California Toolkit

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Quality health plans & benefitsHealthier livingFinancial well-beingIntelligent solutionsCalifornia toolkitPlans effective January 1, 2017For businesses with 1 – 100 full-time equivalentsRevised February 1, 2017www.aetna.com14.02.337.1-CA (1/17)

Build sustainable, long-term healthcare solutions with Aetna medicalproducts for small businessesNo two employer groups are alike. So to buildhealthy communities and keep your businesshealthy, we offer a portfolio of benefit solutionsand insurance that meet your needs.Your company is unique. You have your own culture,your own family of employees — and your ownhealth care needs. We answer those unique needswith a wide selection of health benefits andinsurance options. We have designed our medical,pharmacy and specialty benefits for the health ofyour company. Using a broad range of network,cost sharing and funding options, we can help mapout a plan that works for you.Health/Dental benefits, health/dental insurance, vision, life and disability insurance plans/policies are offered and/orunderwritten by Aetna Health of California Inc., Aetna Dental of California Inc. and/or Aetna Life Insurance Company(Aetna). Each insurer has sole financial responsibility for its own products.2

Network information4Networks available by rating area4Aetna Whole Health Networks available by rating area5Plans available by network6Plan mapping7Medical plans9HMO9Managed Choice Open Access13Aetna Whole Health HMO19PPO and Indemnity24Dental plans27Contributory non-voluntary dental 2 – 927Voluntary dental 3 – 930Voluntary and contributory dental 10 – 10033Vision plans40Life plans41Limitations and exclusions423

Network informationNetworks available by rating areaCountyRating areaPPOFull MCSavings PlusHMODeductibleAVN HMOBasic ��–––Colusa1Y––––––Del Y–PPP–El ��YYY–Yolo3YY–YYY–San Francisco4YY–YYYYContra Costa5YY–YYY–Alameda6YY–YYY–Santa Clara7YYYYYYPSan Mateo8YYYYYPPMonterey9PP–––––San Benito9YY–––––Santa d10YY–YY––San 0YY–PP––Fresno11PPYPP––Y Network is available. P Network is available in part of the rating area.4Full HMO

Networks available by rating area (continued)Rating areaPPOFull MCSavings PlusFull P––San Luis Obispo12YY–YY––Santa VN HMOBasic HMOMono13Y––––––Kern14YY–YYP–Los Angeles(906-912, 915, 917,918, and 935)15YYYYYPPLos Angeles(all nge18YYYYYYYSan Diego19YYYYYPPAetna Whole Health Networks availableby rating areaProvidenceHealth & ServicesMC/EPOSCCIPAMC/EPORating areaPrimeCare MC/HMOMemorialCareMC/EPOSanta Clara7–––YLos Angeles(906-912, 915, 917, 918,and 935)15–PP–Los Angeles(all �Orange18–Y––CountyY Network is available. P Network is available in part of the rating area.5

Network informationPlans available by network2017 plan nameHMOPlatinum HMO 15 Copay Plan*Gold HMO 20HMOBasic HMO DeductibleMCSavingsPlusPrimeCareHMO/MC Gold HMO 30 Copay Plan*Gold HMO 45AVN HMOGold HMO Deductible 250 Silver HMO Deductible 1500 Silver HMO Deductible2000 Copay Plan* Silver HMO Deductible 2000 Bronze HMO Deductible6300 Plan* Bronze HMO Deductible 6500 Gold EPO 750 80 Silver EPO 2000 Copay Bronze EPO 4000 Copay Platinum 0 Copay Plan* Gold MC 0 Copay Plan* Gold MC 750 80/50 Silver MC 1000 70/50 Silver MC 2000 Copay Silver MC 2000 60/50 Silver MC 2000 80/50HDHP Plan* Bronze MC 4000 Copay Bronze MC 6500 Copay Bronze MC HDHP 480060/50 HSA Plan* Bronze MC 6550 100/50 HSA Gold PPO 750 80/50**PPO networkSilver Indemnity 1500 80**No network*Mandated coverage California exchange plan.**See underwriting guidelines regarding network/product availability.6MemorialCareProvidence SCCIPA

Plan mappingHMO for 1-100 employees2016 plan name2017 plan namePlatinum HMO 20 Copay PlanGold HMO 20Platinum AVN HMO 20 Copay PlanPlatinum AVN HMO 15 Copay PlanPlatinum Basic HMO 20 Copay PlanPlatinum Basic HMO 15 Copay PlanGold HMO 10Gold HMO 20Gold AVN HMO 10Gold AVN HMO 20Gold Basic HMO 10Gold Basic HMO 20Gold PrimeCare HMO 10Gold PrimeCare HMO 30 Copay PlanGold HMO 20Gold HMO 20Gold AVN HMO 20Gold AVN HMO 20Gold Basic HMO 20Gold Basic HMO 20Gold HMO 30Gold HMO 45Gold AVN 30Gold AVN HMO 45Gold Basic HMO 30Gold Basic HMO 45Gold PrimeCare HMO 30Gold PrimeCare HMO 30 Copay PlanGold HMO 35 Copay PlanCA Gold HMO 45Gold AVN HMO 35 Copay PlanGold AVN HMO 45Gold Basic HMO 35 Copay PlanGold Basic HMO 45Gold HMO Deductible 250Gold HMO Deductible 250Gold Basic HMO Deductible 250Gold Basic HMO 250Gold HMO Deductible 500 80Gold HMO 20Gold Basic HMO Deductible 500 80Gold Basic HMO 20Gold PrimeCare HMO Deductible 500 80Gold PrimeCare HMO 45Silver HMO Deductible 1100Silver HMO Deductible 1500Silver Basic HMO Deductible 1100Silver Basic HMO 1500Silver PrimeCare HMO Deductible 1100Silver PrimeCare HMO Deductible 1500Silver HMO Deductible 1500 Copay PlanSilver HMO Deductible 2000 Copay PlanSilver Basic HMO Deductible 1500 Copay PlanSilver Basic HO 2000 Copay PlanSilver HMO Deductible 2000Silver HMO Deductible 2000Silver Basic HMO Deductible 2000Silver Basic HMO 2000Silver PrimeCare HMO Deductible 2000Silver PrimeCare HMO Deductible 1500Bronze HMO Deductible 5500Bronze HMO Deductible 6500Bronze Basic HMO Deductible 5500Bronze Basic HMO 6500Bronze PrimeCare HMO Deductible 5500Bronze PrimeCare HMO Deductible 6500Bronze HMO Deductible 6000 PlanBronze HMO Deductible 65007

Plan mappingMC, Savings Plus, PPO and Indemnity for 1-100 employees82016 plan name2017 plan namePlatinum MC 0 Copay PlanGold MC 0 Copay PlanPlatinum Savings Plus 0 Copay PlanPlatinum Savings Plus 0 Copay PlanPlatinum MC 250 90/60Gold MC 0 Copay PlanPlatinum Savings Plus 250 90/60Gold Savings Plus 0 Copay PlanGold MC 0 Copay PlanGold MC 0 Copay PlanGold Savings Plus 0 Copay PlanGold Savings Plus 0 Copay PlanGold PrimeCare MC 0 Copay PlanGold PrimeCare MC 750 80/50Gold MC 500 80/50Gold MC 750 80/50Gold Savings Plus 500 80/50Gold Savings Plus 750 80/50Gold MC 750 80/50Gold MC 750 80/50Gold Savings Plus 750 80/50Gold Savings Plus 750 80/50Silver MC 1000 75/50Silver MC 1000 70/50Silver Savings Plus 1000 75/50Silver Savings Plus 1000 70/50Silver MC 1000 60/50Silver MC 1000 70/50Silver Savings Plus 1000 60/50Silver Savings Plus 1000 70/50Silver PrimeCare MC 1000 60/50Silver PrimeCare MC 2000 60/50Silver MC 1500 80 Coinsurance PlanSilver MC 2000 CopaySilver Savings Plus 1500 80 Coinsurance PlanSilver Savings Plus 2000 CopaySilver MC 1500 60/50Silver MC 2000 60/50Silver Savings Plus 1500 60/50Silver Savings Plus 2000 60/50Silver MC 2000 60/50Silver MC 2000 60/50Silver Savings Plus 2000 60/50Silver Savings Plus 2000 60/50Bronze MC 4000 Copay PlanBronze MC 4000 CopayBronze Savings Plus 4000 Copay PlanBronze Savings Plus 4000 CopayBronze PrimeCare 4000 Copay PlanBronze PrimeCare 4000 CopayBronze MC 5000 70/50 HSABronze MC 6550 100/50 HSABronze Savings Plus 5000 70/50 HSABronze Savings Plus 6550 100/50 HSABronze PrimeCare 5000 70/50 HSABronze PrimeCare MC 4000 CopayBronze MC 6000 PlanBronze MC 6500 CopayBronze Savings Plus 6000 PlanBronze Savings Plus 6500 CopayBronze MC 6450 100/50 HSABronze MC 6550 100/50 HSABronze Savings Plus 6450 100/50 HSABronze Savings Plus 6550 100/50 HSABronze MC 6850 100/50Bronze MC 6500 CopayBronze Savings Plus 6850 100/50Bronze Savings Plus 6500 CopayBronze PrimeCare MC 6850 100/50Bronze PrimeCare MC 4000 CopayGold PPO 750 80/50Gold PPO 750 80/50Gold Indemnity 750 80Silver Indemnity 1500 80Silver Indemnity 1500 80Silver Indemnity 1500 80

Medical plansHMOPlatinum AVN HMO15 Copay Plan*Plan name1Platinum Basic HMO15 Copay Plan*Gold HMO 20Gold AVN HMO 20Gold AVN HMO 30Copay Plan*Gold Basic HMO 20Gold Basic HMO30 Copay Plan*In networkIn networkIn networkPlan year deductible (individual/family) 0/ 0 0/ 0 0/ 0Plan out-of-pocket limit (individual/family) 4,000/ 8,000 7,000/ 14,000 6,750/ 13,500Deductible and out-of-pocket limit accumulationEmbedded2Embedded2Embedded2Primary care physician office visit 15 copay 20 copay 30 copaySpecialist office visit 40 copay 50 copay 55 copayWalk-in clinicsNot coveredNot coveredNot coveredDiagnostic testing: Lab 20 copay 20 copay 35 copayDiagnostic testing: X-ray 40 copay 60 copay 55 copayImaging CT/PET scans MRIs 150 copay 250 copay 275 copayInpatient hospital facility 250/day, days 1 – 5 750/day, days 1 – 3 600/day, days 1 – 5Outpatient surgery 250 copayFreestanding facility: 400copay/hospital: 600 copay 600 copayEmergency room 150 copay 300 copay 325 copayUrgent care 15 copay 50 copay 30 copayRehabilitation services (PT/OT/ST) 15 copay 50 copay 30 copayChiropracticNot covered 15 copayNot coveredPediatric dental check-up**(aka preventive/diagnostic)Covered in fullCovered in fullCovered in fullPediatric dental basic**20%30%20%Pediatric dental major**50%50%50%Pediatric dental ortho**50%50%50%Pediatric vision exam**Covered in full 20 copayCovered in fullPediatric vision hardware**Covered in fullCovered in fullCovered in fullPharmacy4Mail order: two times retail copay, up to 90-day supplyIn NetworkIn NetworkIn NetworkPharmacy deductibleNone 300 individual/ 600 familyNonePreferred generic drugsGeneric: 5 copayGeneric: 20 copay;deductible waivedGeneric: 15 copayPreferred brand drugs 15 copay 60 copay after deductible 55 copayNonpreferred drugsGeneric & brand: 25 copayGeneric & brand: 100 copayafter deductibleGeneric & brand: 75 copaySpecialty drugs (includes self-injectable, infusedand oral specialty drugs, retail and mail order up to a30-day supply, excludes insulin)10% up to 25030% up to 250 after deductible20% up to 2503Refer to page 25 for footnotes.9

Medical plansHMO (continued)Gold AVN HMO 45Plan name1Gold HMO Deductible 250Silver HMODeductible 1500Gold Basic HMO 45Gold Basic HMO 250Silver Basic HMO 1500In networkIn networkIn networkPlan year deductible (individual/family) 0/ 0 250/ 500 1,500/ 3,000Plan out-of-pocket limit (individual/family) 7,150/ 14,300 6,000/ 12,000 7,150/ 14,300Deductible and out-of-pocket limit accumulationEmbedded2Embedded2Embedded2Primary care physician office visit 45 copay 20 copay; deductible waived 45 copay; deductible waivedSpecialist office visit 60 copay 40 copay; deductible waived 65 copay; deductible waivedWalk-in clinicsNot coveredNot coveredNot coveredDiagnostic testing: Lab 30 copay 20 copay; deductible waived 65 copay; deductible waivedDiagnostic testing: X-ray 60 copay 40 copay; deductible waived 65 copay; deductible waivedImaging CT/PET scans MRIs 300 copay 250 copay; deductible waived 400 copay; deductible waivedInpatient hospital facility 600/day, days 1 – 5 500/day, days 1 – 3after deductible35% after deductibleOutpatient surgeryFreestanding facility: 500copay/hospital: 750 copayFreestanding facility: 400 copayafter deductible/hospital: 600copay after deductibleFreestanding facility: 600 copayafter deductible/hospital: 800copay after deductibleEmergency room 325 copay 300 copay after deductible 325 copay after deductibleUrgent care 60 copay 50 copay; deductible waived 50 copay; deductible waivedRehabilitation services (PT/OT/ST) 60 copay 40 copay; deductible waived 65 copay; deductible waivedChiropractic 3 15 copay 15 copay; deductible waived 15 copay; deductible waivedPediatric dental check-up**(aka preventive/diagnostic)Covered in fullCovered in full; deductible waivedCovered in full; deductible waivedPediatric dental basic**30%30% after deductible30% after deductiblePediatric dental major**50%50% after deductible50% after deductiblePediatric dental ortho**50%50% after deductible50% after deductiblePediatric vision exam** 45 copay 20 copay; deductible waived 45 copay; deductible waivedPediatric vision hardware**Covered in fullCovered in full; deductible waivedCovered in full; deductible waivedPharmacy4Mail order: two times retail copay, up to 90-day supplyIn NetworkIn NetworkIn NetworkPharmacy deductible 300 individual/ 600 family 250 individual/ 500 family 300 individual/ 600 familyPreferred generic drugsGeneric: 20 copay;deductible waivedGeneric: 25 copay;deductible waivedGeneric: 35 copay;deductible waivedPreferred brand drugs 60 copay after deductible 50 copay after deductible 60 copay after deductibleNonpreferred drugsGeneric & brand: 100 copayafter deductibleGeneric & brand: 100 copayafter deductibleGeneric & brand: 100 copayafter deductibleSpecialty drugs (includes self-injectable, infusedand oral specialty drugs, retail and mail order up to a30-day supply, excludes insulin)30% up to 250 after deductible30% up to 250 after deductible30% up to 250 after deductibleRefer to page 25 for footnotes.10Gold HMO 45

Medical plansHMO (continued) Silver Basic HMO 2000Silver HMO Ded 2000Copay Plan*Plan name1Silver Basic HMO2000 Copay Plan*Silver HMODeductible 2000Bronze HMODeductible 6500Silver Basic HMO 2000Bronze Basic HMO 6500In NetworkIn NetworkIn networkPlan year deductible (individual/family) 2,000/ 4,000 2,000/ 4,000 6,500/ 13,000Plan out-of-pocket limit (individual/family) 6,800/ 13,600 7,150/ 14,300 7,150/ 14,300Deductible and out-of-pocket limit accumulationEmbedded2Embedded2Embedded2Primary care physician office visit 45 copay; deductible waived 40 copay; deductible waived 50 copay; deductible waivedSpecialist office visit 75 copay; deductible waived 60 copay; deductible waived 75 copay; deductible waivedWalk-in clinicsNot coveredNot coveredNot coveredDiagnostic testing: Lab 40 copay; deductible waived 40 copay; deductible waived 50 copay; deductible waivedDiagnostic testing: X-ray 70 copay; deductible waived 60 copay; deductible waived 75 copay; deductible waivedImaging CT/PET scans MRIs 300 copay; deductible waived 400 copay; deductible waived 100 copay after deductibleInpatient hospital facility20% after deductible 500/day, days 1 – 3after deductible50% after deductibleOutpatient surgeryFreestanding facility: 20%deductible waived/hospital:20% deductible waivedFreestanding facility: 600 copayafter deductible/hospital: 750copay after deductible 800 copay after deductibleEmergency room 350 copay; deductible waived 300 copay after deductible50% after deductibleUrgent care 45 copay; deductible waived 50 copay; deductible waived 50 copay; deductible waivedRehabilitation services (PT/OT/ST) 45 copay; deductible waived 60 copay; deductible waived 50 copay; deductible waivedChiropractic 3Not covered 15 copay; deductible waived 15 copay; deductible waivedPediatric dental check-up**(aka preventive/diagnostic)Covered in full; deductible waivedCovered in full; deductible waivedCovered in full; deductible waivedPediatric dental basic**20% deductible waived30% after deductible30% after deductiblePediatric dental major**50% deductible waived50% after deductible50% after deductiblePediatric dental ortho**50% deductible waived50% after deductible50% after deductiblePediatric vision exam**Covered in full; deductible waived 40 copay; deductible waived 50 copay; deductible waivedPediatric vision hardware**Covered in full; deductible waivedCovered in full; deductible waivedCovered in full; deductible waivedPharmacy4Mail order: two times retail copay, up to 90-day supplyIn NetworkIn NetworkIn NetworkPharmacy deductible 250 individual/ 500 familyNone 500 individual/ 1,000 familyPreferred generic drugsGeneric: 15 copay;deductible waivedGeneric: 15 copayGeneric: 35 copay;deductible waivedPreferred brand drugs 55 copay after deductible 50 copay 100 copay after deductibleNonpreferred drugsGeneric & brand: 85 copayafter deductibleGeneric & brand: 100 copayGeneric & brand: 180 copayafter deductibleSpecialty drugs (includes self-injectable, infusedand oral specialty drugs, retail and mail order up to a30-day supply, excludes insulin)20% up to 250 after deductible30% up to 25030% up to 500 after deductibleRefer to page 25 for footnotes.11

Medical plansHMO (continued)Plan name1Bronze Basic HMO6300 Plan*In NetworkPlan year deductible (individual/family) 6,300/ 12,600Plan out-of-pocket limit (individual/family) 6,800/ 13,600Deductible and out-of-pocket limit accumulationEmbedded2Primary care physician office visit 75 copay; deductible waivedSpecialist office visit 105 copay; deductible waivedWalk-in clinicsNot coveredDiagnostic testing: Lab 40 copay; deductible waivedDiagnostic testing: X-ray100% after deductibleImaging CT/PET scans MRIs100% after deductibleInpatient hospital facility100% after deductibleOutpatient surgeryFreestanding facility: 100%after deductible/hospital:100% after deductibleEmergency room100% after deductibleUrgent care 75 copay; deductible waivedRehabilitation services (PT/OT/ST) 75 copay; deductible waivedChiropractic 3Not coveredPediatric dental check-up**(aka preventive/diagnostic)Covered in full; deductible waivedPediatric dental basic**20% deductible waivedPediatric dental major**50% deductible waivedPediatric dental ortho**50% deductible waivedPediatric vision exam**Covered in full; deductible waivedPediatric vision hardware**Covered in full; deductible waivedPharmacy4Mail order: two times retail copay, up to 90-day supplyIn NetworkPharmacy deductible 500 individual/ 1,000 familyPreferred generic drugsGeneric: 100% up to 500after deductiblePreferred brand drugs100% up to 500 after deductibleNonpreferred drugsGeneric & brand: 100% up to 500 after deductibleSpecialty drugs (includes self-injectable, infusedand oral specialty drugs, retail and mail order up to a30-day supply, excludes insulin)100% up to 500 after deductibleRefer to page 25 for footnotes.12

Medical plansManaged Choice Open AccessGold MC 0 Copay Plan*Plan name1Platinum Savings Plus 0 Copay Plan*Gold Savings Plus 0 Copay Plan*In networkOut of networkIn networkOut of networkPlan year deductible (individual/family) 0/ 0 1,000/ 2,000 0/ 0 1,000/ 2,000Plan out-of-pocket limit (individual/family) 4,000/ 8,000 8,000/ 16,000 6,750/ 13,500Deductible and out-of-pocket limit accumulation 13,500/ 27,000Embedded2Embedded2Primary care physician office visit 15 copay50% after deductible 30 copay50% after deductibleSpecialist office visit 40 copay50% after deductible 55 copay50% after deductibleWalk-in clinics 15 copayNot covered 30 copayNot coveredDiagnostic testing: Lab 20 copay50% after deductible 35 copay50% after deductibleDiagnostic testing: X-ray 40 copay50% after deductible 55 copay50% after deductibleImaging CT/PET scans MRIs 150 copay50% after deductible 275 copay50% after deductibleInpatient hospital facility 250/day, days 1 – 550% after deductible 600/day, days 1 – 550% after deductibleOutpatient surgery 250 copay50% after deductible 600 copay50% after deductibleEmergency room 150 copayPaid as in-network 325 copayPaid as in-networkUrgent care 15 copayPaid as in-network 30 copayPaid as in-networkRehabilitation services (PT/OT/ST) 15 copay50% after deductible 30 copay50% after deductibleChiropractic 3Not coveredNot coveredNot coveredNot coveredPediatric dental check-up**(aka preventive/diagnostic)Covered in full30% after deductibleCovered in full30% after deductiblePediatric dental basic**20%50% after deductible20%50% after deductiblePediatric dental major**50%50% after deductible50%50% after deductiblePediatric dental ortho**50%50% after deductible50%50% after deductiblePediatric vision exam**Covered in fullNot coveredCovered in fullNot coveredPediatric vision hardware**Covered in fullNot coveredCovered in fullNot coveredPharmacy4Mail order: two times retail copay, up to 90-day supplyIn NetworkOut of NetworkIn NetworkOut of NetworkPharmacy deductibleNoneNoneNoneNonePreferred generic drugsGeneric: 5 copayGeneric: Not coveredGeneric: 15 copayGeneric: Not coveredPreferred brand drugs 15 copayNot covered 55 copayNot coveredNonpreferred drugsGeneric & brand: 25 copayGeneric & brand:Not coveredGeneric & brand: 75 copayGeneric & brand:Not coveredSpecialty drugs (includes self-injectable, infusedand oral specialty drugs, retail and mail order up to a30-day supply, excludes insulin)10% up to 250Not covered20% up to 250Not coveredRefer to page 25 for footnotes.13

Medical plansManaged Choice Open Access (continued)Plan name1Gold MC 750 80/50Silver MC 1000 70/50Gold Savings Plus 750 80/50Silver Savings Plus 1000 70/50In networkOut of networkIn networkOut of networkPlan year deductible (individual/family) 750/ 1,500 1,500/ 3,000 1,000/ 2,000 2,000/ 4,000Plan out-of-pocket limit (individual/family) 6,000/ 12,000 12,000/ 24,000 7,150/ 14,300Deductible and out-of-pocket limit accumulationPrimary care physician office visit 30 copay;deductible waived50% after deductible 30 copay;deductible waived50% after deductibleSpecialist office visit 40 copay;deductible waived50% after deductible 40 copay;deductible waived50% after deductibleWalk-in clinics 30 copay;deductible waivedNot covered 30 copay;deductible waivedNot coveredDiagnostic testing: Lab 15 copay;deductible waived50% after deductible 30 copay;deductible waived50% after deductibleDiagnostic testing: X-ray 15 copay;deductible waived50% after deductible 50 copay;deductible waived50% after deductibleImaging CT/PET scans MRIs20% after deductible50% after deductible30% after deductible50% after deductibleInpatient hospital facility20% after deductible50% after deductible30% after deductible50% after deductibleOutpatient surgeryFreestanding facility: 500 copay afterdeductible/hospital: 750copay after deductibleFreestanding facility: 50%after deductible/hospital:50% after deductibleFreestanding facility: 700 Freestanding facility: 50%copay after deductible/after deductible/hospital:hospital: 1,000 copay50% after deductibleafter deductibleEmergency room20% after deductiblePaid as in-network30% after deductiblePaid as in-networkUrgent care 50 copay;deductible waivedPaid as in-network 50 copay;deductible waivedPaid as in-networkRehabilitation services (PT/OT/ST)20% after deductible50% after deductible30% after deductible50% after deductibleChiropractic 320% after deductible50% after deductible30% after deductible50% after deductiblePediatric dental check-up**(aka preventive/diagnostic)Covered in full;deductible waived30% after deductibleCovered in full;deductible waived30% after deductiblePediatric dental basic**30% after deductible50% after deductible30% after deductible50% after deductiblePediatric dental major**50% after deductible50% after deductible50% after deductible50% after deductiblePediatric dental ortho**50% after deductible50% after deductible50% after deductible50% after deductiblePediatric vision exam** 30 copay;deductible waivedNot covered 30 copay;deductible waivedNot coveredPediatric vision hardware**Covered in full;deductible waivedNot coveredCovered in full;deductible waivedNot coveredPharmacy4Mail order: two times retail copay, up to 90-day supplyIn NetworkOut of NetworkIn NetworkOut of NetworkPharmacy deductibleNoneNone 250 individual/ 500 familyNonePreferred generic drugsGeneric: 20 copayGeneric: Not coveredGeneric: 35 copay;deductible waivedGeneric: Not coveredPreferred brand drugs 60 copayNot covered 70 copayafter deductibleNot coveredNonpreferred drugsGeneric & brand: 75 copayGeneric & brand:Not coveredGeneric & brand: 100copay after deductibleGeneric & brand:Not coveredSpecialty drugs (includes self-injectable, infusedand oral specialty drugs, retail and mail order up to a30-day supply, excludes insulin)30% up to 250Not covered30% up to 250after deductibleNot coveredRefer to page 25 for footnotes.14 14,300/ 28,600Embedded2Embedded2

Medical plansManaged Choice Open Access (continued)Plan name1Silver MC 2000 CopaySilver MC 2000 60/50Silver Savings Plus 2000 CopaySilver Savings Plus 2000 60/50In networkOut of networkIn networkOut of networkPlan year deductible (individual/family) 2,000/ 4,000 4,000/ 8,000 2,000/ 4,000 4,000/ 8,000Plan out-of-pocket limit (individual/family) 7,000/ 14,000 14,000/ 28,000 7,150/ 14,300Deductible and out-of-pocket limit accumulation 14,300/ 28,600Embedded2Embedded2Primary care physician office visit 35 copay;deductible waived50% after deductible 30 copay;deductible waived50% after deductibleSpecialist office visit 60 copayafter deductible50% after deductible 50 copay;deductible waived50% after deductibleWalk-in clinics 35 copay;deductible waivedNot covered 30 copay;deductible waivedNot coveredDiagnostic testing: Lab 35 copay;deductible waived50% after deductible 30 copay;deductible waived50% after deductibleDiagnostic testing: X-ray 60 copayafter deductible50% after deductible 35 copay;deductible waived50% after deductibleImaging CT/PET scans MRIs 250 copayafter deductible50% after deductible40% after deductible50% after deductibleInpatient hospital facility 750 copay per admissionafter deductible50% after deductible40% after deductible50% after deductibleOutpatient surgeryFreestanding facility: 500 copay afterdeductible/hospital: 600copay after deductibleFreestanding facility: 50%after deductible/hospital:50% after deductibleFreestanding facility: 700 copay afterdeductible/hospital: 1,000 copayafter deductibleFreestanding facility: 50%after deductible/hospital:50% after deductibleEmergency room 300 copayafter deductiblePaid as in-network40% after deductiblePaid as in-networkUrgent care 50 copay;deductible waivedPaid as in-network 50 copay;deductible waivedPaid as in-networkRehabilitation services (PT/OT/ST) 50 copayafter deductible50% after deductible40% after deductible50% after deductibleChiropractic3 35 copayafter deductible50% after deductible40% after deductible50% after deductiblePediatric dental check-up**(aka preventive/diagnostic)Covered in full;deductible waived30% after deductibleCovered in full;deductible waived30% after deductiblePediatric dental basic**30% after deductible50% after deductible30% after deductible50% after deductiblePediatric dental major**50% after deductible50% after deductible50% after deductible50% after deductiblePediatric dental ortho**50% after deductible50% after deductible50% after deductible50% after deductiblePediatric vision exam** 35 copay;deductible waivedNot covered 30 copay;deductible waivedNot coveredPediatric vision hardware**Covered in full;deductible waivedNot coveredCovered in full;deductible waivedNot coveredPharmacy4Mail order: two times retail copay, up to 90-day supplyIn NetworkOut of NetworkIn NetworkOut of NetworkPharmacy deductible 150 individual/ 300 familyNone 150 individual/ 300 familyNonePreferred generic drugsGeneric: 20 copay;deductible waivedGeneric: Not coveredGeneric: 15 copay;deductible waivedGeneric: Not coveredPreferred brand drugs 50 copayafter deductibleNot covered 55 copayafter deductibleNot coveredNonpreferred drugsGeneric & brand: 70copay after deductibleGeneric & brand:Not coveredGeneric & brand: 75copay after deductibleGeneric & brand:Not coveredSpecialty drugs (includes self-injectable, infusedand oral specialty drugs, retail and mail order up to a30-day supply, excludes insulin)30% up to 250after deductibleNot covered30% up to 250after deductibleNot coveredRefer to page 25 for footnotes.15

Medical plansManaged Choice Open Access (continued)Silver MC 2000 80/50 HDHP Plan*Plan name1Silver Savings Plus 2000 80/50 HDHP Plan* Bronze Savings Plus 4000 CopayIn networkOut of networkIn networkOut of networkPlan year deductible (individual/family) 2,000/ 4,000 4,000/ 8,000 4,000/ 8,000 8,000/ 16,000Plan out-of-pocket limit (individual/family) 6,550/ 13,100 13,100/ 26,200 7,150/ 14,300Deductible and out-of-pocket limit accumulation 14,300/ 28,600Embedded2Embedded2Primary care physician office visit20% after deductible50% after deductible 50 copay;deductible waived50% after deductibleSpecialist office visit20% after deductible50% after deductible 75 copayafter deductible50% after deductibleWalk-in clinics20% after deductibleNot covered 50 copay;deductible waivedNot coveredDiagnostic testing: Lab20% after deductible50% after deductible 50 copay;deductible waived50% after deductibleDiagnostic testing: X-ray20% after deductible50% after deductible 125 copayafter deductible50% after deductibleImaging CT/PET scans MRIs20% after deductible50% after deductible 500 copayafter deductible50% after deductibleInpatient hospital facility20% after deductible50% after deductible 850 copay per admissionafter deductible50% after deductibleOutpatient surgery20% after deductible50% after deductible 500 copayafter deductible50% after deductibleEmergency room20% after deductiblePaid as in-network 500 copayafter deductiblePaid as in-networkUrgent care20% after deductiblePaid as in-network 50 copay;deductible waivedPaid as in-networkRehabilitation services (PT/OT/ST)20% after deductible50% after deductible 50 copayafter deductible50% after deductibleChiropractic3Not coveredNot covered 50 copayafter deductible50% after deductiblePediatric dental check-up**(aka preventive/diagnostic)Covered in full;deductible waived20% after deductibleCovered in full;deductible waived30% after deductiblePediatric dental basic**20% deductible waived50% after deductible30% after deductible50% after deductiblePediatric dental major**50% deductible waived50% after deductible50% after deductible50% after deductiblePediatric dental ortho**50% deductible waived50% after deductible50% after deductible50% after deductiblePediatric vision exam**Covered in full;deductible waivedNot covered 50 copay;deductible waivedNot coveredPediatric vision hardware**Covered in full;deductible waivedNot coveredCovered in full;deductible waivedNot coveredPharmacy4Mail order: two times retail copay, up to 90-day supplyIn NetworkOut of NetworkIn NetworkOut o

Health/Dental benefits, health/dental insurance, vision, life and disability insurance plans/policies are offered and/or underwritten by Aetna Health of California Inc., Aetna Dental of California Inc. and/or Aetna Life Insurance Company (Aetna). Each insurer

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Pain as the 5 th Vital Sign Toolkit Page 6 Overview of the Toolkit This Pain as the 5 th Vital Sign Toolkit has been prepared as a resource toolkit for use by healthcare professionals. It is organized into the following sections: Section 1: Introduction.

Copies of both ISO 27001 and ISO 27002 The No 1 ISMS Toolkit contains, in addition to the contents of the No 5 Toolkit, BS7799-3, the risk assessment standard The No 3 ISMS Toolkit contains, in addition to the contents of the No 1 Toolkit, vsRisk , the definitive ISO27001 risk a

TOOLKIT for Making Written Material Clear and Effective SECTION 5: Detailed guidelines for translation PART 11: Understanding and using the "Toolkit Guidelines for Culturally Appropriate Translation" 1 Introduction Background on the Toolkit The Toolkit for Making Written Material Clear and Effective is an 11-part health literacy resource from

We hope that you find this toolkit useful and that you are willing to share your input and ideas on how to improve the toolkit with us. We are always looking to improve upon the toolkit, and we are stronger and better when we have more ideas included in the toolkit. So, please contact us to provide input, brainstorm, or find ways we can partner on