PLAN FEATURES NON- Deductible (per calendar year) $1,300 Individual $2,000 Individual $2,600 Family $4,000 Family All covered expenses including prescription drugs accumulate toward both the preferred and non-preferred deductible. Unless otherwise indicated, the deductible must be met prior to benefits being payable. Once the family deductible is met, all family members will be considered as having met their deductible for the remainder of the calendar year. Member Coinsurance Applies to all expenses unless otherwise stated. Out-of-Pocket Maximum (per calendar year) 10% $2,500 Individual 30% $3,500 Individual $5,000 Family $7,000 Family All covered expenses including deductible and prescription drugs accumulate toward both the preferred and non-preferred outof-pocket maximum. Certain member cost sharing elements may not apply toward the out-of-pocket maximum. Only those out-of-pocket expenses resulting from the application of coinsurance percentage, deductibles, and prescription drug copays (except any penalty amounts) may be used to satisfy the out of pocket maximum. Once the 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. Lifetime Maximum (Maximum amount paid by the plan) Unlimited Unlimited Primary Care Physician Selection Strongly Recommended Not applicable *Precertification Requirements Precertification for certain types of non-preferred care must be obtained to avoid a reduction in benefits paid for that care. Precertification applies for the following non-preferred care services: Hospital Admissions, Treatment Facility Admissions, Convalescent Facility Admissions, Home Health Care, Durable Medical Equipment, Hospice Care and Private Duty Nursing. If precertification is not obtained, the reduction in benefit will be $400 per occurrence which will be applied separately to each type of expense. Referral Requirement PREVENTIVE CARE Routine Adult Physical Exams/ Immunizations None None NON- 1 exam per 24 months for members age 22 to age 50; 1 exam per 12 months for adults age 50 and older. Routine Well Child Exams/Immunizations 7 exams in the first 12 months of life, 3 exams in the second 12 months of life, 3 exams in the third 12 months of life. 1 exam per 12 months thereafter to age 22. Routine Gynecological Care Exams Includes routine tests and related lab fees, limited to 2 exams per calendar year. Routine Mammograms 1 exam per calendar year for covered females age 40 and older. Women's Health Includes: Screening for gestational diabetes, HPV (Human Papillomavirus) DNA testing, counseling for sexually transmitted infections, counseling and screening for human immunodeficiency virus, screening and counseling for interpersonal and domestic violence, breastfeeding support, supplies and counseling. Contraceptive methods, sterilization procedures, patient education and counseling. Limitations may apply. Routine Digital Rectal Exam / Prostatespecific Antigen Test 1 exam per calendar year for covered males. Page 1
PREVENTIVE CARE Colorectal Cancer Screening Starting at age 50, fecal occult blood test once per year. Sigmoidoscopy every 5 years. Double contract barium enema every 5 years. Colonoscopy every 10 years. Routine Eye Exams 1 routine exam per 24 months. High Deductible Health Plan - H S A Routine Hearing Screenings - Audiometric Exam 1 rountine exam per 24 months PHYSICIAN SERVICES Office Visits to PCP Includes services of an internist, general physician, family practitioner or pediatrician. Specialist Office Visits Maternity OB Visits Pre-Natal Maternity Allergy Testing Allergy Injections DIAGNOSTIC PROCEDURES Diagnostic Laboratory and X-ray Diagnostic Outpatient Complex Imaging (CT/CTA, MRIs/MRAs, PET scans and Nuclear Imaging) EMERGENCY MEDICAL CARE Urgent Care Provider (benefit availability may vary by location) Emergency Room Non-Emergency care in an Emergency Room Ambulance Outpatient Surgery Covered same as Specialist Office Visit for initial visit only; thereafter covered 100%; deductible waived 15% after deductible Not Covered Outpatient Hospital Expenses (excluding surgery) The member cost sharing applies to all Covered Benefits incurred during a member's outpatient visit. NON- NON- NON- 15% after deductible NON- Same as preferred care. Not Covered Same as preferred care. HOSPITAL CARE Inpatient Coverage NON- Inpatient Maternity Coverage Page 2
MENTAL HEALTH SERVICES Inpatient Outpatient The member cost sharing applies to all covered benefits incurred during a member's outpatient visit. ALCOHOL/DRUG ABUSE SERVICES Inpatient NON- Outpatient The member cost sharing applies to all covered benefits incurred during a member's outpatient visit. OTHER SERVICES Convalescent Facility NON- Limited to 120 days per calendar year. Home Health Care Hospice Care - Inpatient - Unlimited Hospice Care - Outpatient - Unlimited Aetna Compassionate Care Program (ACCP) - Enrollment available to members with a 12 month terminal prognosis. Members would be able to continue receiving curative care. Private Duty Nursing - Outpatient Limited to 70 eight hour shifts per calendar year. Each visit by a nurse or therapist is equal to one visit. Each visit up to 4 hours by a home health care aid is equal to one visit. Outpatient Short-Term Rehabilitation Spinal Manipulation Therapy (Chiropractic Care) *Maintenance services are not covered. Limited to 120 visits per calendar year. Limited to 70 eight hour shifts per calendar year. Each visit by a nurse or therapist is equal to one visit. Each visit up to 4 hours by a home health care aid is equal to one visit. Covered 100% after deductible Covered 100% after deductible NON- Aetna Compassionate Care Program (ACCP) - provides a full spectrum of support and services to terminally ill members and their families, including nurse case management support, online tools and information. All Aetna medical members with Aetna case management automatically have the case management component of the Aetna Compassionate Care Program (ACCP). Enrollment available to members with a 12 month terminal prognosis. The member cost sharing applies to all covered benefits incurred during a member's outpatient visit. Includes Speech, Physical, and Occupational Therapy. *Combined benefits limited to 60 visits per calendar year. Durable Medical Equipment OTHER SERVICES Contraceptive drugs and devices not obtainable at a pharmacy (includes coverage for contraceptive visits) NON- Page 3
Generic FDA-approved Women's Contraceptives Covered 100% ; deductible waived Page 4
OTHER SERVICES Mouth, Jaws and Teeth (oral surgery procedures, medical in nature) FAMILY PLANNING Voluntary Sterilization Including tubal ligation and vasectomy. INFERTILITY SERVICES Comprehensive Infertility Services Member cost sharing is based on the type of service performed. NON- NON- NON- Advanced Reproductive Technology (ART) ART coverage includes: In vitro fertilization (IVF), zygote intra-fallopian transfer (ZIFT), gamete intrafallopian transfer (GIFT), cryopreserved embryo transfers, intracytoplasmic sperm injection (ICSI) or ovum microsurgery. Lifetime maximum of $20,000 applies to all procedures (Comprehensive and ART) covered by any Aetna plan except where prohibited by law. PHARMACY NON- The full cost of the drug (at the negotiated rate) is applied to the deductible before benefits are considered for payment under the pharmacy plan. Preventive and Chronic Medications - Deductible is waived for certain preventive and chronic medications. A full list of these drugs is available on Aetna Navigator or from your employer. Retail Mail Order After the deductible is met, members pay a $10 copay for generic drugs, $30 copay for formulary brand-name drugs, and $50 copay for nonformulary brand-name drugs for up to a 30 day supply at participating pharmacies. Coverage includes contraceptive drugs, devices obtainable from a pharmacy, and diabetic supplies. After the deductible is met, members pay a $20 copay for generic drugs, $60 copay for formulary brand-name drugs, and $100 copay for nonformulary brand-name drugs up to a 31-90 day supply from Aetna Rx Home Delivery. After the deductible is met, members pay 30% of submitted cost after combined medical/rx plan deductible and a $10 copay for generic drugs, $30 copay for formulary brand-name drugs, and $50 copay for nonformulary brand-name drugs up to a 30 day supply. Not applicable Step Therapy - We encourage appropriate, cost-effective drug use through a program called Step-Therapy. With Step- Therapy, some drugs are covered by your benefits plan only after you try one or more prerequisites. Aetna Specialty CareRx - focuses solely on specialty medications like injectibles, infused or taken orally, medications. First prescription can be filled at any participating retail drug facility. Subsequent refills must be through Aetna Specialty Pharmacy. Precert for growth hormones required. Page 5
GENERAL PROVISIONS Dependent Eligibility Your spouse, unless you are divorced or your marriage has been annulled; Your grandfathered qualified domestic partner, as defined by Ithaca College; Your children who are under 26 years of age; Your children who are older than the age dependent coverage would otherwise terminate and who are incapable of self-sustaining employment because of mental illness, developmental disability or mental retardation, as defined in the New York State Mental Hygiene Law, or because of physical handicap. The condition must have occurred before the child reached age 19 and the child must currently be enrolled under an sponsored medical plan. The child's disability must be certified by a physician. In addition to this certification, the plan has the right to check whether a child is and continues to qualify as an incapacitated child. GENERAL PROVISIONS This plan does not cover all health care expenses and includes exclusions and limitations. Members should refer to their plan All medical or hospital services not specifically covered in, or which are limited or excluded in the plan documents; Charges related to any eye surgery mainly to correct refractive errors; Cosmetic surgery, including breast reduction; Custodial care; Dental care and X-rays; Donor egg retrieval; Hearing Aids. Experimental and investigational procedures; unless specifically listed as covered in your plan documents; Nonmedically necessary services or supplies; Over-the-counter medications and supplies; Reversal of sterilization; Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies, or counseling; and special duty nursing. 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 results or outcomes. Consult the plan documents (i.e. Group Insurance Certificate and/or Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitation relating to the plan. With the exception of Aetna Rx Home Delivery, all preferred providers and vendors are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change without notice. Some benefits are subject to limitations or visit maximums. 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 s preferred provider is coordinating care, the preferred provider will obtain the precertification. When the member utilizes a nonpreferred provider, Member must obtain the precertification. Precertification requirements may vary. Depending on the plan selected, new prescription drugs not yet reviewed by our medication review committee are either available under plans with an open formulary or excluded from coverage unless a medical exception is obtained under plans that use a closed formulary. Page 6
They may also be subject to precertification. Non-prescription drugs and drugs in the Limitations and Exclusions section of the plan documents (received after open enrollment) are not covered, and medical exceptions are not available for them. While this information is believed to be accurate as of the print date, it is subject to change. Plans are administered by Aetna Life Insurance Company. Page 7