Aetna Open Access POS II

Transcription

1 Aetna Open Access POS II The Aetna Open Access Point-of-Service (POS) II Options combine the advantages of managed healthcare with the freedom of traditional medical coverage. With the POS options, every time you receive care, you can choose to receive it on an in-network or out-of-network basis. You have access to participating network providers through the POS II network, as well as out-of-network care. However, with the POS II options, you are not required to have your care coordinated by a primary care physician (PCP). You may elect one of the following Aetna Open Access POS II options: 75%/25% option 80%/20% option 85%/15% option You should know that all of these options cover the same treatments and services. They differ in how you share in the cost of coverage. For example, with the 75%/25 option, you pay less in contributions but have a higher deductible and out-of-pocket maximum. With the 85%/15% option, you pay more in contributions but have a lower deductible and out-ofpocket maximum. In addition, some services are covered at the same level across all of these options. For example, certain preventive care services are covered at 100% and coverage for prescription drug benefits through Express Scripts are identical across all POS options. Additional Important Information Be sure to read the About This Guide and Plan Administration sections for more important details about the plan and this description, and for references to the official plan documents that contain the full specifics about the plan. Salaried and Hourly Employees (excluding Napoleon and Paris Hourly Employees) 37

2 This section describes the Aetna Open Access POS II options. See the Participating in the Healthcare Plans section for other important information. Reservation of Rights Campbell reserves the right to amend, modify, reduce or curtail any aspect of any benefit under the plan, or terminate this plan at any time for any reason. The plan does not provide a vested benefit. In addition, Campbell reserves the right to amend any of the plans, programs and arrangements described in Your Campbell Benefits (including changing the method of providing benefits and curtailing or reducing future benefits) or to terminate at any time for any reason, any or all of the plans, programs and arrangements herein described. Neither Your Campbell Benefits nor the benefits described create a contract of employment or a guarantee of employment between Campbell and any employee. In This Section See Page At a Glance...39 How the POS Option Works...41 In-Network Benefits Out-of-Network Benefits Annual Deductible Coinsurance Annual Out-of-Pocket Maximum Maximum Lifetime Benefit Hospital Notification Understanding Precertification If You Need Emergency Care What Is Covered...47 How the POS Plan Pays Benefits Coverage Limits...51 Newborns and Mothers Health Protection Act Women s Health and Cancer Rights Act of Inpatient Hospital and Related Services Outpatient Services Other Covered Services Medical Plan Exclusions...77 Claiming Benefits...86 Claims Administrator s Contact Information Appealing Claims Salaried and Hourly Employees (excluding Napoleon and Paris Hourly Employees)

3 At a Glance 2014 Medical Option Feature Cost Sharing 75%/25% Option In-Network Annual Deductible ** $700 per individual Annual Out-of-Pocket Maximum ** (deductibles and copays apply toward OOP Max) Aetna Open Access POS II: or 80%/20% Option In-Network 85%/15% Option In-Network All Options Deductibles and Out-of-Pocket Maximums apply to all services unless otherwise noted $3,500 per individual $10,000 maximum $500 per individual $3,000 per individual $10,000 maximum $500 per individual 2,500 per individual $10,000 maximum Out-of-Network * $700 per individual $3,500 per individual $10,000 maximum Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Outpatient Services Primary Doctor Office Visit 75%, no deductible 80%, no deductible 85%, no deductible 60% Specialist Office Visit 75%, no deductible 80%, no deductible 85%, no deductible 60% X-rays and Lab Work 75% 80% 85% 60% Outpatient Surgery 75% 80% 85% 60% Routine Eye Exam Eyewear Reimbursement (lenses, frames and contacts) *** 75%, no deductible; one per calendar year $200 maximum every 24 months 80%, no deductible; one per calendar year $200 maximum every 24 months 85%, no deductible; one per calendar year $200 maximum every 24 months Outpatient Preventive Services (subject to U.S. Preventive Services Taskforce guidelines) Routine Adult Physical Exams/ Immunizations One per calendar year Annual OB/GYN Visit For covered females One per calendar year Well Child Exams/Immunizations Subject to age and frequency limits as noted under Outpatient Services on page 53. Not covered $200 maximum every 24 months 100%, no deductible 100%, no deductible 100%, no deductible 60% 100%, no deductible 100%, no deductible 100%, no deductible 60% 100%, no deductible 100%, no deductible 100%, no deductible 60% Salaried and Hourly Employees (excluding Napoleon and Paris Hourly Employees) 39

4 2014 Medical Option Feature Inpatient Services 75%/25% Option In-Network Aetna Open Access POS II: or 80%/20% Option In-Network 85%/15% Option In-Network All Options Out-of-Network * Hospital Room & Board 75% 80% 85% 60% Physician (including surgery) Emergency Room $100 copay; 75% (copay waived if admitted) 75% 80% 85% 60% $100 copay; 80% (copay waived if admitted) $100 copay; 85% (copay waived if admitted) Same as in-network Urgent Care $50 copay; 75% $50 copay; 80% $50 copay; 85% $50 copay; 60% Behavioral Health Services Provided under Your Life Resources Program section administered by Aetna Behavioral Health: or SOUP (7687) Behavioral Health Outpatient Behavioral Health Inpatient Prescription Drug**** 75%, no deductible for physician office visit 80%, no deductible for physician office visit 85%, no deductible for physician office visit 60% 75% 80% 85% 60% Provided under the Prescription Drug Program section, administered by Express Scripts: or Annual Out-of-Pocket Maximum Retail (up to 30 day supply) Mail Order (up to 90 day supply) Generic: 15% coinsurance ($10 min) Brand: 30% coinsurance ($15 min) Generic: 15% coinsurance ($20 min) Brand: 30% coinsurance ($30 min) $1,500 per member * Out-of-network benefits are subject to usual and customary (U&C) limits; charges above these limits are the responsibility of the covered member. ** Covered expenses count toward both the in- and out-of-network deductible and out-of-pocket maximum amounts. *** Combined in- and out-of-network. ****The medical annual deductible and out-of-pocket maximums do not apply to the Express Scripts Prescription Drug program. 40 Salaried and Hourly Employees (excluding Napoleon and Paris Hourly Employees)

5 How the POS Option Works The POS options have networks of participating physicians, hospitals, and other healthcare professionals who have agreed to a negotiated fee arrangement for covered health services. You may view an online provider directory by visiting Aetna online at or calling the number on your ID card. Please Note: Even though service providers participating in the network can change during the year, you won t be able to change to another option until the next annual enrollment period, unless you experience a qualified status change. Here are highlights of how the plan works: Each time you receive care, you can choose to receive care from in-network or out-of-network providers. You may, but are not required to, designate a primary care physician (PCP). For in-network physician office visits, you pay coinsurance only, no deductible. The plan offers 100% coverage for eligible in-network preventive medical care, with no deductible, subject to U.S. Preventive Services Taskforce guidelines. For in-network care, the provider files claims, obtains authorization for hospital admission and obtains any required precertification for services. Network providers have agreed to accept a reduced fee called the negotiated charge; and therefore you are not subject to usual and customary (U&C) limits for in-network services. Out-of-network care is generally subject to a higher annual deductible and out-of-pocket maximums, and expenses are covered at a lower coinsurance percentage than in-network services. Out-of-network expenses are subject to U&C limits; you are responsible for any amounts in excess of these limits. For out-of-network services, you are also responsible for filing any required claim forms, obtaining authorizations for hospital admissions and obtaining any required precertifications for services. When you enroll in one of the Campbell healthcare options, you are automatically enrolled in the Express Scripts Prescription Drug Program. In-Network Benefits Contacting Aetna Aetna has selected a group of healthcare professionals and facilities for the Aetna network. All providers in the POS network must meet certain quality criteria established by Aetna. Aetna monitors the quality of services patients receive through regular practice reviews, site visits, chart reviews and numerous other measures. When you receive in-network care through the POS options, the following benefit features apply: You are covered at 100% for eligible preventive care screenings. You usually don t have to file any claim forms; your network provider will usually file claims for you. Your deductible and out-of-pocket expenses will be lower compared to your expenses for the same type of care on an out-of-network basis. Doctor s office visits are subject to the coinsurance only; the deductible does not apply. The doctors have agreed to accept negotiated fees that are generally lower than what you would pay out-of-network; as a result usual and customary (U&C) fees do not apply. You may view an online provider directory at Salaried and Hourly Employees (excluding Napoleon and Paris Hourly Employees) 41

6 Out-of-Network Benefits Under the POS options, you can choose to visit an out-of-network physician, hospital, or other provider at any time. For all of the options, if you choose to receive covered services on an out-of-network basis: Services performed by providers not participating in the network will be reimbursed at the out-of-network level of benefits, based on U&C limits, for covered services. You are responsible for any amounts above the U&C limits. You ll need to file a claim form to receive out-of-network benefits. See Claiming Benefits on page 86 for more information. You ll need to obtain any required precertifications for services as well as authorizations for hospital admissions. (See Hospital Notification on page 44 and Understanding Precertification on page 44 for more information.) Your costs for medically necessary covered services generally will be higher than if you received in-network care. Annual Deductible Before you receive coverage for many services from any of the POS options, you need to satisfy an annual deductible. Exceptions include in-network preventive care, in-network doctor s office visits and Express Scripts prescription drug benefits, which are not subject to the deductible. All other services are subject to the deductible and only covered services count toward the deductible. This includes only U&C charges for medically necessary services out-of-network. Amounts above U&C limits are not covered services and do not count toward your deductible. There are no U&C limits for in-network services. Covered expenses count toward both the in-network and out-of-network deductibles. The annual deductible for each option is shown below: 75%/25 In-Network $700 per individual Annual Deductible* 80%/20% 85%/15% In-Network In-Network $500 per individual $500 per individual All Options Out-of-Network $700 per individual * The deductible does not apply to the Express Scripts Prescription Drug program, in-network doctor office visits or in-network preventive care. Under the POS options, each covered person must pay for all covered expenses that are subject to the deductible until the individual deductible is met. Once the individual deductible is satisfied, any additional eligible expenses incurred by that individual are covered at the coinsurance level for that option, until the out-of-pocket maximum is reached. After a covered person meets the individual deductible amount, that person will pay no further expenses towards the deductible, but other covered persons must continue to pay for covered expenses towards their deductibles until that person s individual deductible is satisfied. 42 Salaried and Hourly Employees (excluding Napoleon and Paris Hourly Employees)

7 Coinsurance Once you satisfy the plan deductible, you and the plan will share the cost of covered services. Your share of this cost is known as the coinsurance, and this is the percentage of a covered medical expense that you must pay. For example, under the 80%/20% POS option, the plan will reimburse 80% of the allowable charge and you will pay the remaining 20% coinsurance. When you use out-ofnetwork providers, you must also pay all charges above the U&C limits. Annual Out-of-Pocket Maximum Under the POS options, this is the maximum amount of covered, eligible expenses that you would pay in a calendar year (including your annual deductible and coinsurance payments). Once the out-of-pocket maximum is satisfied, additional eligible expenses are then covered at 100%. If you use an out-ofnetwork provider, only U&C charges for medically necessary services will count toward the annual out-of-pocket maximum. Amounts above U&C are not covered expenses and do not count toward your annual out-of-pocket maximum. The outof-pocket maximum for each option is shown below: Charges that Exceed U&C or Other Plan Limits You are responsible for paying any charges above the U&C limits when you use out-ofnetwork providers and any charges for services that exceed other plan limits (such as charges for certain services that limit the number of visits or days). Such charges are not considered covered charges and do not apply toward the out-of-pocket maximum. 75%/25% In-Network $3,500 per individual $10,000 maximum Annual Out-of-Pocket Maximum* 80%/20% 85%/15% In-Network In-Network $3,000 per individual $10,000 maximum 2,500 per individual $10,000 maximum All Options Out-of-Network $3,500 per individual $10,000 maximum * The out-of-pocket maximum does not apply to the Express Scripts Prescription Drug benefits. Each covered person must pay their portion of all eligible out-of-pocket expenses until the individual maximum is met. Once the individual out-of-pocket maximum is met, any additional eligible expenses incurred are then covered at 100% for that person. All other covered persons must continue to pay their portion of all eligible expenses until that person s individual out-of-pocket maximum is satisfied or until the combined out-of-pocket payments for eligible expenses for all family members meet the total out-of-pocket maximum of $10,000. If the maximum out-of-pocket maximum of $10,000 is satisfied, any additional eligible expenses incurred by covered members will be covered at 100%. Maximum Lifetime Benefit There is no maximum lifetime benefit limit for in-network or out-of-network care for each individual covered under the POS options. However, there is a separate $35,000 lifetime maximum for Advanced Reproductive Technology (ART) benefits. Certain treatment limits may apply to different types of service, like infertility, for example. Salaried and Hourly Employees (excluding Napoleon and Paris Hourly Employees) 43

8 Hospital Notification For out-of-network services, you must contact the claims administrator within 48 hours before all scheduled hospital admissions, convalescent facility admissions, home healthcare expenses and skilled nursing care. In the event of an emergency, you can make this notification within 48 hours after your admission. You must also contact the claims administrator if a maternity stay will exceed 48 hours for the mother and newborn child following a vaginal delivery, or 96 hours for the mother and newborn child following a cesarean section delivery. Failure to pre-certify a hospital stay will result in a $400 penalty. For in-network services, your network provider will be responsible for the hospital notification. Understanding Precertification Certain services, such as inpatient stays, certain tests, procedures and outpatient surgery require precertification by Aetna. Precertification is a process that helps you and your physician determine whether the services being recommended are covered expenses under the plan. It also allows Aetna to help your provider coordinate your transition from an inpatient setting to an outpatient setting (called discharge planning), and to register you for specialized programs or case management when appropriate. How to Precertify To precertify certain medical services, you need to call Aetna at the number on the back of your ID card. In-Network Services: You do not need to precertify services provided by a network provider. Network providers will be responsible for obtaining necessary precertification for you. Since precertification is the provider s responsibility, there is no additional out-of-pocket cost to you as a result of a network provider s failure to precertify services. Out-of-Network Services: When you go to an out-of-network provider, it is your responsibility to obtain precertification from Aetna for any services or supplies on the precertification list below. If you do not precertify, your benefits may be reduced, or the plan may not pay any benefits. What Is the Difference Between Hospital Notification and Precertification? Hospital notification lets Aetna know that you are being admitted to the hospital (or, in the case of an emergency, you have been admitted). Aetna will then determine how long your stay should be, based on your medical condition. If you need to stay longer than originally determined, Aetna must be notified. Precertification determines whether a recommended service or hospital admission is covered by the plan. It also facilitates transition from an inpatient setting to an outpatient setting and provides access to specialized programs or case management when appropriate. The Precertification Process Prior to being hospitalized or receiving certain other medical services or supplies there are certain precertification procedures that must be followed. Important Note Please read the following sections in their entirety for important information on the precertification process and any impact it may have on your coverage. 44 Salaried and Hourly Employees (excluding Napoleon and Paris Hourly Employees)

9 For out-of-network services, you are responsible for obtaining precertification. You or a member of your family, a hospital staff member, or the attending physician, must notify Aetna by calling the telephone number on your ID card to precertify the admission or medical services and expenses prior to receiving any of the services or supplies that require precertification in accordance with the following timelines: For non-emergency admissions: For an emergency outpatient medical condition: For an emergency admission: For an urgent admission: For outpatient non-emergency medical services requiring precertification: You, your physician or the facility will need to call and request precertification at least 14 days before the date you are scheduled to be admitted. You or your physician should call prior to the outpatient care, treatment or procedure if possible; or as soon as reasonably possible. You, your physician or the facility must call within 48 hours or as soon as reasonably possible after you have been admitted. You, your physician or the facility will need to call before you are scheduled to be admitted. An urgent admission is a hospital admission by a physician due to the onset of or change in an illness; the diagnosis of an illness; or an injury. You or your physician must call at least 14 days before the outpatient care is provided, or the treatment or procedure is scheduled. Aetna will provide a written notification to you and your physician of the precertification decision for out-of-network services. If your precertified expenses are approved the approval is good for 60 days as long as you remain enrolled in the plan. When you have an inpatient admission to an out-of-network facility, Aetna will notify you, your physician and the facility about your precertified length of stay. If your physician recommends that your stay be extended, additional days will need to be certified. You, your physician, or the facility will need to call Aetna at the number on your ID card as soon as reasonably possible, but no later than the final authorized day. Aetna will review and process the request for an extended stay. You and your physician will receive a notification of an approval or denial. If precertification determines that the out-of-network stay or services and supplies are not covered expenses, the notification will explain why and how Aetna s decision can be appealed. You or your provider may request a review of the precertification decision pursuant to the Claims Procedure as outlined in the Plan Administration section. For in-network services, your network provider is responsible for obtaining the necessary precertification for you and Aetna will notify your provider of the precertification decision. Services and Supplies Which Require Precertification Precertification is required for the following types of medical expenses: Stays in a hospital Stays in a skilled nursing facility Stays in a rehabilitation facility Salaried and Hourly Employees (excluding Napoleon and Paris Hourly Employees) 45

10 Stays in a hospice facility Outpatient hospice care Stays in a residential treatment facility for treatment of mental disorders, alcoholism or drug abuse treatment Comprehensive infertility services Home health care Private duty nursing care. Contact Aetna Member Services at the number on your ID card with any questions on precertification requirements for specific services and to begin the precertification process for out-of-network services as needed. How Failure to Precertify Affects Your Benefits A precertification benefit reduction will be applied to the benefits paid if you fail to obtain a required precertification prior to incurring medical expenses. This means Aetna will reduce the amount paid towards your coverage, or your expenses may not be covered at all. You will be responsible for the unpaid balance of the bills. You are responsible for obtaining the necessary precertification from Aetna prior to receiving services from an out-of-network provider. Your provider may precertify your treatment for you; however you should verify with Aetna prior to the procedure, that the provider has obtained precertification from Aetna. If your treatment is not precertified by you or your provider, the benefit payable may be significantly reduced or your expenses may not be covered. How Your Benefits for Inpatient and Outpatient Care, Procedures and Treatment Are Affected The chart below illustrates the effect of precertification on your benefits, including the effect if the required precertification for outpatient or inpatient services, procedures and treatments is not obtained. If precertification is: Requested and approved by Aetna Requested and denied Not requested, but would have been covered if requested Not requested, would not have been covered if requested Then the expenses are: Covered Not covered Covered after a $400 precertification benefit reduction is applied Not covered It is important to remember that any additional out-of-pocket expenses incurred because your precertification requirement was not met will not count toward your deductible or payment percentage or maximum out-of-pocket limit. If You Need Emergency Care If you have a medical emergency that s sudden, urgent, and life-threatening, you should call 911 or go to the nearest physician, hospital emergency room, or other urgent care facility. Your emergency care will be covered based on the deductible and coinsurance provisions of your POS option (either 75%, 80% or 85%) after a $100 copay. If you are admitted to the hospital, the emergency room copay is waived. 46 Salaried and Hourly Employees (excluding Napoleon and Paris Hourly Employees)

11 What Is Covered The Point-of-Service (POS) Options cover a wide variety of services, as long as the services are medically necessary. While all POS options cover the same types of services, how services are covered may differ and/or be subject to certain limits or restrictions. How the POS Plan Pays Benefits The level at which benefits are paid depends on which POS option you choose and whether you receive your care in-network or out-of-network. See the table below to find out how common treatments and services are covered. Unless otherwise noted, deductibles and out-of-pocket maximums apply to the coverages shown in the table. Be sure to review Coverage Limits on page 51 to see which limits apply. Please Note: All the options cover in-network preventive care (for example, routine well woman preventive exam office visits, including Pap smears, and certain preventive immunizations) at 100% with no deductible. And, prescription drug benefits are the same for all of the plan options. Certain Limitations Keep in mind that certain services listed here are limited to a specific number of visits or days of treatment. Any services that have such limits (for example, chiropractic treatment) continue to be determined by medical necessity requirements. In other words, the treatment must be medically necessary, even if the number of visits or days of treatment is within the prescribed limitations. The limitations are described within each coverage chart Aetna POS Options Feature Cost Sharing 75%/25% Option In-Network Annual Deductible ** $700 per individual Coinsurance Percentage Annual Out-of-Pocket $3,500 per Maximum ** individual 80%/20% Option In-Network 85%/15% Option In-Network All Options Out-of- Network* Deductibles and out-of-pocket maximums apply to all services unless otherwise noted $10,000 maximum $500 per individual $500 per individual $700 per individual 75% 80% 85% 60% $3,000 per individual $10,000 maximum 2,500 per individual $10,000 maximum $3,500 per individual $10,000 maximum Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Preventive Care (subject to the U.S. Preventive Taskforce guidelines and the comprehensive guidelines supported by the Health Resources and Services Administration.) Routine Physical exams Over age 18, one per calendar year 100%, no deductible 100%, no deductible 100%, no deductible 60% Salaried and Hourly Employees (excluding Napoleon and Paris Hourly Employees) 47

12 2014 Aetna POS Options Feature OB/GYN Exams and Pap Smears For covered females, one per calendar year Well Child Care See Well Child Care on page 59 for age and frequency limits. Routine Immunization and Related Office Visits Routine Cancer Screenings See Routine Cancer Screenings on page 56 for more information. Screening & Counseling Services for Obesity, Misuse of Alcohol and/or Drugs and Use of Tobacco Prenatal Care Office Visits Comprehensive Lactation Support and Counseling Services Family Planning Services 75%/25% Option In-Network 100%, no deductible 100%, no deductible 100%, no deductible 80%/20% Option In-Network 100%, no deductible 100%, no deductible 100%, no deductible 100%, no deductible 85%/15% Option In-Network 100%, no deductible 100%, no deductible 100%, no deductible Maximums: Subject to age and visit limitations provided in the U.S. Preventive Task Force recommendations and the comprehensive guidelines supported by the Health Resources and Services Administration. For details, contact your physician, log onto the Aetna website at or call the number on the back of your ID card. 100%, no deductible See Screening and Counseling Services on page 57 for more information. 100%, no deductible See Prenatal Care on page 57 for more information. All Options Out-of- Network* 60% 60% 60% 60% 60% 60% 100% per visit, no deductible 60% Lactation counseling services Maximum of six facility or office visits per calendar year; visits in excess of this maximum are covered as doctor office visits Breast pumps and supplies 100% per item, no deductible See Comprehensive Lactation Support and Counseling Services on page 58 and Breast Feeding Durable Medical Equipment on page 58 for more information. 100%, no deductible Female contraceptive counseling Maximum of two office per 12 months; visits in excess of this maximum are covered under the Physician Services, Office Visit provisions of this plan Not covered 60% 60% 48 Salaried and Hourly Employees (excluding Napoleon and Paris Hourly Employees)

13 2014 Aetna POS Options Feature Family Planning Other (Outpatient) Voluntary Termination of Pregnancy Voluntary Sterilization for Males Voluntary Sterilization for Females Routine Eye Exams One exam per calendar year Eyewear Expenses Up to $200 every 24 months*** Routine Hearing Exams For covered individuals, one exam every 24 months 75%/25% Option In-Network Outpatient Medical Services Doctor Office Visits Specialist Office Visits 80%/20% Option In-Network 85%/15% Option In-Network All Options Out-of- Network* 75% 80% 85% 60% 75% 80% 85% 60% 100%, no deductible 75%, no deductible 100%; no deductible 100%; no deductible 80%, no deductible 85%, no deductible 60% Not covered 100% 100% 100% 100% 100%, no deductible 75%, no deductible 75%, no deductible 100%, no deductible 100%, no deductible 80%, no deductible 85%, no deductible 80%, no deductible 85%, no deductible X-rays and Labs 75% 80% 85% 60% Outpatient Medical Services Infertility Services 75% 80% 85% 60% Advance Reproductive Technology (ART) Speech, Physical, or Occupational Therapy 60% 60% 60% 75% 80% 85% Not covered 75% 80% 85% 60% Chiropractic Care 20 visits per calendar year*** 75% 80% 85% 60% Salaried and Hourly Employees (excluding Napoleon and Paris Hourly Employees) 49

14 2014 Aetna POS Options Feature Private Duty Nursing Care Maximum of 70 shifts per calendar year*** Inpatient Medical Services 75%/25% Option In-Network 80%/20% Option In-Network 85%/15% Option In-Network All Options Out-of- Network* 75% 80% 85% 60% Acute Hospital Care 75% 80% 85% 60% Behavioral Health Services Provided under Your Life Resources Program section administered by Aetna Behavioral Health: or SOUP (7687) Mental Healthcare Outpatient Mental Healthcare Inpatient Substance Abuse Outpatient Substance Abuse Care Inpatient Other Services 75%, no deductible for physician office visit 80%, no deductible for physician office visit 85%, no deductible for physician office visit 60% 75% 80% 85% 60% 75%, no deductible for physician office visit Emergency Room $100 copay; 75% (copay waived if admitted) 80%, no deductible for physician office visit 85%, no deductible for physician office visit 60% 75% 80% 85% 60% $100 copay; 80% (copay waived if admitted) $100 copay; 85% (copay waived if admitted) Same as Innetwork Urgent Care $50 copay; 75% $50 copay; 80% $50 copay; 85% $50 copay; 60% Home Healthcare 120 visits per calendar year*** Skilled Nursing Facility Maximum of 60 days per calendar year*** Hospice Care See Hospice Care on page 71, under Other Covered Services on page 59 for limitations 75% 80% 85% 60% 75% 80% 85% 60% 75% 80% 85% 60% 50 Salaried and Hourly Employees (excluding Napoleon and Paris Hourly Employees)

15 2014 Aetna POS Options Feature Durable Medical Equipment and Prosthetics Prescription Drugs 75%/25% Option In-Network 80%/20% Option In-Network 85%/15% Option In-Network All Options Out-of- Network* 75% 80% 85% 60% Please see the Prescription Drug section of this book. * Generally, all out-of-network expenses are subject to U&C limits. You should note that since in-network charges for covered services have been negotiated with the providers, U&C limits do not apply. ** Annual deductible applies toward out-of-pocket maximum. *** Combined in-network and out-of-network. All out-of-network expenses are subject to U&C limits. Coverage Limits This section describes the coverage, along with the limits that may apply to covered treatments and services. Newborns and Mothers Health Protection Act In accordance with the Newborns and Mothers Health Protection Act, group medical plans and health insurance issuers may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a normal vaginal delivery, or to less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother s or newborn s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours as applicable). Women s Health and Cancer Rights Act of 1998 Solely to the extent required under the Women s Health and Cancer Rights Act (hereinafter WHCRA ), the Medical Plan will provide certain benefits related to benefits received in connection with a mastectomy. The Medical Plan will include coverage for reconstructive surgery following a mastectomy. If you or your dependent(s) (including your spouse or domestic partner) are receiving benefits under the plan in connection with a medically necessary mastectomy and you or your dependent(s) (including your spouse or domestic partner) elect breast reconstruction, the coverage will be provided in a manner determined in consultation with the attending physician and the patient, including coverage for the following: All stages of reconstruction of the breast on which the mastectomy was performed Surgery and reconstruction for the other breast to produce a symmetrical appearance Prostheses Treatment of physical complications of the mastectomy, including lymphedema. Salaried and Hourly Employees (excluding Napoleon and Paris Hourly Employees) 51

16 This coverage will be subject to the same annual deductible and coinsurance provisions that apply for the mastectomy. If you have any questions regarding coverage for mastectomies and reconstructive surgery, please contact your health coverage carrier by calling the number on the back of your ID card. Inpatient Hospital and Related Services The Aetna POS options cover medically necessary inpatient hospital admissions for an unlimited number of days based on the hospital s standard rate for semi-private or common rooms, except for isolation of communicable diseases. Hospital pre-notification is required for non-emergency admissions. Covered services include, but are not limited to the following services, subject to any limitations or requirements of the plan: Administration of blood and blood products, but not the cost of the blood or blood products Allergy testing and treatment, when provided as part of inpatient care for another covered condition and based on medical necessity Anesthetics and their administration Bariatric surgery subject to claims administrator guidelines (see Obesity Treatment on page 68 for additional information) Basic metabolic examinations Certain dental surgeries that are medical in nature and required to be performed in a hospital setting or medical doctor s office, if the surgery is needed because of a congenital disorder or accidental injury and treatment is received within 12 months of the accident, and charges are not covered by the Campbell Dental Plan Convalescent facility expenses up to 60 days per calendar year Cosmetic surgery when needed to reconstruct or treat a functional defect of a congenital disorder or malfunction, treat an infection or disease, or treat an injury or accident (see Reconstructive or Cosmetic Surgery and Supplies on page 65 for additional information) Diagnostic services, including: EEG, EKG, and other diagnostic medical procedures Laboratory and pathology tests Radiology services. Electrocardiographic and physiotherapeutic equipment Hemodialysis for kidney failure Intensive care unit service if medically necessary Maternity care, including: Any required care for an illness or injury that the newborn develops either before or after birth, as long as you and your newborn are enrolled in the appropriate coverage category within prescribed enrollment timeframes Care required due to miscarriage or ectopic pregnancy Coverage of eligible expenses if your dependent child has a baby, but not including nursery or other expenses incurred by the newborn child Delivery by a certified, registered nurse or midwife in a birthing center 52 Salaried and Hourly Employees (excluding Napoleon and Paris Hourly Employees)

17 Drugs, medications, and anesthesia Normal or cesarean section delivery Routine medical and hospital nursery care for your covered newborn child Circumcision by a licensed provider (for your covered newborn child) A semi-private room. The period of hospitalization for childbirth (for either the mother or the covered newborn child) is up to 48 hours following a vaginal delivery or 96 hours following a cesarean section. (However, your attending physician after consulting with the mother may decide to discharge the mother or newborn child earlier.) Gender reassignment subject to claims administrator guidelines. Covered services include any treatment, drug, service or supply related to changing sex or sexual characteristics, including: Surgical procedures to alter the appearance or function of the body Hormones and hormone therapy Prosthetic devices Medical or psychological counseling. Operative and surgical procedures by a licensed provider for the treatment of a disease or injury, including pre-operative preparation and post-operative care Pre-admission testing when completed within seven days of hospital admission Take-home drugs and medications. This list is subject to change at any time. Outpatient Services As with inpatient services, the Aetna POS options cover many of the same medically necessary outpatient services. Covered services include, but are not limited to the following services, subject to any limitations or requirements of the plan: Acupuncture when used as a form of pain control and performed by a licensed provider (check with your claims administrator) Allergy testing and treatment Chemotherapy and radiation treatments Chiropractic care (up to 20 visits/calendar year) when medically necessary as determined by the claims administrator to diagnose or treat illness, injury, or disease. Coverage ends once maximum medical recovery has been achieved and treatment is primarily for maintenance or managing pain Contraceptives: The following contraceptives and contraceptive devices: Injectable contraceptives Contraceptive rings Implantable contraceptives and IUDs are covered when obtained from a physician. The physician will provide insertion and removal of the drugs or device Over the counter contraceptive supplies including but not limited to condoms, contraceptive foams, jellies and ointments. See Family Planning Services Female Contraceptives on page 59 for more information. Salaried and Hourly Employees (excluding Napoleon and Paris Hourly Employees) 53

18 Diagnostic services, including: EEG, EKG, and other medical electronic procedures Laboratory and pathology tests Radiology services. Education therapy, but only for participants with a diagnosis of diabetes mellitus Hemodialysis provided at a free-standing facility such as a dialysis center, or your home, when ordered by a licensed provider Licensed, general hospital emergency room use for treatment of an injury or sudden illness, including: Emergency treatment rooms Laboratory and pathology tests Licensed providers services Supplies and medicines administered during the visit Radiology services. Licensed provider-prescribed respiratory therapy approved by the claims administrator Occupational therapy rendered by a licensed therapist (See Short-Term Rehabilitation Therapy Services on page 66 for additional information.) Outpatient surgery and related follow-up care Physical therapy rendered by a licensed therapist (See Short-Term Rehabilitation Therapy Services on page 66 for additional information.) Podiatric care when medically necessary as determined by the claims administrator to diagnose or treat illness, injury, or disease. Coverage ends once maximum medical recovery has been achieved and treatment is primarily for maintenance or managing pain Prenatal care Routine eye exam/eyewear expenses: covered medical expenses include charges for a complete eye exam, including refraction, which is furnished by a legally qualified ophthalmologist or optometrist to a person, and eyewear supplies. Routine eye exams are limited to one exam per calendar year. Covered expenses for routine eyewear are limited to a maximum of $200 per 24 months. Speech therapy rendered by a licensed therapist (See Short-Term Rehabilitation Therapy Services on page 66 for additional information.) Routine Physical Exams Covered expenses include charges made by your physician for routine physical exams. This includes routine vision and hearing screenings given as part of the routine physical exam. A routine exam is a medical exam given by a physician for a reason other than to diagnose or treat a suspected or identified illness or injury. Covered services include: Evidence-based services and items based on the current U.S. Preventive Services Task Force recommendation with a rating of A or B 54 Salaried and Hourly Employees (excluding Napoleon and Paris Hourly Employees)

19 For women, screenings and counseling services as provided for in the comprehensive guidelines recommended by the Health Resources and Services Administration. These services may include but are not limited to: Screening and counseling services, such as: Interpersonal and domestic violence Sexually transmitted diseases Human Immune Deficiency Virus (HIV) infections. Screening for gestational diabetes High-risk human papillomavirus (HPV) DNA testing for women age 30 and older. X-rays, lab and other tests given in connection with the exam For covered newborns, an initial hospital check up. Limitations Unless specified above, charges for the following are not covered under routine physical exams: Services which are covered to any extent under any other part of this plan Services which are for diagnosis or treatment of a suspected or identified illness or injury Exams given during your stay for medical care Services not given by a physician or under his or her direction Psychiatric, psychological, personality or emotional testing or exams. Preventive Care Immunizations Covered expenses include charges made by your physician or a facility for: Immunizations for infectious diseases The materials for administration of immunizations that have been recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. Limitations Charges for immunizations that are not considered preventive care such as those required due to your employment or travel are not covered under preventive care immunizations. Well Woman Preventive Visits Covered expenses include charges made by your physician for a routine well woman preventive exam office visit, including Pap smears, in accordance with the recommendations by the Health Resources and Services Administration. A routine well woman preventive exam is a medical exam given by a physician for a reason other than to diagnose or treat a suspected or identified illness or injury. The following women s preventive care services are covered at 100% with no deductible when you use an in-network provider: Well-woman exams Gestational diabetes screenings Salaried and Hourly Employees (excluding Napoleon and Paris Hourly Employees) 55

20 Human papiliomavirus (HPV) DNA testing for women age 30 and older Screenings for sexually transmitted infections Screening and counseling for HIV Screening and counseling for domestic violence Counseling for and payment of United States Food and Drug Administration (FDA)- approved contraception methods (for example, oral contraception, emergency contraception and injectables) Counseling for breastfeeding and payment of rental equipment and supplies Limitations Unless specified above, charges for the following are not covered under well woman preventive visits: Services which are covered to any extent under any other part of this plan Services which are for diagnosis or treatment of a suspected or identified illness or injury Exams given during your stay for medical care Services not given by a physician or under his or her direction Psychiatric, psychological, personality or emotional testing or exams. Routine Cancer Screenings Covered expenses include, but are not limited to, charges incurred for routine cancer screening as follows: Mammograms Fecal occult blood tests Digital rectal exams Prostate specific antigen (PSA) tests Sigmoidoscopies Double contrast barium enemas (DCBE) Colonoscopies. These benefits will be subject to any age, family history, and frequency guidelines that are: Evidence-based items or services items based on the current U. S. Preventive Services Task Force recommendation with a rating of A or B Evidence-informed items or services provided in the comprehensive guidelines supported by the Health Resources and Services Administration. Limitations Unless specified above, services which are covered to any extent under any other part of this plan are not covered under routine cancer screenings. 56 Salaried and Hourly Employees (excluding Napoleon and Paris Hourly Employees)

21 Important Reminders Refer to How the POS Plan Pays Benefits beginning on page 47 for details about cost sharing and benefit maximums that apply to preventive care. For details on the frequency and age limits that apply to routine physical exams and routine cancer screenings, contact your physician, log on to the Aetna website at or call the Member Services at the number on the back of your ID card. Screening and Counseling Services Covered expenses include charges made by your primary care physician in an individual or group setting for the following: Obesity Screening and counseling services to aid in weight reduction due to obesity. Coverage includes: Preventive counseling visits and/or risk factor reduction intervention Medical nutrition therapy Nutrition counseling Healthy diet counseling visits provided in connection with hyperlipidemia (high cholesterol) and other known risk factors for cardiovascular and diet-related chronic disease. Use of Tobacco Products Screening and counseling services to aid in the cessation of the use of tobacco products. Tobacco product means a substance containing tobacco or nicotine including: cigarettes, cigars, smoking tobacco, snuff, smokeless tobacco, and candy-like products that contain tobacco. Coverage includes: Preventive counseling visits Treatment visits Class visits to aid in the cessation of the use of tobacco products. Limitations Unless specified above, charges for the following are not covered: Services which are covered to any extent under any other part of this plan Services which are for diagnosis or treatment of a suspected or identified illness or injury Exams given during your stay for medical care Prenatal Care Prenatal care is covered as preventive care for services received by a pregnant woman in a physician s, obstetrician s, or gynecologist s office but only to the extent described below. Coverage for prenatal care under preventive care is limited to pregnancy-related physician office visits including the initial and subsequent history and physical exams of the pregnant woman (maternal weight, blood pressure and fetal heart rate check). Salaried and Hourly Employees (excluding Napoleon and Paris Hourly Employees) 57

22 Limitations Unless specified above, charges for the following are not covered: Services which are covered to any extent under any other part of this plan Pregnancy expenses (other than prenatal care as described above). Comprehensive Lactation Support and Counseling Services Covered expenses include comprehensive lactation support (assistance and training in breast feeding) and counseling services provided to women during pregnancy and in the post partum period by a certified lactation support provider. The post partum period means the one-year period directly following the child s date of birth. Covered expenses incurred during the post partum period also include the rental or purchase of breast feeding equipment as described in Breast Feeding Durable Medical Equipment below. Lactation support and lactation counseling services are covered expenses when provided in either a group or individual setting. Benefits for lactation counseling services are subject to the visit maximum shown in How the POS Plan Pays Benefits beginning on page 47. Breast Feeding Durable Medical Equipment Coverage includes the rental or purchase of breast feeding durable medical equipment for the purpose of lactation support (pumping and storage of breast milk) as follows. Breast Pump Covered expenses include: The rental of a hospital-grade electric pump for a newborn child when the newborn child is confined in a hospital The purchase of: An electric breast pump (non-hospital grade), if requested within 60 days from the date of the birth of the child. A purchase will be covered once every three years following the date of the birth. A manual breast pump, if requested within 12 months from the date of the birth of the child. A purchase will be covered once every three years following the date of the birth. If an electric breast pump was purchased within the previous three year period, the purchase of an electric or manual breast pump will not be covered until a three-year period has elapsed from the last purchase of an electric pump. Breast Pump Supplies Coverage is limited to only one purchase per pregnancy in any year where a covered woman would not qualify for the purchase of a new pump. Coverage for the purchase of breast pump equipment is limited to one item of equipment, for the same or similar purpose, and the accessories and supplies needed to operate the item. You are responsible for the entire cost of any additional pieces of the same or similar equipment you purchase or rent for personal convenience or mobility. Aetna reserves the right to limit the payment of charges up to the most cost efficient and least restrictive level of service or item which can be safely and effectively provided. The decision to rent or purchase is at the discretion of Aetna. 58 Salaried and Hourly Employees (excluding Napoleon and Paris Hourly Employees)