online The Aetna Navigator, our secure member website, is available 24 hours a day, 7 days a week. Members may use it to perform common transactions involving Aetna medical, dental, prescription drug or flexible spending account (FSA) plans. They can send a secure to Aetna Member Services, access claims, who s covered, and general health information as well as decisionsupport tools. Log on to the Aetna Navigator site 5

6 How to renew your Aetna health plans To renew to the plan that most closely matches your current plan(s) The renewal process is complete for you. Your benefits will change to renewal plan(s) on the effective date. The selected renewal plan(s) has been chosen as it most closely matches your current benefit(s). Please review plan documents for details on changes that apply to renewal plan(s). To renew your renewal plan(s) AND select an additional alternate plan(s) n Please check off the Renewal plan and also check off any Alternate plans you d like to add on the Plan Sponsor Signature Page in your renewal packet and fax it to or to SESalesSupport@aetna.com. n Please submit a letter or list of employees to identify the correct plan selection of all employees. To move to an Alternate plan(s) n Please check off any Alternate plans you d like to add on the Plan Sponsor Signature Page in your renewal packet and fax it to or to SESalesSupport@aetna.com. n Enrollment applications should be provided for any new enrollees or those adding or removing dependents. n Employees moving plans within the same platform will not need to submit an Employee Change of Coverage Form. n Please submit a letter or list of employees to identify the correct plan selection of all employees. Complete all items in full and send to us so we receive it no later than the day before the requested effective date. Submit Dental and Life adds 15 days before the requested effective date. Mail any correspondence to: Aetna 841 Prudential Drive F390 Jacksonville, FL

7 2012 Summary comparison Aetna is always looking to enhance our health care solutions to better serve you. Our goal is to provide flexible, affordable health benefits that align with your company s objectives. Please refer to the list below for an at-a-glance view of your 2012 options. This is a partial description of plans and benefits available; for more information, refer to the specific plan design summary. The dollar amount copayments indicate what the member is required to pay and the percentage copayments indicate what Aetna is required to pay unless otherwise noted. You may select any plan available in our new portfolio, but if you do not actively change your plan, you will be assigned to the Renewal Plan shown in this guide. YOUR CURRENT PLAN YOUR RENEWAL PLAN CHANGES HMO GK 1914 compared to HNOnly See page 8 HMO GK 1917S compared to HNOnly 12-10K-100S See page 9 HMO OA 1900 compared to HNOnly COMPASS See page 10 HMO OA 1902 compared to HNOnly See page 11 HMO OA 1903 compared to HNOnly See page 12 HMO OA 1911 compared to HNOnly See page 13 HMO OA 1912 compared to HNOnly See page 14 HMO OA 1913 compared to HNOnly See page 15 HMO OA 1914 compared to HNOnly See page 16 HMO OA 1915 compared to HNOnly See page 17 HMO OA 1916 compared to HNOnly A-50 See page 18 HMO OA 1917 compared to HNOnly 12-10K-100 See page 19 HMO OA 1917S compared to HNOnly 12-10K-100S See page 20 HMO OA 1922 compared to HNOnly See page 21 HMO OA 1923 compared to HNOnly See page 22 HMO OA 1936 (HDHP) compared to HNOnly 12-10K-100 See page 23 POS OA 1902 compared to HNOnly See page 24 POS OA 1911 compared to HNOption See page 25 POS OA 1912 compared to HNOption See page 26 POS OA 1913 compared to HNOption See page 27 POS OA 1921 compared to HNOption See page 28 POS OA 1922 compared to HNOption See page 29 POS OA 1935 (HDHP) compared to HNOption HSA See page 30 POS OA 1936 (HDHP) compared to HNOnly 12-10K-100 See page 31 MC OA 1911 compared to MC OA See page 32 MC OA 1912 compared to MC OA See page 33 MC OA 1913 compared to MC OA See page 34 MC OA 1917S compared to MC OA 12-10K-100S See page 35 MC OA 1922 compared to MC OA See page 36 MC OA 1935 (HDHP) compared to MC OA HSA See page 37 SUMMARY OF PLANS AVAILABLE ON 3/1/2012 FOR NEW AND RENEWING BUSINESS See page

8 HMO GK 1914 HNOnly Plan changes effective March 1, 2012 PLAN NAME HMO GK 1914 HNOnly HNOnly Referral Required? Yes No No Coinsurance 70% 70% 50% $2,000/$4,000 $2,000/$4,000 $2,000/$4,000 Type of Deductible Embedded Embedded Embedded $7,000/$14,000 $6,000/$12,000 $7,000/$14,000 Not Covered $60, ded waived $50, ded waived PCP Office Visit $25, ded waived $30, ded waived $25, ded waived Specialist Office Visit $50, ded waived $60, ded waived $50, ded waived Inpatient Hospital 70%, ded applies 70%, ded applies 50%, ded applies Outpatient Lab $0, ded waived $0, ded waived $0, ded waived Outpatient X-ray $50, ded waived $60, ded waived 50%, ded waived Complex Imaging 70%, ded applies 70%, ded applies 50%, ded applies Outpatient Surgery 70%, ded applies 70%, ded applies 50%, ded applies Emergency Room $250, ded waived $350, ded waived $400, ded waived Urgent Care $75, ded waived $75, ded waived $75, ded waived Retail Pharmacy Copay $10/$45/$65 $10/$45/$65 $10/$45/$65 Specialty Rx 25% 20% up to $180 20% up to $180 Preventive Rx Waiver Not applicable Not applicable Not applicable Coinsurance Not applicable Not applicable Not applicable 8

9 HMO GK 1917S HNOnly 12-10K-100S PLAN NAME HMO GK 1917S HNOnly 12-10K-100S HNOnly 12-10K-80S Referral Required? Yes No No Coinsurance 100% 0% 80% $10,000/$10,000 $10,000/$10,000 $10,000/$10,000 Type of Deductible Embedded (1x) Embedded (1x) Embedded (1x) $10,000/$10,000 $10,000/$10,000 $15,000/$15,000 Not Covered $35, ded waived $35, ded waived PCP Office Visit $35, ded waived $35, ded waived $35, ded waived Specialist Office Visit $70, ded waived $70, ded waived $70, ded waived Inpatient Hospital 100%, ded applies 100%, ded applies 80%, ded applies Outpatient Lab 100%, ded applies 100%, ded applies 80%, ded applies Outpatient X-ray 100%, ded applies 100%, ded applies 80%, ded applies Complex Imaging 100%, ded applies 100%, ded applies 80%, ded applies Outpatient Surgery 100%, ded applies 100%, ded applies 80%, ded applies Emergency Room 100%, ded applies 100%, ded applies 80%, ded applies Urgent Care 100%, ded applies 100%, ded applies 80%, ded applies Retail Pharmacy Copay $20/$50/$75 $20/$50/$75 $10 generic only Specialty Rx 25% 20% up to $225 20% up to $225 Preventive Rx Waiver Not applicable Not applicable Not applicable Coinsurance Not applicable Not applicable Not applicable 9

10 HMO OA 1900 (Compass) HNOnly (Compass) PLAN NAME HMO OA 1900 (Compass) HNOnly (Compass) HNOnly HSA Coinsurance 90% / 70% 90%/70% 90% $1,000/$2,000 $1,500/$3,000 $2,000/$4,000 Type of Deductible Embedded Embedded Non-Embedded $4,000/$8,000 $4,000/$8,000 $4,000/$8,000 $0, ded waived $0, ded waived $0, ded waived PCP Office Visit $25, ded waived $25, ded waived 90%, ded applies Specialist Office Visit 70%, ded applies 70%, ded applies 90%, ded applies Inpatient Hospital 90% after $500/day, ded applies 90% after $500 copay, ded applies 90%, ded applies Outpatient Lab 70%, ded applies 70%, ded applies 90%, ded applies Outpatient X-ray 70%, ded applies 70%, ded applies 90%, ded applies Complex Imaging 70%, ded applies 70%, ded applies 90%, ded applies Outpatient Surgery 90% after $250, ded applies 90% after $250 copay, ded applies 90%, ded applies Emergency Room 70%, ded applies 70%, ded applies 90%, ded applies Urgent Care 70%, ded applies 70%, ded applies 90%, ded applies Retail Pharmacy Copay $5/$40/$60 $5/$40/$60 $20/$50/$75 ded applies Specialty Rx 25% 20% up to $180 20% up to $225 Preventive Rx Waiver Not applicable Not applicable Ded waived for certain Preventive Rx Coinsurance Not applicable Not applicable Not applicable 10

11 HMO OA 1902 HNOnly PLAN NAME HMO OA 1902 HNOnly HNOnly Coinsurance N/A N/A 80% N/A N/A $1,000/$2,000 Type of Deductible N/A Embedded Embedded $3,000/$6,000 $3,000/$6,000 $3,000/$6,000 Preventive Care Services $0 $0 $0, ded waived Not Covered $50 $50, ded waived PCP Office Visit $20 $25 $25, ded waived Specialist Office Visit $50 $50 $50, ded waived Inpatient Hospital $500/day, days 1-4 $500/day, days %, ded applies Outpatient Lab $0 $0 $0, ded waived Outpatient X-ray $50 $50 $50, ded waived Complex Imaging 70% 70% 80%, ded applies Outpatient Surgery $500 $500 80%, ded applies Emergency Room $250 $250 $300, ded waived Urgent Care $75 $75 $75, ded waived Retail Pharmacy Copay $5/$40/$60 $10/$45/$65 $5/$40/$60 Specialty Rx 25% 20% up to $180 20% up to $180 Preventive Rx Waiver Not applicable Not applicable Not applicable Coinsurance Not applicable Not applicable Not applicable 11

12 HMO OA 1903 HNOnly PLAN NAME HMO OA 1903 HNOnly HNOnly Coinsurance N/A 80% 80% N/A $1,000/$2,000 $1,500/$3,000 Type of Deductible N/A Embedded Embedded $5,000/$10,000 $3,000/$6,000 $4,000/$8,000 Preventive Care Services $0 $0, ded waived $0, ded waived Not Covered $50, ded waived $50, ded waived PCP Office Visit $35 $25, ded waived $25, ded waived Specialist Office Visit $70 $50, ded waived $50, ded waived Inpatient Hospital $1000/day, days %, ded applies 80%, ded applies Outpatient Lab $0 $0, ded waived $0, ded waived Outpatient X-ray $70 $50, ded waived $50, ded waived Complex Imaging $500 80%, ded applies 80%, ded applies Outpatient Surgery $ %, ded applies 80%, ded applies Emergency Room $300 $300, ded waived $300, ded waived Urgent Care $150 $75, ded waived $75, ded waived Retail Pharmacy Copay $20/$50/$75 $5/$40/$60 $10/$45/$65 Specialty Rx 25% 20% up to $180 20% up to $180 Preventive Rx Waiver Not applicable Not applicable Not applicable Coinsurance Not applicable Not applicable Not applicable 12

13 HMO OA 1911 HNOnly PLAN NAME HMO OA 1911 HNOnly HNOnly Coinsurance 80% 80% 0% $500/$1,000 $1,000/$2,000 $2,000/$6,000 Type of Deductible Embedded Embedded 3X $4,500/$9,000 $3,000/$6,000 $2,000/$6,000 Not Covered $50, ded waived $50, ded waived PCP Office Visit $20, ded waived $25, ded waived $25, ded waived Specialist Office Visit $50, ded waived $50, ded waived $50, ded waived Inpatient Hospital 80%, ded applies 80%, ded applies 100%, ded applies Outpatient Lab $0, ded waived $0, ded waived $0, ded waived Outpatient X-ray $50, ded waived $50, ded waived $50, ded waived Complex Imaging 80%, ded applies 80%, ded applies 100%, ded applies Outpatient Surgery 80%, ded applies 80%, ded applies 100%, ded applies Emergency Room $200, ded waived $300, ded waived $300, ded waived Urgent Care $75, ded waived $75, ded waived $75, ded waived Retail Pharmacy Copay $5/$40/$60 $5/$40/$60 $10/$45/$65 Specialty Rx 25% 20% up to $180 80% up to $180 Preventive Rx Waiver Not applicable Not applicable Not applicable Coinsurance Not applicable Not applicable Not applicable 13

14 HMO OA 1912 HNOnly PLAN NAME HMO OA 1912 HNOnly HNOnly Coinsurance 80% 80% 80% $1,000/$2,000 $1,000/$2,000 $1,500/$3,000 Type of Deductible Embedded Embedded Embedded $4,000/$8,000 $3,000/$6,000 $4,000/$8,000 Not Covered $50, ded waived $50, ded waived PCP Office Visit $25, ded waived $25, ded waived $25, ded waived Specialist Office Visit $50, ded waived $50, ded waived $50, ded waived Inpatient Hospital 80%, ded applies 80%, ded applies 80%, ded applies Outpatient Lab $0, ded waived $0, ded waived $0, ded waived Outpatient X-ray $50, ded waived $50, ded waived $50, ded waived Complex Imaging 80%, ded applies 80%, ded applies 80%, ded applies Outpatient Surgery 80%, ded applies 80%, ded applies 80%, ded applies Emergency Room $200, ded waived $300, ded waived $300, ded waived Urgent Care $75, ded waived $75, ded waived $75, ded waived Retail Pharmacy Copay $10/$45/$65 $5/$40/$60 $10/$45/$65 Specialty Rx 25% 20% up to $180 20% up to $180 Preventive Rx Waiver Not applicable Not applicable Not applicable Coinsurance Not applicable Not applicable Not applicable 14

15 HMO OA 1913 HNOnly PLAN NAME HMO OA 1913 HNOnly HNOnly Coinsurance 70% 70% 70% $1,500/$3,000 $1,500/$3,000 $2,000/$4,000 Type of Deductible Embedded Embedded Embedded $4,500/$9,000 $5,000/$10,000 $6,000/$12,000 Not Covered $60, ded waived $60, ded waived PCP Office Visit $25, ded waived $30, ded waived $30, ded waived Specialist Office Visit $50, ded waived $60, ded waived $60, ded waived Inpatient Hospital 70%, ded applies 70%, ded applies 70%, ded applies Outpatient Lab $0, ded waived $0, ded waived $0, ded waived Outpatient X-ray $50, ded waived $60, ded waived $60, ded waived Complex Imaging 70%, ded applies 70%, ded applies 70%, ded applies Outpatient Surgery 70%, ded applies 70%, ded applies 70%, ded applies Emergency Room $250, ded waived $300, ded waived $350, ded waived Urgent Care $75, ded waived $75, ded waived $75, ded waived Retail Pharmacy Copay $10/$45/$65 $10/$45/$65 $10/$45/$65 Specialty Rx 25% 20% up to $180 20% up to $180 Preventive Rx Waiver Not applicable Not applicable Not applicable Coinsurance Not applicable Not applicable Not applicable 15

16 HMO OA 1914 HNOnly PLAN NAME HMO OA 1914 HNOnly HNOnly Coinsurance 70% 70% 50% $2,000/$4,000 $2,500/$5,000 $2,000/$4,000 Type of Deductible Embedded Embedded Embedded $7,000/$14,000 $5,000/$10,000 $7,000/$14,000 Not Covered $60, ded waived $50, ded waived PCP Office Visit $25, ded waived $30, ded waived $25, ded waived Specialist Office Visit $50, ded waived $60, ded waived $50, ded waived Inpatient Hospital 70%, ded applies 70%, ded applies 50%, ded applies Outpatient Lab $0, ded waived $0, ded waived $0, ded waived Outpatient X-ray $50, ded waived $60, ded waived 50%, ded waived Complex Imaging 70%, ded applies 70%, ded applies 50%, ded applies Outpatient Surgery 70%, ded applies 70%, ded applies 50%, ded applies Emergency Room $250, ded waived $350, ded waived $400, ded waived Urgent Care $75, ded waived $100, ded waived $75, ded waived Retail Pharmacy Copay $10/$45/$65 $10/$45/$65 $10/$45/$65 Specialty Rx 25% 20% up to $180 20% up to $180 Preventive Rx Waiver Not applicable Not applicable Not applicable Coinsurance Not applicable Not applicable Not applicable 16

17 HMO OA 1915 HNOnly PLAN NAME HMO OA 1915 HNOnly HNOnly A-50 Coinsurance 50% 50% 50% $2,000/$4,000 $2,000/$4,000 $3,000/$6,000 Type of Deductible Embedded Embedded Embedded $7,000/$14,000 $7,000/$14,000 $9,000/$18,000 Not Covered $50, ded waived $35, ded waived PCP Office Visit $25, ded waived $25, ded waived $35, ded waived Specialist Office Visit $50, ded waived $50, ded waived $70, ded waived Inpatient Hospital 50%, ded applies 50%, ded applies 50%, ded applies Outpatient Lab $0, ded waived $0, ded waived $0, ded waived Outpatient X-ray 50%, ded waived 50%, ded waived 50%, ded applies Complex Imaging 50%, ded applies 50%, ded applies 50%, ded applies Outpatient Surgery 50%, ded applies 50%, ded applies 50%, ded applies Emergency Room $250, ded waived $400, ded waived $400, ded waived Urgent Care $75, ded waived $75, ded waived $100, ded waived Retail Pharmacy Copay $10/$45/$65 $10/$45/$65 $20/$50/$75 Specialty Rx 25% 20% up to $180 20% up to $225 Preventive Rx Waiver Not applicable Not applicable Not applicable Coinsurance Not applicable Not applicable Not applicable 17

18 HMO OA 1916 HNOnly A-50 PLAN NAME HMO OA 1916 HNOnly A-50 HNOnly B-50 Coinsurance 50% 50% 50% $3,000/$6,000 $3,000/$6,000 $3,000/$6,000 Type of Deductible Embedded Embedded Embedded $9,000/$18,000 $9,000/$18,000 $9,000/$18,000 Not Covered $35, ded waived $40, ded waived PCP Office Visit $35, ded waived $35, ded waived $40, ded waived Specialist Office Visit $70, ded waived $70, ded waived $80, ded waived Inpatient Hospital 50%, ded applies 50%, ded applies 50%, ded applies Outpatient Lab $0, ded waived $0, ded waived $0, ded waived Outpatient X-ray 50%, ded waived 50%, ded applies 50%, ded applies Complex Imaging 50%, ded applies 50%, ded applies 50%, ded applies Outpatient Surgery 50%, ded applies 50%, ded applies 50%, ded applies Emergency Room $250, ded waived $400, ded waived 50%, ded applies Urgent Care $100, ded waived $100, ded waived 50%, ded applies Retail Pharmacy Copay $20/$50/$75 $20/$50/$75 $20/$50/$75 Specialty Rx 25% 20% up to $225 20% up to $225 Preventive Rx Waiver Not applicable Not applicable Not applicable Coinsurance Not applicable Not applicable Not applicable 18

19 HMO OA 1917 HNOnly 12-10K-100 PLAN NAME HMO OA 1917 HNOnly 12-10K-100 HNOnly 12-10K-80 Coinsurance 100% 100% 80% $10,000/$10,000 $10,000/$10,000 $10,000/$10,000 Type of Deductible Embedded (1x) Embedded (1x) Embedded (1x) $10,000/$10,000 $10,000/$10,000 $15,000/$15,000 Not Covered $35, ded waived $35, ded waived PCP Office Visit $35, ded waived $35, ded waived $35, ded waived Specialist Office Visit 100%, ded applies 100%, ded applies 80%, ded applies Inpatient Hospital 100%, ded applies 100%, ded applies 80%, ded applies Outpatient Lab 100%, ded applies 100%, ded applies 80%, ded applies Outpatient X-ray 100%, ded applies 100%, ded applies 80%, ded applies Complex Imaging 100%, ded applies 100%, ded applies 80%, ded applies Outpatient Surgery 100%, ded applies 100%, ded applies 80%, ded applies Emergency Room 100%, ded applies 100%, ded applies 80%, ded applies Urgent Care 100%, ded applies 100%, ded applies 80%, ded applies Retail Pharmacy Copay $20/$50/$75 $20/$50/$75 $10 generic only Specialty Rx 25% 20% up to $225 20% up to $225 Preventive Rx Waiver Not applicable Not applicable Not applicable Coinsurance Not applicable Not applicable Not applicable 19

20 HMO OA 1917S HNOnly 12-10K-100S PLAN NAME HMO OA 1917S HNOnly 12-10K-100S HNOnly 12-10K-80S Coinsurance 100% 100% 80% $10,000/$10,000 $10,000/$10,000 $10,000/$10,000 Type of Deductible Embedded (1x) Embedded (1x) Embedded (1x) $10,000/$10,000 $10,000/$10,000 $15,000/$15,000 Not Covered $35, ded waived $35, ded waived PCP Office Visit $35, ded waived $35, ded waived $35, ded waived Specialist Office Visit $70, ded waived $70, ded waived $70, ded waived Inpatient Hospital 100%, ded applies 100%, ded applies 80%, ded applies Outpatient Lab 100%, ded applies 100%, ded applies 80%, ded applies Outpatient X-ray 100%, ded applies 100%, ded applies 80%, ded applies Complex Imaging 100%, ded applies 100%, ded applies 80%, ded applies Outpatient Surgery 100%, ded applies 100%, ded applies 80%, ded applies Emergency Room 100%, ded applies 100%, ded applies 80%, ded applies Urgent Care 100%, ded applies 100%, ded applies 80%, ded applies Retail Pharmacy Copay $20/$50/$75 $20/$50/$75 $10 generic only Specialty Rx 25% 20% up to $225 20% up to $225 Preventive Rx Waiver Not applicable Not applicable Not applicable Coinsurance Not applicable Not applicable Not applicable 20

21 HMO OA 1922 HNOnly PLAN NAME HMO OA 1922 HNOnly HNOnly Coinsurance 100% 100% 100% $2,000/$6,000 $2,000/$6,000 $3,000/$9,000 Type of Deductible 3X 3X 3X $2,000/$6,000 $2,000/$6,000 $3,000/$9,000 Not Covered $50, ded waived $60, ded waived PCP Office Visit $25, ded waived $25, ded waived $30, ded waived Specialist Office Visit $50, ded waived $50, ded waived $60, ded waived Inpatient Hospital 100%, ded applies 100%, ded applies 100%, ded applies Outpatient Lab $0, ded waived $0, ded waived $0, ded waived Outpatient X-ray $50, ded waived $50, ded waived $60, ded waived Complex Imaging 100%, ded applies 100%, ded applies 100%, ded applies Outpatient Surgery 100%, ded applies 100%, ded applies 100%, ded applies Emergency Room $200, ded waived $300, ded waived $350, ded waived Urgent Care $75, ded waived $75, ded waived $75, ded waived Retail Pharmacy Copay $10/$45/$65 $10/$45/$65 $10/$45/$65 Specialty Rx 25% 20% up to $180 20% up to $180 Preventive Rx Waiver Not applicable Not applicable Not applicable Coinsurance Not applicable Not applicable Not applicable 21

22 HMO OA 1923 HNOnly PLAN NAME HMO OA 1923 HNOnly HNOnly Coinsurance 100% 100% 100% $3,000/$9,000 $3,000/$9,000 $5,000/$15,000 Type of Deductible 3X 3X 3X $3,000/$9,000 $3,000/$9,000 $5,000/$15,000 Not Covered $60, ded waived $60, ded waived PCP Office Visit $25, ded waived $30, ded waived $30, ded waived Specialist Office Visit $50, ded waived $60, ded waived $60, ded waived Inpatient Hospital 100%, ded applies 100%, ded applies 100%, ded applies Outpatient Lab $0, ded waived $0, ded waived $0, ded waived Outpatient X-ray $50, ded waived $60, ded waived $60, ded waived Complex Imaging 100%, ded applies 100%, ded applies 100%, ded applies Outpatient Surgery 100%, ded applies 100%, ded applies 100%, ded applies Emergency Room $250, ded waived $350, ded waived $400, ded waived Urgent Care $100, ded waived $75, ded waived $75, ded waived Retail Pharmacy Copay $10/$45/$65 $10/$45/$65 $20/$50/$75 Specialty Rx 25% 20% up to $180 20% up to $225 Preventive Rx Waiver Not applicable Not applicable Not applicable Coinsurance Not applicable Not applicable Not applicable 22

23 HMO OA 1936 (HDHP) HNOnly 12-10K-100 PLAN NAME HMO OA 1936 (HDHP) HNOnly 12-10K-100 HNOnly 12-10K-80 Coinsurance 100% 100% 80% $5,950/$11,900 $10,000/$10,000 $10,000/$10,000 Type of Deductible Non-Embedded Embedded (1x) Embedded (1x) $5,950/$11,900 $10,000/$10,000 $15,000/$15,000 Not Covered $35, ded waived $35, ded waived PCP Office Visit 100%, ded applies $35, ded waived $35, ded waived Specialist Office Visit 100%, ded applies 100%, ded applies 80%, ded applies Inpatient Hospital 100%, ded applies 100%, ded applies 80%, ded applies Outpatient Lab 100%, ded applies 100%, ded applies 80%, ded applies Outpatient X-ray 100%, ded applies 100%, ded applies 80%, ded applies Complex Imaging 100%, ded applies 100%, ded applies 80%, ded applies Outpatient Surgery 100%, ded applies 100%, ded applies 80%, ded applies Emergency Room 100%, ded applies 100%, ded applies 80%, ded applies Urgent Care 100%, ded applies 100%, ded applies 80%, ded applies Retail Pharmacy Copay Discount card only $20/$50/$75 $10 generic only Specialty Rx N/A 20% up to $225 20% up to $225 Preventive Rx Waiver N/A Not applicable Not applicable Coinsurance Not applicable Not applicable Not applicable 23

24 POS OA 1902 HNOnly PLAN NAME POS OA 1902 HNOnly HNOption Coinsurance N/A N/A 100% N/A N/A $2,000/$6,000 Type of Deductible N/A Embedded 3X $3,000/$6,000 $3,000/$6,000 $2,000/$6,000 Preventive Care Services $0 $0 $0, ded waived Not Covered $50 $50, ded waived PCP Office Visit $20 $25 $25, ded waived Specialist Office Visit $50 $50 $50, ded waived Inpatient Hospital $500/day, days 1-4 $500/day, days %, ded applies Outpatient Lab $0 $0 $0, ded waived Outpatient X-ray $50 $50 $50, ded waived Complex Imaging 70% 70% 100%, ded applies Outpatient Surgery $500 $ %, ded applies Emergency Room $250 $250 $300, ded waived Urgent Care $75 $75 $75, ded waived Retail Pharmacy Copay $5/$40/$60 $10/$45/$65 $10/$45/$65 Specialty Rx 25% 20% up to $180 20% up to $180 Preventive Rx Waiver Not applicable Not applicable Not applicable Coinsurance 50% Not applicable 70% $2,000/$4,000 $3,000/$9,000 $8,000/$16,000 $6,000/$18,000 24

25 POS OA 1911 HNOption PLAN NAME POS OA 1911 HNOption HNOption Coinsurance 80% 80% 100% $500/$1,000 $1,000/$2,000 $2,000/$6,000 Type of Deductible Embedded Embedded 3X $4,500/$9,000 $3,000/$6,000 $2,000/$6,000 Not Covered $50, ded waived $50, ded waived PCP Office Visit $20, ded waived $25, ded waived $25, ded waived Specialist Office Visit $50, ded waived $50, ded waived $50, ded waived Inpatient Hospital 80%, ded applies 80%, ded applies 100%, ded applies Outpatient Lab $0, ded waived $0, ded waived $0, ded waived Outpatient X-ray $50, ded waived $50, ded waived $50, ded waived Complex Imaging 80%, ded applies 80%, ded applies 100%, ded applies Outpatient Surgery 80%, ded applies 80%, ded applies 100%, ded applies Emergency Room $200, ded waived $300, ded waived $300, ded waived Urgent Care $75, ded waived $75, ded waived $75, ded waived Retail Pharmacy Copay $5/$40/$60 $5/$40/$60 $10/$45/$65 Specialty Rx 25% 20% up to $180 20% up to $180 Preventive Rx Waiver No Not applicable Not applicable Coinsurance 50% 50% 70% $2,000/$4,000 $2,000/$4,000 $3,000/$9,000 $8,000/$16,000 $6,000/$12,000 $6,000/$18,000 25

26 POS OA 1912 HNOption PLAN NAME POS OA 1912 HNOption HNOption Coinsurance 80% 80% 80% $1,000/$2,000 $1,000/$2,000 $1,500/$3,000 Type of Deductible Embedded Embedded Embedded $4,000/$8,000 $3,000/$6,000 $4,000/$8,000 Not Covered $50, ded waived $50, ded waived PCP Office Visit $25, ded waived $25, ded waived $25, ded waived Specialist Office Visit $50, ded waived $50, ded waived $50, ded waived Inpatient Hospital 80%, ded applies 80%, ded applies 80%, ded applies Outpatient Lab $0, ded waived $0, ded waived $0, ded waived Outpatient X-ray $50, ded waived $50, ded waived $50, ded waived Complex Imaging 80%, ded applies 80%, ded applies 80%, ded applies Outpatient Surgery 80%, ded applies 80%, ded applies 80%, ded applies Emergency Room $200, ded waived $300, ded waived $300, ded waived Urgent Care $75, ded waived $75, ded waived $75, ded waived Retail Pharmacy Copay $10/$45/$65 $5/$40/$60 $10/$45/$65 Specialty Rx 25% 20% up to $180 20% up to $180 Preventive Rx Waiver No Not applicable Not applicable Coinsurance 50% 50% 50% $2,000/$4,000 $2,000/$4,000 $2,000/$4,000 $8,000/$16,000 $6,000/$12,000 $6,000/$12,000 26

27 POS OA 1913 HNOption PLAN NAME POS OA 1913 HNOption HNOption Coinsurance 70% 70% 70% $1,500/$3,000 $1,500/$3,000 $2,000/$4,000 Type of Deductible Embedded Embedded Embedded $4,500/$9,000 $5,000/$10,000 $6,000/$12,000 Not Covered $60, ded waived $60, ded waived PCP Office Visit $25, ded waived $30, ded waived $30, ded waived Specialist Office Visit $50, ded waived $60, ded waived $60, ded waived Inpatient Hospital 70%, ded applies 70%, ded applies 70%, ded applies Outpatient Lab $0, ded waived $0, ded waived $0, ded waived Outpatient X-ray $50, ded waived $60, ded waived $60, ded waived Complex Imaging 70%, ded applies 70%, ded applies 70%, ded applies Outpatient Surgery 70%, ded applies 70%, ded applies 70%, ded applies Emergency Room $250, ded waived $300, ded waived $350, ded waived Urgent Care $75, ded waived $75, ded waived $75, ded waived Retail Pharmacy Copay $10/$45/$65 $10/$45/$65 $10/$45/$65 Specialty Rx 25% 20% up to $180 20% up to $180 Preventive Rx Waiver No Not applicable Not applicable Coinsurance 50% 50% 50% $2,000/$4,000 $2,000/$4,000 $3,000/$6,000 $8,000/$16,000 $8,000/$16,000 $10,000/$20,000 27

28 POS OA 1921 HNOption PLAN NAME POS OA 1921 HNOption HNOption Coinsurance 100% 100% 80% $1,500/$4,500 $2,000/$6,000 $1,500/$3,000 Type of Deductible 3X 3X Embedded $1,500/$4,500 $2,000/$6,000 $4,000/$8,000 Not Covered $50, ded waived $50, ded waived PCP Office Visit $20, ded waived $25, ded waived $25, ded waived Specialist Office Visit $50, ded waived $50, ded waived $50, ded waived Inpatient Hospital 100%, ded applies 100%, ded applies 80%, ded applies Outpatient Lab $0, ded waived $0, ded waived $0, ded waived Outpatient X-ray $50, ded waived $50, ded waived $50, ded waived Complex Imaging 100%, ded applies 100%, ded applies 80%, ded applies Outpatient Surgery 100%, ded applies 100%, ded applies 80%, ded applies Emergency Room $200, ded waived $300, ded waived $300, ded waived Urgent Care $75, ded waived $75, ded waived $75, ded waived Retail Pharmacy Copay $5/$40/$60 $10/$45/$65 $10/$45/$65 Specialty Rx 25% 20% up to $180 20% up to $180 Preventive Rx Waiver Not applicable Not applicable Not applicable Coinsurance 70% 70% 50% $2,000/$6,000 $3,000/$9,000 $2,000/$4,000 $5,000 /$15,000 $6,000/$18,000 $6,000/$12,000 28

29 POS OA 1922 HNOption PLAN NAME POS OA 1922 HNOption HNOption Coinsurance 100% 100% 100% $2,000/$6,000 $2,000/$6,000 $3,000/$9,000 Type of Deductible 3X 3X 3X $2,000/$6,000 $2,000/$6,000 $3,000/$9,000 Not Covered Not Covered $60, ded waived PCP Office Visit $25, ded waived $25, ded waived $30, ded waived Specialist Office Visit $50, ded waived $50, ded waived $60, ded waived Inpatient Hospital 100%, ded applies 100%, ded applies 100%, ded applies Outpatient Lab $0, ded waived $0, ded waived $0, ded waived Outpatient X-ray $50, ded waived $50, ded waived $60, ded waived Complex Imaging 100%, ded applies 100%, ded applies 100%, ded applies Outpatient Surgery 100%, ded applies 100%, ded applies 100%, ded applies Emergency Room $200, ded waived $300, ded waived $350, ded waived Urgent Care $75, ded waived $75, ded waived $75, ded waived Retail Pharmacy Copay $10/$45/$65 $10/$45/$65 $10/$45/$65 Specialty Rx 25% 20% up to $180 20% up to $180 Preventive Rx Waiver Not applicable Not applicable Not applicable Coinsurance 70% 70% 70% $3,000/$9,000 $3,000/$9,000 $4,000/$12,000 $6,000/$18,000 $6,000/$18,000 $6,000/$18,000 29

30 POS OA 1935 (HDHP) HNOption HSA PLAN NAME POS OA 1935 (HDHP) HNOption HSA HNOnly HSA Coinsurance 80% 80% 80% $2,500/$5,000 $2,500/$5,000 $3,000/$6,000 Type of Deductible Non-Embedded Non-Embedded Non-Embedded $5,000/$10,000 $5,000/$10,000 $6,000/$12,000 Not Covered $0, ded waived $0, ded waived PCP Office Visit 80%, ded applies 80%, ded applies 80%, ded applies Specialist Office Visit 80%, ded applies 80%, ded applies 80%, ded applies Inpatient Hospital 80%, ded applies 80%, ded applies 80%, ded applies Outpatient Lab 80%, ded applies 80%, ded applies 80%, ded applies Outpatient X-ray 80%, ded applies 80%, ded applies 80%, ded applies Complex Imaging 80%, ded applies 80%, ded applies 80%, ded applies Outpatient Surgery 80%, ded applies 80%, ded applies 80%, ded applies Emergency Room 80%, ded applies 80%, ded applies 80%, ded applies Urgent Care 80%, ded applies 80%, ded applies 80%, ded applies Retail Pharmacy Copay $5/$40/$60 $20/$50/$75 ded applies $20/$50/$75 ded applies Specialty Rx 25% 20% up to $225 20% up to $225 Preventive Rx Waiver Not applicable Ded waived for certain Preventive Rx Ded waived for certain Preventive Rx Coinsurance 70% 50% Not applicable $3,000/$6,000 $3,000/$6,000 $6,000/$12,000 $6,000/$12,000 30

31 POS OA 1936 (HDHP) HNOnly 12-10K-100 PLAN NAME POS OA 1936 (HDHP) HNOnly 12-10K-100 HNOnly 12-10K-80 Coinsurance 100% 100% 80% $5,950/$11,900 $10,000/$10,000 $10,000/$10,000 Type of Deductible Non-Embedded Embedded (1x) Embedded (1x) $5,950/$11,900 $10,000/$10,000 $15,000/$15,000 Not Covered $35, ded waived $35, ded waived PCP Office Visit 100%, ded applies $35, ded waived $35, ded waived Specialist Office Visit 100%, ded applies 100%, ded applies 80%, ded applies Inpatient Hospital 100%, ded applies 100%, ded applies 80%, ded applies Outpatient Lab 100%, ded applies 100%, ded applies 80%, ded applies Outpatient X-ray 100%, ded applies 100%, ded applies 80%, ded applies Complex Imaging 100%, ded applies 100%, ded applies 80%, ded applies Outpatient Surgery 100%, ded applies 100%, ded applies 80%, ded applies Emergency Room 100%, ded applies 100%, ded applies 80%, ded applies Urgent Care 100%, ded applies 100%, ded applies 80%, ded applies Retail Pharmacy Copay Discount card only $20/$50/$75 $10 generic only Specialty Rx Not applicable 20% up to $225 20% up to $225 Preventive Rx Waiver Not applicable Not applicable Not applicable Coinsurance 70% Not applicable Not applicable $7,000/$14,000 $10,000 /$20,000 31

32 MC OA 1911 MC OA PLAN NAME MC OA 1911 MC OA MC OA Coinsurance 80% 80% 80% $500/$1,000 $1,000/$2,000 $1,500/$3,000 Type of Deductible Embedded Embedded Embedded $4,500/$9,000 $3,000/$6,000 $4,000/$8,000 Not Covered $50, ded waived $50, ded waived PCP Office Visit $20, ded waived $25, ded waived $25, ded waived Specialist Office Visit $50, ded waived $50, ded waived $50, ded waived Inpatient Hospital 80%, ded applies 80%, ded applies 80%, ded applies Outpatient Lab $0, ded waived $0, ded waived $0, ded waived Outpatient X-ray $50, ded waived $50, ded waived $50, ded waived Complex Imaging 80%, ded applies 80%, ded applies 80%, ded applies Outpatient Surgery 80%, ded applies 80%, ded applies 80%, ded applies Emergency Room $200, ded waived $300, ded waived $300, ded waived Urgent Care $75, ded waived $75, ded waived $75, ded waived Retail Pharmacy Copay $5/$40/$60 $5/$40/$60 $10/$45/$65 Specialty Rx 25% 20% up to $180 20% up to $180 Preventive Rx Waiver No Not applicable Not applicable Coinsurance 50% 50% 50% $2,000/$4,000 $2,000/$4,000 $2,000/$4,000 $8,000/$16,000 $6,000/$12,000 $6,000/$12,000 32

33 MC OA 1912 MC OA PLAN NAME MC OA 1912 MC OA MC OA Coinsurance 80% 80% 80% $1,000/$2,000 $1,000/$2,000 $1,500/$3,000 Type of Deductible Embedded Embedded Embedded $4,000/$8,000 $3,000/$6,000 $4,000/$8,000 Not Covered $50, ded waived $50, ded waived PCP Office Visit $25, ded waived $25, ded waived $25, ded waived Specialist Office Visit $50, ded waived $50, ded waived $50, ded waived Inpatient Hospital 80%, ded applies 80%, ded applies 80%, ded applies Outpatient Lab $0, ded waived $0, ded waived $0, ded waived Outpatient X-ray $50, ded waived $50, ded waived $50, ded waived Complex Imaging 80%, ded applies 80%, ded applies 80%, ded applies Outpatient Surgery 80%, ded applies 80%, ded applies 80%, ded applies Emergency Room $200, ded waived $300, ded waived $300, ded waived Urgent Care $75, ded waived $75, ded waived $75, ded waived Retail Pharmacy Copay $10/$45/$65 $5/$40/$60 $10/$45/$65 Specialty Rx 25% 20% up to $180 20% up to $180 Preventive Rx Waiver No Not applicable Not applicable Coinsurance 50% 50% 50% $2,000/$4,000 $2,000/$4,000 $2,000/$4,000 $8,000/$16,000 $6,000/$12,000 $6,000/$12,000 33

34 MC OA 1913 MC OA PLAN NAME MC OA 1913 MC OA MC OA Coinsurance 70% 70% 70% $1,500/$3,000 $1,500/$3,000 $2,000/$4,000 Type of Deductible Embedded Embedded Embedded $4,500/$9,000 $5,000/$10,000 $6,000/$12,000 Not Covered $60, ded waived $60, ded waived PCP Office Visit $25, ded waived $30, ded waived $30, ded waived Specialist Office Visit $50, ded waived $60, ded waived $60, ded waived Inpatient Hospital 70%, ded applies 70%, ded applies 70%, ded applies Outpatient Lab $0, ded waived $0, ded waived $0, ded waived Outpatient X-ray $50, ded waived $60, ded waived $60, ded waived Complex Imaging 70%, ded applies 70%, ded applies 70%, ded applies Outpatient Surgery 70%, ded applies 70%, ded applies 70%, ded applies Emergency Room $250, ded waived $300, ded waived $350, ded waived Urgent Care $75, ded waived $75, ded waived $75, ded waived Retail Pharmacy Copay $10/$45/$65 $10/$45/$65 $10/$45/$65 Specialty Rx 25% 20% up to $180 20% up to $180 Preventive Rx Waiver Not applicable Not applicable Not applicable Coinsurance 50% 50% 50% $2,000/$4,000 $2,000/$4,000 $3,000/$6,000 $8,000/$16,000 $8,000/$16,000 $10,000/$20,000 34

35 MC OA 1917S MC OA 12-10K-100S * PLAN NAME MC OA 1917S MC OA 12-10K-100S MC OA 12-10K-100C Coinsurance 100% 100% 100% $10,000/$10,000 $10,000/$10,000 $10,000/$10,000 Type of Deductible Embedded (1x) Embedded (1x) Embedded (1x) $10,000/$10,000 $10,000/$10,000 $10,000/$10,000 Not Covered $35, ded waived $30, ded waived PCP Office Visit $35, ded waived $35, ded waived $30, ded waived Specialist Office Visit $70, ded waived $70, ded waived $60, ded waived Inpatient Hospital 100%, ded applies 100%, ded applies 100%, ded applies Outpatient Lab 100%, ded applies 100%, ded applies $25, ded waived Outpatient X-ray 100%, ded applies 100%, ded applies $75, ded waived Complex Imaging 100%, ded applies 100%, ded applies $400, ded waived Outpatient Surgery 100%, ded applies 100%, ded applies 100%, ded applies Emergency Room 100%, ded applies 100%, ded applies 100%, ded applies Urgent Care 100%, ded applies 100%, ded applies $75, ded waived Retail Pharmacy Copay $20/$50/$75 $20/$50/$75 $20/$50/$75 Specialty Rx 25% 20% up to $225 20% up to $225 Preventive Rx Waiver Not applicable Not applicable Not applicable Coinsurance 70% 70% 70% $10,000/$10,000 $10,000/$10,000 $10,000/$10,000 $15,000 / $30,000 $15,000 / $30,000 $15,000 / $30,000 *Note: this plan is not a lower cost plan than Renewal Plan. 35

36 MC OA 1922 MC OA PLAN NAME MC OA 1922 HNOption MC OA Coinsurance 100% 100% 70% $2,000/$6,000 $3,000/$9,000 $1,500/$3,000 Type of Deductible 3X 3X Embedded $2,000/$6,000 $3,000/$9,000 $5,000/$10,000 Not Covered $60, ded waived $60, ded waived PCP Office Visit $25, ded waived $30, ded waived $30, ded waived Specialist Office Visit $50, ded waived $60, ded waived $60, ded waived Inpatient Hospital 100%, ded applies 100%, ded applies 70%, ded applies Outpatient Lab $0, ded waived $0, ded waived $0, ded waived Outpatient X-ray $50, ded waived $60, ded waived $60, ded waived Complex Imaging 100%, ded applies 100%, ded applies 70%, ded applies Outpatient Surgery 100%, ded applies 100%, ded applies 70%, ded applies Emergency Room $200, ded waived $350, ded waived $300, ded waived Urgent Care $75, ded waived $75, ded waived $75, ded waived Retail Pharmacy Copay $10/$45/$65 $10/$45/$65 $10/$45/$65 Specialty Rx 25% 20% up to $180 20% up to $180 Preventive Rx Waiver Not applicable Not applicable Not applicable Coinsurance 70% 70% 50% $3,000/$9,000 $4,000/$12,000 $2,000/$4,000 $6,000/$18,000 $6,000/$18,000 $8,000/$16,000 36

37 MC OA 1935 (HDHP) MC OA HSA PLAN NAME MC OA 1935 (HDHP) MC OA HSA MC OA HSA Coinsurance 80% 80% 80% $2,500/$5,000 $2,500/$5,000 $3,000/$6,000 Type of Deductible Non-Embedded Non-Embedded Non-Embedded $5,000/$10,000 $5,000/$10,000 $6,000/$12,000 Not Covered $0, ded waived $0, ded waived PCP Office Visit 80%, ded applies 80%, ded applies 80%, ded applies Specialist Office Visit 80%, ded applies 80%, ded applies 80%, ded applies Inpatient Hospital 80%, ded applies 80%, ded applies 80%, ded applies Outpatient Lab 80%, ded applies 80%, ded applies 80%, ded applies Outpatient X-ray 80%, ded applies 80%, ded applies 80%, ded applies Complex Imaging 80%, ded applies 80%, ded applies 80%, ded applies Outpatient Surgery 80%, ded applies 80%, ded applies 80%, ded applies Emergency Room 80%, ded applies 80%, ded applies 80%, ded applies Urgent Care 80%, ded applies 80%, ded applies 80%, ded applies Retail Pharmacy Copay $5/$40/$60 $20/$50/$75 ded applies $20/$50/$75 ded applies Specialty Rx 25% 20% up to $225 20% up to $225 Preventive Rx Waiver Not applicable Ded waived for certain Preventive Rx Ded waived for certain Preventive Rx Coinsurance 70% 50% 50% $3,000/$6,000 $3,000/$6,000 $6,000/$12,000 $6,000/$12,000 $6,000/$12,000 $10,000/$20,000 37

38 New Standard Plans FL Plans Available 3/1/2012 Coins Deductible In Network Services In Network Out of Network Services HNOnly (HMO OOP (includes deductible) PCP OV Spec OV I/P Hosp ER UC Pharmacy Coins Deductible OOP (includes deductible) Open Access) HNOption (POS Open Access) MC Open Access Compass 90%/70% $1,500/$3,000 $4,000/$8,000 $25 70% 90% after $500 70% 70% $5/$40/$60 Not applicable X % $2,000/$6,000 $2,000/$6,000 $25 $50 100% $300 $75 $10/$45/$65 70% $3,000/$9,000 $6,000/$18,000 X X % $3,000/$9,000 $3,000/$9,000 $30 $60 100% $350 $75 $10/$45/$65 70% $4,000/$12,000 $6,000/$18,000 X X X % $5,000/$15,000 $5,000/$15,000 $30 $60 100% $400 $75 $20/$50/$75 Not applicable X % $1,000/$2,000 $3,000/$6,000 $25 $50 80% $300 $75 $5/$40/$60 50% $2,000/$4,000 $6,000/$12,000 X X X % $1,500/$3,000 $4,000/$8,000 $25 $50 80% $300 $75 $10/$45/$65 50% $2,000/$4,000 $6,000/$12,000 X X X % $1,500/$3,000 $5,000/$10,000 $30 $60 70% $300 $75 $10/$45/$65 50% $2,000/$4,000 $8,000/$16,000 X X X % $2,000/$4,000 $5,000/$10,000 $25 $50 80% $300 $75 $10/$45/$65 50% $3,000/$6,000 $7,000/$14,000 X X X % $2,000/$4,000 $6,000/$12,000 $30 $60 70% $350 $75 $10/$45/$65 50% $3,000/$6,000 $10,000/$20,000 X X X % $2,500/$5,000 $5,000/$10,000 $30 $60 70% $350 $100 $10/$45/$65 50% $3,000/$6,000 $8,000/$16,000 X X HSA 80% $1,500/$3,000 $2,500/$5,000 80% 80% 80% 80% 80% $20/$50/$75 * 50% $3,000/$6,000 $6,000/$12,000 X X HSA 90% $2,000/$4,000 $4,000/$8,000 90% 90% 90% 90% 90% $20/$50/$75 * Not applicable X HSA 80% $2,500/$5,000 $5,000/$10,000 80% 80% 80% 80% 80% $20/$50/$75 * 50% $3,000/$6,000 $6,000/$12,000 X X X HSA 80% $3,000/$6,000 $6,000/$12,000 80% 80% 80% 80% 80% $20/$50/$75 * 50% $6,000/$12,000 $10,000/$20,000 X X % $2,000/$4,000 $7,000/$14,000 $25 $50 50% $400 $75 $10/$45/$65 Not applicable X A-50 50% $3,000/$6,000 $9,000/$18,000 $35 $70 50% $400 $100 $20/$50/$75 50% $4,000/$8,000 $12,000 / $24,000 X X B-50 50% $3,000/$6,000 $9,000/$18,000 $40 $80 50% 50% 50% $20/$50/$75 Not applicable X % $5,000/$10,000 $10,000/$20,000 $40 $80 50% 50% $100 $20 / $50 (closed formulary) Not applicable X 12-10K-100C 100% $10,000/$10,000 $10,000/$10,000 $30 $60 100% 100% $75 $20/$50/$75 70% $10,000/$10,000 $15,000 / $30,000 X X 12-10K-100S 100% $10,000/$10,000 $10,000/$10,000 $35 $70 100% 100% 100% $20/$50/$75 70% $10,000/$10,000 $15,000 / $30,000 X X 12-10K % $10,000/$10,000 $10,000/$10,000 $35 100% 100% 100% 100% $20/$50/$75 Not applicable X 12-10K-80S 80% $10,000/$10,000 $15,000/$15,000 $35 $70 80% 80% 80% $10 generic only Not applicable X 12-10K-80 80% $10,000/$10,000 $15,000/$15,000 $35 80% 80% 80% 80% $10 generic only Not applicable X N/A N/A $3,000/$6,000 $25 $50 $500/day, days 1-4 $250 $75 $10/$45/$65 Not applicable X Aetna Specialty Rx 20% member coinsurance (maximum copay applies, refer to plan documents for details). * Deductible must be met before Rx copays apply on HSA Plans, however deductible is waived for certain preventive medications. A complete list of these medications is available on Aetna Navigator. This is a partial description of plans and benefits available. For more information, refer to the specific plan design summary. The dollar amount copayments indicate what the member is required to pay and the percentage copayments indicate what Aetna is required to pay unless otherwise noted. 38

39 PLAN VALUE PLAN NAME $ $$ $$$ $$$$ HNOnly 12-10K-80 HNOnly 12-10K-80S HNOnly 12-10K-100 HNOnly 12-10K-100S HNOnly 12-10K-100C HNOnly HSA MC OA 12-10K-100S HNOnly HNOnly HSA HNOnly B-50 HNOption HSA HNOnly A-50 MC OA 12-10K-100C MC OA HSA HNOnly HSA MC OA HSA HNOnly HNOnly HNOnly HSA HNOnly COMPASS MC OA A-50 HNOnly HNOnly HNOnly HNOption HNOnly HNOnly MC OA HSA HNOnly HNOption HNOption HNOption MC OA HNOnly MC OA HNOption HNOnly MC OA HNOption MC OA MC OA HNOption MC OA MC OA HNOnly HNOnly - HMO Open Access style plan HNOption - POS Open Access style Plan MC OA - Managed Choice Open Access Plan 39

40 Limitations and exclusions Medical These plans do not cover all health care expenses and includes exclusions and limitations. Members should refer to their plan documents to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. All medical and hospital services not specifically covered or that are limited or excluded by your plan documents, including costs of services before coverage begins and after coverage terminates. Cosmetic surgery Custodial care Dental care and dental X-rays Donor egg retrieval Hearing aids Home births Immunizations for travel or work Implantable drugs and certain injectable drugs Infertility services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services unless specifically listed as covered in your plan documents Nonmedically necessary services or supplies Orthotics Over-the-counter medications and supplies Radial keratotomy or related procedures Reversal of sterilization Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies, or counseling Special duty nursing Therapy or rehabilitation other than those listed as covered in the plan documents 40

41 Pre-existing conditions exclusion provisions all plans These plans do not immediately cover pre-existing conditions unless the enrollee has creditable prior coverage from another health benefits carrier. A pre-existing conditions exclusion means that if the enrollee has a medical condition before coming to our plan, he or she might have to wait a certain period of time before the plan will provide coverage for that condition. This exclusion applies only to conditions for which medical advice, diagnosis or treatment was recommended or received or for which the individual took prescribed drugs within 180 days. Generally, this period ends the day before coverage becomes effective. However, if the enrollee was in a waiting period for coverage, the 180-day period ends on the day before the waiting period begins. The exclusion period, if applicable, may last up to 365 days from the first day of coverage or, if the enrollee was in a waiting period, from the first day of the waiting period. If the enrollee had prior creditable coverage within 63 days immediately before the date enrolled under this plan, then the pre-existing conditions exclusion in the plan, if any, will be waived. If the individual had no prior creditable coverage within the 63 days prior to the enrollment date (either because of no prior coverage or because there was more than a 63-day gap from the date the prior coverage terminated to the enrollment date), we will apply the plan s pre-existing exclusion. In order to reduce or possibly eliminate the exclusion period based on creditable coverage, enrollees should provide us a copy of a Certificate of Creditable Coverage. Enrollees may call Aetna Member Services at AETNA for help with getting a Certificate of Creditable Coverage from the prior carriers. The pre-existing conditions exclusion does not apply to pregnancy nor to an individual under the age of 19. For late enrollees, coverage will be delayed until the plan s next open enrollment; the preexisting exclusion will be applied from the individual s effective date of coverage. 41