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j1 \et 1.a.
City of Okeechobee
Proposed effective date: 08 -01 -2008
AETNA CHOICETM POS - Florida
PLAN DESIGN AND BENEFITS
PROVIDED BY AETNA HEALTH INC. - FULL RISK
PLAN FEATURES
PARTICIPATING PROVIDERS NON - PARTICIPATING
PROVIDERS
$500 Individual
$1,500 Family
Deductible (per calendar year) None Individual
None Family
Unless otherwise indicated, the Deductible must be met prior to benefits being payable.
Member cost sharing for certain services including member cost sharing for prescription drugs, as indicated in the plan,
are excluded from charges to meet the Deductible.
Once Family Deductible is met, all family members will be considered as having met their Deductible for the remainder
of the calendar year.
Out -of- Pocket Maximum $1,500 Individual $3,000 Individual
(per calendar year) $3,000 Family $6,000 Family
Member cost sharing for certain services may not apply toward the Out -of- Pocket Maximum.
Only those participating providers and non - participating providers out of pocket expenses resulting from the application
of coinsurance percentage and copays (except any penalty amounts and pharmacy cost sharing) may be used to satisfy
the Out -of Pocket Maximum.
Once Family Out -of- Pocket Maximum is met, all family members will be considered as having met their Out -of- Pocket
Maximum for the remainder of the calendar year.
The deductible does not apply towards the Out -of- Pocket Maximum.
Lifetime Maximum Unlimited unless otherwise $1,000,000
indicated.
Primary Care Physician Selection Not Required Not Applicable
Precertification Requirement Certain non - participating providers /participating provider self referred services require
precertification or benefits will be reduced. Refer to your plan documents for a complete list of services that require
precertification.
Referral Requirements
PREVENTIVE CARE
None
PARTICIPATING PROVIDERS
Routine Adult Physical Exams /
Immunizations
(Age and frequency schedules apply)
Well Child Exams / Immunizations
(Age and frequency schedules apply)
Routine Gynecological Care Exams
Includes Pap smear and related lab fees.
Ob /Gyn providers may be chosen as PCP's.
One exam per calendar year.
$15 copay; deductible waived
None
NON - PARTICIPATING
PROVIDERS
Not Covered
$15 copay; deductible waived 30% for children up to age 16
$25 copay; deductible waived Not Covered
Routine Mammograms $25 copay; deductible waived 30%
One baseline mammogram for females age 35 -39; and one annual mammogram for females age 40 and over
Routine Digital Rectal Exams / Prostate Member cost sharing is based on Member cost sharing is based on
Specific Antigen Test the type of service performed and the type of service performed and
For males age 40 and over the place of service where it is the place of service where it is
rendered.; deductible waived rendered.
Prepared: 06/12/2008 11:00 AM Page 1
City of Okeechobee
Proposed effective date: 08 -01 -2008
AETNA CHOICETM POS - Florida
PLAN DESIGN AND BENEFITS
PROVIDED BY AETNA HEALTH INC. - FULL RISK
Colorectal Cancer Screening
For all members 50 and over.
Frequency schedule applies
Routine Eye Exam
Age /Frequency Schedule may apply.
Routine Hearing Screening
PHYSICIAN SERVICES
Member cost sharing is based on
the type of service performed and
the place of service where it is
rendered.; deductible waived
$25 copay
Subject to Routine Physical Exam
cost sharing
PARTICIPATING PROVIDERS
Member cost sharing is based on
the type of service performed and
the place of service where it is
rendered.
Not Covered
Not Covered
Primary Care Physician Visits
Specialist Office Visits
Maternity OB Visits
Allergy Treatment
Allergy Testing
Office Hours: $15 copay
After Office Hours /Home: $20
copay
$25 copay 30%
$25 copay for initial visit only, 30%
thereafter covered 100%
Same as applicable participating 30%
provider office visit member cost
sharing
Same as applicable participating 30%
provider office visit member cost
sharing
NON - PARTICIPATING
PROVIDERS
30%
DIAGNOSTIC PROCEDURES
PARTICIPATING PROVIDERS NON - PARTICIPATING
PROVIDERS
30%
physician, expenses are covered subject to the
Diagnostic Laboratory $25 copay
If performed as a part of a physician's office visit and billed by the
ap_licable physician's office visit cost sharing.
Diagnostic X -ray $25 copay
Outpatient hospital or other Outpatient facility
(except for Complex Imaging Services)
Diagnostic X -ray for Complex Imaging $25 copay
Services
EMERGENCY MEDICAL CARE
30%
30%
PARTICIPATING PROVIDERS
Urgent Care
Non - Urgent use of Urgent Care Provider
Emergency Room
$50 copay
Not Covered
$100 copay
Non - Emergency Care in an Emergency Not Covered
Room
NON - PARTICIPATING
PROVIDERS
30%
Not Covered
Refer to participating provider
benefit.
Not Covered
Ambulance Covered 100% Refer to participating provider
HOSPITAL CARE
benefit.
PARTICIPATING PROVIDERS NON - PARTICIPATING
PROVIDERS
Inpatient Coverage
The member cost sharing applies
npatient Maternity Coverage
The member cost sharing applie s
Outpatient Surgery
The member cost sharing applies
$500 per admission copay 30% per admission
to all covered benefits incurred duringa member's inpatient stay.
$500 per admission copay 30% per admission
to all covered benefits incurred during a member's inpatient stay.
$200 copay per visit 30% per visit
to all covered benefits incurred during a member's outpatient visit.
Prepared: 06/12/2008 11:00 AM Page 2
r
Xi\etiia.
r.- '
_
City of Okeechobee
Proposed effective date: 08 -01 -2008
AETNA CHOICE' POS - Florida
PLAN DESIGN AND BENEFITS
PROVIDED BY AETNA HEALTH INC. - FULL RISK
MENTAL HEALTH SERVICES PARTICIPATING PROVIDERS NON - PARTICIPATING
PROVIDERS
Inpatient Mental Illness $500 per admission copay 30% per admission
Limited to 30 days per calendar Limited to 30 days per calendar
year year
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay.
Outpatient Mental Illness $25 copay per visit 30% per visit
Limited to 20 visits per calendar Limited to 20 visits per calendar
year year
The member cost sharing applies to all covered benefits incurred during a member's outpatient visit.
ALCOHOL /DRUG ABUSE SERVICES PARTICIPATING PROVIDERS NON - PARTICIPATING
PROVIDERS
Inpatient Detoxification $500 per admission copay 30% per admission
7 days per admission, 4
admissions per lifetime
The member cost sharing applies to all covered benefits incurred during _a member's inpatient stay.
Outpatient Detoxification $25 copay 30% per visit
The member cost sharing applies to all covered benefits incurred during a member's outpatient visit.
Inpatient Rehabilitation $500 per admission copay 30% per admission
Limited to 30 days per calendar Limited to 30 days per calendar
year year
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay.
Outpatient Rehabilitation $25 copay 30% per visit
Limited to 30 visits per calendar Limited to 30 visits per calendar
year year
The member cost sharing applies to all covered benefits incurred during a member's outpatient visit.
OTHER SERVICES PARTICIPATING PROVIDERS NON - PARTICIPATING
PROVIDERS
Skilled Nursing Facility $500 per admission copay 30% per admission
Limited to 240 days per calendar
year
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay.
Home Health Care Covered 100% 30% per visit
Coverage includes nutritional counseling and services of a medical social worker.
Hospice Care - Inpatient $500 per admission copay 30% per admission
$10,000 lifetime maximum
combined for inpatient and
outpatient care.
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay.
Hospice Care - Outpatient Covered 100% 30% per visit
$10,000 lifetime maximum
combined for inpatient and
outpatient care.
The member cost sharing applies to all covered benefits incurred during a member's outpatient visit.
Private Duty Nursing Not Covered Not Covered
Outpatient Rehabilitation Therapy (Includes $25 copay 30%
speech, physical and occupational therapy)
Subluxation
Limited to 20 visits per calendar Limited to 20 visits per calendar
year. year.
$25 copay 30% per visit
Limited to 20 visits per calendar
year
$1,000 calendar year maximum.
Prepared: 06/12/2008 11:00 AM Page 3
\et i
City of Okeechobee
Proposed effective date: 08 -01 -2008
AETNA CHOICETM POS - Florida
PLAN DESIGN AND BENEFITS
PROVIDED BY AETNA HEALTH INC. - FULL RISK
Durable Medical Equipment
Covered 100%
Diabetic Supplies
Dental
Vision Eyewear
Pharmacy cost sharing applies if
Pharmacy coverage is included;
otherwise PCP office visit cost
sharing applies.
Not Covered
Not Covered
Transplants
$500 per admission copay
Coverage is provided at an IOE
30% (must precertify if over
$1,500)
30%
Not Covered
Covered same as participating
provider benefit
30% per admission
Coverage is provided at an Non-
contracted facility only IOE contracted facility only
Bariatric Surgery Not Covered Not Covered
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay.
FAMILY PLANNING PARTICIPATING PROVIDERS NON - PARTICIPATING
PROVIDERS
Infertility Treatment Member cost sharing is based on Member cost sharing is based on
Diagnosis and treatment of the underlying the type of service performed and the type of service performed and
medical condition. the place of service where it is the place of service where it is
rendered. rendered.
Comprehensive Infertility Services Not Covered Not Covered
Coverage includes Artificial Insemination and Ovulation Induction
Advanced Reproductive Technology (ART) Not Covered Not Covered
ART coverage includes In -Vitro Fertilization (IVF), Zygote Infra- Fallopian Transfer (ZIFT), Gamete Intra - Fallopian
Transfer (GIFT), cryopreserved embryo transfers, Intra -Cy o _plasmic S_erm Injection TCSI) or ovum microsurgery.
Voluntary Sterilization
Including tubal ligation and vasectomy.
PHARMACY - PRESCRIPTION DRUG
BENEFITS
Subject to applicable service type
member cost sharing
PARTICIPATING PROVIDERS
Subject to applicable service type
member cost sharing
NON - PARTICIPATING
PROVIDERS
Retail
Mail Order
$10 copay for formulary generic Not Covered
drugs, $25 copay for formulary
and -g, 0 cop
for non - nforame ulary brand -name and and
ay
generic drugs up to a 30 day
suppjy br at �articdru
mpasting pharmacies. $4
$20 copay for formulary generic Not Covered
drugs, $50 copay for formulary
brand -name drugs, and $80 copay
for non - formulary brand -name and
generic drugs up to a 31 -90 day
supply from Aetna Rx Home
Delivery ?.
Pharmacy Managed Self Injectables (PMSI)
First prescription fill at any retail or mail order drug facility. Subsequent fills must be through Aetna Specialty Pharmacy`"
No Mandatory Generic (NO MG) - Member is responsible to pay the applicable copay only.
Plan Includes : Contraceptive drugs and devices obtainable from a pharmacy.
Members may choose from a network of available providers (physicians and facilities) or may visit a nonparticipating
provider. The nonparticipating provider will be paid based on Aetna's Recognized Amount (Aetna Market Fee Schedule
(AMFS) and Aetna Facility Fee Schedule), which is the charge Aetna determines to be the appropriate charge level for
the geographic area where the covered service is furnished. The member may be balance billed for the difference
between the nonparticipating provider's usual fee and the amount allowed by the plan, in addition to any coinsurance or
co- payments due under the plan provisions.
Prepared: 06/12/2008 11:00 AM Page 4
5TAet
City of Okeechobee
Proposed effective date: 08 -01 -2008
AETNA CHOICETM POS - Florida
PLAN DESIGN AND BENEFITS
PROVIDED BY AETNA HEALTH INC. - FULL RISK
Spouse, dependent children covered from birth until the end of the calendar year in which they attain age 25, regardless
of student status.
Exclusions and Limitations
"Aetna" is the brand name used for products and services provided by one or more of the Aetna group of subsidiary
companies. The Aetna companies that offer, underwrite or administer benefits include Aetna Health Inc. While this
material is believed to be accurate as of the print date, it is subject to change
This plan does 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. However, your plan documents may contain exceptions to
this list based on state mandates or the plan design or rider(s) purchased.
• All medical and hospital services not specifically covered in, or which 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.
• Durable medical equipment.
• Experimental and investigational procedures, (except for coverage for medically necessary routine patient care costs
for Members participating in a cancer clinical trial).
• Hearing aids.
• Home births
• Immunizations for travel or work
• Implantable drugs and certain injectable drugs including injectable infertility drugs.
• Infertility services including, but not limited to, 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 except diabetic orthotics.
• Outpatient prescription drugs (except for treatment of diabetes), unless covered by a prescription plan rider and over -
the- counter medications (except as provided in a hospital) 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.
• Weight control services including surgical procedures, medical treatments, weight control /loss programs, dietary
regimens and supplements, appetite suppressants and other medications; food or food supplements, exercise
programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or
treat obesity, including Morbid Obesity, or for the purpose of weight reduction, regardless of the existence of comorbid
conditions.
This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a
partial, general description of plan benefits or programs and does not constitute a contract. Aetna does not provide
health care services and therefore, cannot guarantee any results or outcomes. Consult the plan document (i.e.
Schedule of Benefits, Certificate of Coverage, Evidence of Coverage, Group Agreement, Group Insurance Certificate
and /or Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitations
relating to the plan. The availability of a plan or program may vary by geographic service area. Some benefits are
subject to limitations or visit maximums. With the exception of Aetna Rx Home Delivery, all participating physicians,
hospitals and other health care providers are independent contractors and are neither agents nor employees of Aetna.
The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change.
Notice of the change shall be provided in accordance with applicable state law.
Prepared: 06/12/2008 11:00 AM Page 5
X \et i ia.
City of Okeechobee
Proposed effective date: 08 -01 -2008
AETNA CHOICETM POS - Florida
PLAN DESIGN AND BENEFITS
PROVIDED BY AETNA HEALTH INC. - FULL RISK
Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC. If your plan covers
outpatient prescription drugs, your plan may include a drug formulary (preferred drug list). A formulary is a list of
prescription drugs generally covered under your prescription drug benefits plan on a preferred basis subject to
applicable limitations and conditions. Your pharmacy benefit is generally not limited to the drugs listed on the formulary.
The medications listed on the formulary are subject to change in accordance with applicable state law. For information
regarding how medications are reviewed and selected for the formulary, formulary information, and information about
other pharmacy programs such as precertification and step- therapy, please refer to Aetna's website at www.aetna.com,
or the Aetna Medication Formulary Guide. Many drugs, including many of those listed on the formulary, are subject to
rebate arrangements between Aetna and the manufacturer of the drugs. Rebates received by Aetna from drug
manufacturers are not reflected in the cost paid by a member for a prescription drug.
In addition, in circumstances where your prescription plan utilizes copayments or coinsurance calculated on a
percentage basis or a deductible, use of formulary drugs may not necessarily result in lower costs for the member.
Members should consult with their treating physicians regarding questions about specific medications. Refer to your
plan documents or contact Member Services for information regarding the terms and limitations of coverage. Aetna Rx
Home Delivery® refers to Aetna Rx Home Delivery, LLC, a subsidiary of Aetna Inc., that is a licensed pharmacy
providing mail -order pharmacy services. Aetna's negotiated charge with Aetna Rx Home Delivery may be higher than
Aetna Rx Home Delivery's cost of purchasing drugs and providing mail -order pharmacy services.
Certain primary care providers are affiliated with integrated delivery systems or other provider groups (such as
independent practice associations and physician - hospital organizations), and members who select these providers will
generally be referred to specialists and hospitals within those systems or groups. However, if a system or group does
not include a provider qualified to meet member's medical needs, member may request to have services provided by a
non - system or non -group providers. Member's request will be reviewed and will require prior authorization from the
system or group and /or Aetna to be a covered benefit.
Certain services require precertification, or prior approval of coverage. Failure to precertify for these services may lead
to substantially reduced benefits or denial of coverage.
Some of the benefits requiring precertification may include, but are not limited to, inpatient hospital, inpatient mental
health, inpatient skilled nursing, outpatient surgery, substance abuse (detoxification), inpatient and outpatient
rehabilitation). When the Member obtains covered services from participating providers, the provider will obtain
precertification. If the Member obtains covered services from a nonparticipating provider, the Member must obtain the
precertification. Precertification requirements may vary. Members may refer to their plan documents for a complete list
of medical services that require precertification. Certain benefits like comprehensive infertility and advanced
reproductive technology (ART) services, if covered under your plan, are subject to a select network of participating
providers, from which you will be required to seek care to receive covered benefits.
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