Aetna Avenue® — Your Destination for Small Business Solutions®
NEW JERSEY PLAN GUIDE
PLANS EFFECTIVE FEBRUARY 1, 2012
For businesses with 51–100 eligible employees
64.10.301.1-NJ A (11/11)
NEW JERSEY PLAN GUIDE
TEAM WITH AETNA
F O R T H E H E A LT H O F Y O U R B U S I N E S S
2
Our business commitment
3
Benefits for every stage of life
4
Medical overview
7
Managing health care expenses
8
Medical plan options
30 Dental overview
32 Dental plan options
Introducing a new suite of products and
services designed specifically for companies
with 51 to 100 employees
Aetna is committed to helping employers build healthy businesses. In today’s
rapidly changing economy, we recognize the need for less expensive, less
complex health plan choices. Now, Aetna offers a variety of newly streamlined
plans, from medical and dental to life and disability*, to provide more affordable
options and to help simplify plan selection and administration.
38 Limitations and exclusions
You can count on Aetna to provide health
plans that help simplify decision making
and plan administration so you can focus
on the health of your business.
Employers and their employees can benefit from…
■
Affordable plan options
■
Online self-service tools and capabilities
■
Enhanced services for consumer-directed health plans
■
24-hour access to Employee Assistance Program services
■
Preventive care covered 100 percent
■
Aetna disease management and wellness programs
*Aetna has a robust, flexible portfolio of life and disability plans for groups with 51 or more lives. Please contact your
Aetna representative for a plan designed to meet your group’s needs.
The federal health care reform legislation, known as the Patient Protection and Affordable Care Act, was
signed into law on March 23, 2010. A number of new reforms were effective September 23, 2010, including
coverage for dependents up to age 26, elimination of lifetime benefits dollar maximums, restriction of annual
dollar maximums on essential health benefits, removal of cost sharing for preventive services and elimination
of pre-existing condition exclusions for dependent children under 19 years of age. Your Aetna Avenue benefits
program does comply with the new reform legislation.
Health/dental benefits plans, health/dental insurance plans, life insurance and disability
insurance plans/policies are offered, underwritten or administered by Aetna Health Inc., Aetna
Health Insurance Company, Aetna Dental Inc., and/or Aetna Life Insurance Company (Aetna).
64.43.301.1-NJ A (11/11)
IN THIS GUIDE:
64.44.301.1-NJ A (11/11)
WITH AETNA,
WE KNOW IT’S ABOUT…
OPTIONS
SIMPLICITY
TRUST
We provide a variety of health
benefits and insurance plan options
to help meet your employees’ needs,
including medical, dental, disability
and life insurance.
We know the health of your
business is your top priority. Aetna’s
streamlined plans and variety of
services make it easier for you to
focus on your business by simplifying
administration and management.
We work hard to provide health plan
solutions you can trust.
And, with access to a wide network
of health care providers, you can be
sure employees have options in how
they access their health care.
Medical plans
Standard plans
■ Cost-sharing
plans
Aetna makes it easy to manage
health insurance benefits with
simplified enrollment, billing,
and claims processing so you can
focus on what matters most.
Our account executives, underwriters
and customer service representatives
are committed to providing small
businesses and their employees with
service and care they can trust.
■
■
Aetna resources are designed
to fortify the health of your business
HSA-compatible plans
Dental, life and disability plans
Dental-DMO®
■ Dental-PPO
■
■
Dental-PPO Max
■ Dental
Freedom-of-Choice plan
design option
■ Basic
term life, supplemental life,
spouse and child life, and AD&D*
■ Short-term, long-term, and
mid-term disability designs*
■
■
■
■
■
■
■
rack medical claims and take advantage of online services with your
T
Aetna Navigator® secure member website. It features a Personal Health Record
Tool and printable temporary member ID cards.
et real cost and health information to help make the right care
G
decision with an online Cost of Care Estimator.
Manage health records online with the Personal Health Record (PHR) tool.
se of the Aetna Health ConnectionsSM Disease Management
U
Program, which provides personal support to members to help them
manage their conditions.
Enjoy 24/7 access to a nurse to help with personal health-related questions.
elp members work toward health goals with wellness initiatives, such as
H
the Simple Steps to a Healthier Life® online program.
ake advantage of discount programs for vision, dental, and general health
T
care that encourage use of plan offerings.
*Please contact your Aetna representative for life and disability plans designed to meet your group’s needs.
1
NEW JERSEY PLAN GUIDE
AETNA IS COMMIT TED TO THE
H E A LT H O F YO U R B U S I N E S S
At Aetna, we understand your business has unique needs. That’s why
we have streamlined our plan options for employers with 51 to 100 employees.
We are committed to providing you with value and quality you can count on.
Our variety of products and services allows you to focus on the health of
your business.
Aetna’s health plan options are
designed with the health of your business in mind
BASIC
■
■
■
Basic benefits for
your employees
L imiting the expense to
your business
llow employees to
A
buy up and share more
of the cost
– NJ
QPOS CS
1000 80/50 30/30
15/35/60 51+
– NJ HNOption CS
500 90/70 20/40
15/35/60 51+
– NJ HNOption CS
2000 90/50 30/50
15/35/60 51+
2
VALUE
■
■
■
E ncouraging employee
responsibility in their
health care decisions
T ools and resources to
support consumerism
Innovative plan design
– NJ HNOption HSA
1500 100/70 15/35/60
51+
– NJ HNOption
HSA 2000 80/50
15/35/60 51+
– NJ HNOption
HSA 2500 90/50
15/35/60 51+
STANDARD
■
■
S tandard
benefits plans
L imit the financial
impact on employees
– NJ QPOS 20/40/150d
15/35/60 51+
– NJ HNOption 20/20/0
100/70 5/20/40 51+
– NJ HNOption
20/40/250d
15/35/60 51+
H E A LT H I N S U R A N C E B E N E F I T S
F O R E V E RY S TAG E O F L I F E
For young individuals and
couples without children…
■
Lower monthly payments
■
Modest out-of-pocket costs
■
Quality preventive care
■
Prescription drug coverage
■
Financial protection
For married couples and
single parents with teens
and college-age children…
■
■
■
Cost-sharing plans
HSA-compatible plans
Checkups and care for injuries
and illness
Preventive care and screenings that
promote a healthy lifestyle
National network of health
care providers
Standard plans
HSA-compatible plans
For married couples and
single parents with young
children or teens…
For men and women 55 years
of age and over with no
children at home…
Lower fees for office visits
■
■
Financial security
Lower monthly payments
■
■
Quality prescription drug coverage
Caps on out-of-pocket expenses
Quality preventive care for the
entire family
■
Hospital inpatient/outpatient services
■
Emergency care
■
■
Standard plans
Standard plans
HSA-compatible plans
HSA-compatible plans
3
NEW JERSEY PLAN GUIDE
M E D I C A L OVERVIEW
4
PCP
Required
Referrals
Required
DocFind Plan
Name
QPOS (Quality Point-of-Service) is a two-tiered product that allows
members to access care in one of two ways: 1. PCP referred in network,
2. Self-referred, in or out of network
Members have lower out-of-pocket costs when they use the HMO
(referred) tier of the plan and follow the PCP referral process. Member
cost sharing increases if members decide to self-refer in or out of
network.
Yes
No
QPOS
Health Network Option
(HNOption)
HNOption is a two-tiered product that allows members to access care
in or out of network. Members have lower out-of-pocket costs when
they use the in-network tier of the plan. Member cost sharing increases
if members decide to go out of network. Members may go to their
PCP or directly to a participating specialist without a referral. It is their
choice, each time they seek care.
Yes/Optional
No
Aetna Health
Network OptionSM
(Open Access)
Open Access
Managed Choice®
(OA MC)
The Open Access Managed Choice plan is available for employees who
live outside the plan’s network service area but reside in an OA MC
service area. OA MC members can access any recognized provider for
covered services without a referral. Each time members seek health
care, they have the freedom to choose either network providers at
lower out-of-pocket costs or non-network providers at higher out-ofpocket costs.
Optional
No
Managed Choice®
POS (Open Access)
Indemnity
This indemnity plan option is available for employees who live outside
the plan’s network service area. Members coordinate their own health
care and may access any recognized provider for covered services
without a referral.
No
No
N/A
Product Name
Product Description
QPOS®
MEDICAL
5
NEW JERSEY PLAN GUIDE
HEALTH REIMBURSEMENT
ARRANGEMENT (HRA)
A d m inist ra t ive fees
FEE DESCRIPTION
FEE
POP
Initial set-up*
$175
Monthly fees
$100
HRA and FSA** fees
Initial
set-up*
Renewal
fee
51-100 Employees
$550
$325
Monthly fees***
$5.25 per participant
Additional set-up fee
$150
Participation fee
$10.25 per participant
for “stacked” plans (those
electing an Aetna HRA and FSA
simultaneously)
for “stacked” participants
Minimum fees
51-100 Employees
$50 per-month minimum
COBRA
Annual fee
51-100 Employees
The Aetna HealthFund® HRA combines
the protection of a deductible-based
health plan with a health fund that pays
for eligible health care services. The
member cannot contribute to the HRA,
and employers have control over HRA
plan designs and fund rollover. The fund
is available to an employee for qualified
expenses on the plan’s effective date.
The HRA and the HSA provide members with
financial support for higher out-of-pocket
health care expenses. Aetna’s consumerdirected health products and services give
members the information and resources they
need to help make informed health care
decisions for themselves and their families
while helping lower employers’ costs.
$175
Per employee per month
51-100 Employees
$1.02
Initial notice fee
$1.50 per notice
(includes notices at time of
implementation and during
ongoing administration)
TRA
Annual fee
$350
Transit monthly fees
$4.25 per participant
Parking monthly fees
$3.15 per participant
COBRA
A D M I N I S T R AT I O N
Aetna COBRA administration offers a full
range of notification, documentation and
record-keeping processes that can assist
employers with managing the complex
billing and notification processes required
for COBRA compliance, while also helping
save them time and money.
SECTION 125 CAFETERIA
PLANS AND SECTION 132
TRANSIT REIMBURSEMENT
ACCOUNTS
Employees can reduce their taxable income,
and employers can pay less in payroll
taxes. There are three ways to save:
Premium-only plan (POP)
Employees can pay for their portion of
the group health insurance expenses on
a pretax basis.
Flexible spending account (FSA)
FSAs give employees a chance to save for
health expenses with pretax money. Health
Care Spending Accounts allow employees
to set aside pretax dollars to pay for outof-pocket expenses, as defined by the
IRS. Dependent Care Spending Accounts
allow participants to use pretax dollars
to pay child or elder care expenses.
Transit reimbursement account (TRA)
TRAs allow participants to use pretax
dollars to pay transportation and parking
expenses for the purpose of commuting
to and from work.
*Non-discrimination testing provided annually after open enrollment for POP and FSA only. Additional off-cycle
testing available at employee request for $100 fee. Non-discrimination testing only available for FSA and
POP products.
**Aetna FSA pricing is inclusive for POP. Debit cards are available for FSA only. Contact Aetna for further information.
***For HRA, if the employer opts out of Streamline, the fee is increased $1.50 per participant. For FSA, the debit card is
available for an additional $1 per participant per month. Mailing reimbursement checks direct to employee homes is
an additional $1 per participant per month.
6
MEDICAL
A WAY T O M A N A G E H E A LT H A N D
H E A LT H C A R E E X P E N S E S
S AV E A C O PAY ®
PROGRAM
Now Aetna Pharmacy Management is
giving your employees an additional
way to save!
Our Save a Copay program encourages
your Aetna members to use certain
generic drugs in place of their brandname counterparts.
Here’s how the program works:
−−Members who switch to certain
preferred generic medications from
selected brand-name drugs will
make no copayments for six months
after they make the change.
−−At the end of the
initial six-month period, members
will be responsible for paying the
lowest applicable copay outlined in
their pharmacy benefits plans.
−−Use a participating retail or mail-order
pharmacy. With other pharmacies,
the program will not apply.
−−If the member’s pharmacy benefits
plan has a deductible, such as a
high-deductible health plan, the
member must meet the deductible
first before he or she can benefit
from the Save a Copay program.
We preselect eligible members, so
there is no enrollment process.
H E A LT H S AV I N G S A C C O U N T ( H S A )
No set-up or administrative fees
The Aetna HealthFund HSA, when coupled with an HSA-compatible high-deductible
health insurance plan, is a tax-advantaged savings account. Once enrolled, account
contributions can be made by the employee and/or employer. The HSA can be used
to pay for qualified medical expenses tax free.
YOUR HSA PLAN
HSA ACCOUNT
ƒƒYou own your HSA
ƒƒContribute tax free
ƒƒYou choose how and when to use your dollars
ƒƒRoll it over each year and let it grow
ƒƒEarns interest, tax free
T O D AY
Use for qualified expenses
with tax-free dollars
FUTURE
Plan for future and retiree
health-related costs
H I G H - D E D U C T I B L E H E A LT H P L A N
ƒƒEligible in-network preventive care services will not be subject to
the deductible
ƒƒYou pay 100% until deductible is met, then only pay a share of the cost
ƒƒMeet out-of-pocket maximum, then plan pays 100%
7
NEW JERSEY PLAN GUIDE
Q U A L I T Y P O I N T- O F - S E R V I C E ( Q P O S ) P L A N O P T I O N S *
NJ QPOS 20/20/0 5/20/40 51+
Plan Options
Member Benefits
NJ QPOS 20/20/0 15/35/60 51+
Network
Non-Network
Network
Non-Network
PCP Coordinated
No Referral Needed
PCP Coordinated
No Referral Needed
Plan Coinsurance
N/A
30% after deductible
N/A
30% after deductible
Calendar-Year Deductible1
N/A
$2,000 per member
$6,000 family
N/A
$2,000 per member
$6,000 family
Calendar-Year Maximum Out-of-Pocket1
$1,500 per member
$3,000 family
$5,000 per member
$15,000 family
$1,500 per member
$3,000 family
$5,000 per member
$15,000 family
Lifetime Maximum Benefit
Unlimited
Unlimited
Unlimited
Unlimited
Payment for Non-Network Care4
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
Well-Baby/Child Exams
(Age and frequency schedules apply)
$0 copay
30%; deductible waived
$0 copay
30%; deductible waived
Adult Physical Exams
(Age and frequency schedules apply)
$0 copay
30% after deductible
$0 copay
30% after deductible
Routine Gyn Exams
(Age and frequency schedules apply)
$0 copay
30%; deductible waived
$0 copay
30%; deductible waived
Routine Mammograms
(Age and frequency schedules apply)
$0 copay
30% after deductible
$0 copay
30% after deductible
Routine Eye Exams
(Age and frequency schedules apply)
$0 copay
30% after deductible
$0 copay
30% after deductible
Preventive Care
Glasses and Contact Lens Reimbursement
Aetna VisionSM Discount Program
$100/24-month period. Network and non-network combined
$100/24-month period. Network and non-network combined.
Included
Not Covered
Included
Not Covered
Primary Physician Office Visit
$20 copay
30% after deductible
$20 copay
30% after deductible
Specialist Office Visit
$20 copay
30% after deductible
$20 copay
30% after deductible
$0 copay
30% after deductible
$0 copay
30% after deductible
$20 copay
30% after deductible
$20 copay
30% after deductible
Outpatient Complex Imaging
(MRA/MRS, MRI, PET and CAT scans)
$100 copay
30% after deductible
$100 copay
30% after deductible
Chiropractic Services
(Network: 30 visits per calendar-year
Non-Network: $1,000 calendar-year maximum)
$10 copay
25% after deductible
$10 copay
25% after deductible
Outpatient Rehabilitation Therapy
(60 combined visits per calendar-year for physical, occupational and
speech therapy)
$20 copay
30% after deductible
$20 copay
30% after deductible
Durable Medical Equipment
($2,500 calendar-year maximum)
50%
50% after deductible
50%
50% after deductible
Inpatient Hospital
(Including inpatient mental health and substance abuse)
$0 copay
30% after deductible
$0 copay
30% after deductible
Hospital Outpatient Facility
$0 copay
30% after deductible
$0 copay
30% after deductible
Ambulatory Surgical Center or Facility
other than a Hospital Outpatient Facility
$0 copay
30% after deductible
Maximum benefit of $2,000 per
member per calendar year
$0 copay
30% after deductible
Maximum benefit of $2,000 per
member per calendar year
$100 copay
Same as Network
$100 copay
Same as Network
Prescription Drugs: 30-day supply
$5/$20/$40
Not Covered
$15/$35/$60
Not Covered
Retail or Mail Order: 31- to 90-day supply
$10/$40/$80
Not Covered
$30/$70/$120
Not Covered
Contraceptives and Diabetic Supplies
Included
Not Covered
Included
Not Covered
90-Day Transition of Coverage (TOC) for Prior Authorization†
Included
Not Covered
Included
Not Covered
Outpatient Services
Lab
X-Ray
Outpatient Surgery
Emergency Room
Prescription Drugs (Includes self-injectables)
See page 28 for important plan provisions.
8
MEDICAL
Q U A L I T Y P O I N T- O F - S E R V I C E ( Q P O S ) P L A N O P T I O N S *
NJ QPOS 20/40/150d 5/20/40 51+
NJ QPOS 20/40/150d 15/35/60 51+
NJ QPOS 30/50/500d 5/20/40 51+
Network
Non-Network
Network
Non-Network
Network
Non-Network
PCP Coordinated
No Referral Needed
PCP Coordinated
No Referral Needed
PCP Coordinated
No Referral Needed
N/A
50% after deductible
N/A
50% after deductible
N/A
50% after deductible
N/A
$5,000 per member
$15,000 family
N/A
$5,000 per member
$15,000 family
N/A
$5,000 per member
$15,000 family
$1,500 per member
$3,000 per member
$30,000 per member
$90,000 family
$1,500 per member
$3,000 per member
$30,000 per member
$90,000 family
$5,000 per member
$10,000 per member
$30,000 per member
$90,000 family
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
$0 copay
50%; deductible waived
$0 copay
50%; deductible waived
$0 copay
50%; deductible waived
$0 copay
50% after deductible
$0 copay
50% after deductible
$0 copay
50% after deductible
$0 copay
50%; deductible waived
$0 copay
50%; deductible waived
$0 copay
50%; deductible waived
$0 copay
50% after deductible
$0 copay
50% after deductible
$0 copay
50% after deductible
$0 copay
50% after deductible
$0 copay
50% after deductible
$0 copay
50% after deductible
$100/24-month period. Network and non-network combined.
$100/24-month period. Network and non-network combined.
$100/24-month period. Network and non-network combined.
Included
Not Covered
Included
Not Covered
Included
Not Covered
$20 copay
50% after deductible
$20 copay
50% after deductible
$30 copay
50% after deductible
$40 copay
50% after deductible
$40 copay
50% after deductible
$50 copay
50% after deductible
$0 copay
50% after deductible
$0 copay
50% after deductible
$0 copay
50% after deductible
$40 copay
50% after deductible
$40 copay
50% after deductible
$50 copay
50% after deductible
$100 copay
50% after deductible
$100 copay
50% after deductible
$100 copay
50% after deductible
$10 copay
25% after deductible
$10 copay
25% after deductible
$10 copay
25% after deductible
$20 copay
50% after deductible
$20 copay
50% after deductible
$20 copay
50% after deductible
50%
50% after deductible
50%
50% after deductible
50%
50% after deductible
$150 copay per day up to 5 days
per admission
50% after deductible
$150 copay per day up to 5 days
per admission
50% after deductible
$500 copay per day up to 5 days
per admission
50% after deductible
$150 copay
50% after deductible
$150 copay
50% after deductible
$500 copay
50% after deductible
$150 copay
50% after deductible
Maximum benefit of $2,000 per
member per calendar year
$150 copay
50% after deductible
Maximum benefit of $2,000 per
member per calendar year
$500 copay
50% after deductible
Maximum benefit of $2,000 per
member per calendar year
$100 copay
Same as Network
$100 copay
Same as Network
$100 copay
Same as Network
$5/$20/$40
Not Covered
$15/$35/$60
Not Covered
$5/$20/$40
Not Covered
$10/$40/$80
Not Covered
$30/$70/$120
Not Covered
$10/$40/$80
Not Covered
Included
Not Covered
Included
Not Covered
Included
Not Covered
Included
Not Covered
Included
Not Covered
Included
Not Covered
See page 28 for important plan provisions.
9
NEW JERSEY PLAN GUIDE
Q U A L I T Y P O I N T- O F - S E R V I C E ( Q P O S ) P L A N O P T I O N S *
NJ QPOS 30/50/500d 15/35/60 51+
Plan Options
Member Benefits
Network
Non-Network
PCP Coordinated
No Referral Needed
Plan Coinsurance
N/A
50% after deductible
Calendar-Year Deductible1
N/A
$5,000 per member
$15,000 family
Calendar-Year Maximum Out-of-Pocket1
$5,000 per member
$10,000 family
$30,000 per member
$90,000 family
Lifetime Maximum Benefit
Unlimited
Unlimited
Payment for Non-Network Care4
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
Well-Baby/Child Exams
(Age and frequency schedules apply)
$0 copay
50%; deductible waived
Adult Physical Exams
(Age and frequency schedules apply)
$0 copay
50% after deductible
Routine Gyn Exams
(Age and frequency schedules apply)
$0 copay
50%; deductible waived
Routine Mammograms
(Age and frequency schedules apply)
$0 copay
50% after deductible
Routine Eye Exams
(Age and frequency schedules apply)
$0 copay
50% after deductible
Preventive Care
Glasses and Contact Lens Reimbursement
Aetna VisionSM Discount Program
$100/24-month period. Network and non-network combined.
Included
Not Covered
Primary Physician Office Visit
$30 copay
50% after deductible
Specialist Office Visit
$50 copay
50% after deductible
$0 copay
50% after deductible
$50 copay
50% after deductible
Outpatient Complex Imaging
(MRA/MRS, MRI, PET and CAT scans)
$100 copay
50% after deductible
Chiropractic Services
$10 copay
25% after deductible
Outpatient Rehabilitation Therapy
(60 combined visits per calendar-year for physical, occupational and
speech therapy)
$20 copay
50% after deductible
Durable Medical Equipment
($2,500 calendar-year maximum)
50%
50% after deductible
Inpatient Hospital
(Including inpatient mental health and substance abuse)
$500 copay per day up to 5 days per admission
50% after deductible
Hospital Outpatient Facility
$500 copay
50% after deductible
Ambulatory Surgical Center or Facility
other than a Hospital Outpatient Facility
$500 copay
50% after deductible
Maximum benefit of $2,000 per member per
calendar year
$100 copay
Same as Network
Prescription Drugs: 30-day supply
$15/$35/$60
Not Covered
Retail or Mail Order: 31- to 90-day
$30/$70/$120
Not Covered
Contraceptives and Diabetic Supplies
Included
Not Covered
90-Day Transition of Coverage (TOC) for Prior Authorization†
Included
Not Covered
Outpatient Services
Lab
X-Ray
(Network: 30 visits per calendar-year
Non-Network: $1,000 calendar-year maximum)
Outpatient Surgery
Emergency Room
Prescription Drugs (Includes self-injectables)
See page 28 for important plan provisions.
10
MEDICAL
Q U A L I T Y P O I N T- O F - S E R V I C E ( Q P O S ) P L A N O P T I O N S *
NJ QPOS CS 500 90/50 20/40 5/20/40 51+
Plan Options
Member Benefits
NJ QPOS CS 500 90/50 20/40 15/35/60 51+
Network
Non-Network
Network
PCP Coordinated
No Referral Needed
PCP Coordinated
Non-Network
No Referral Needed
Plan Coinsurance
10% after deductible
50% after deductible
10% after deductible
50% after deductible
Calendar-Year Deductible1
$500 per member
$1,000 family
$5,000 per member
$15,000 family
$500 per member
$1,000 family
$5,000 per member
$15,000 family
Calendar-Year Maximum Out-of-Pocket1
$1,500 per member
$3,000 family
$30,000 per member
$90,000 family
$1,500 per member
$3,000 family
$30,000 per member
$90,000 family
Lifetime Maximum Benefit
Unlimited
Unlimited
Unlimited
Unlimited
Payment for Non-Network Care4
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
Well-Baby/Child Exams
(Age and frequency schedules apply)
$0 copay;
deductible waived
50%; deductible waived
$0 copay;
deductible waived
50%; deductible waived
Adult Physical Exams
(Age and frequency schedules apply)
$0 copay;
deductible waived
50% after deductible
$0 copay;
deductible waived
50% after deductible
Routine Gyn Exams
(Age and frequency schedules apply)
$0 copay;
deductible waived
50%; deductible waived
$0 copay;
deductible waived
50%; deductible waived
Routine Mammograms
(Age and frequency schedules apply)
$0 copay;
deductible waived
50% after deductible
$0 copay;
deductible waived
50% after deductible
Routine Eye Exams
(Age and frequency schedules apply)
$0 copay;
deductible waived
50% after deductible
$0 copay;
deductible waived
50% after deductible
Preventive Care
Glasses and Contact Lens Reimbursement
Aetna VisionSM Discount Program
$100/24-month period. Network and non-network combined.
$100/24-month period. Network and non-network combined.
Included
Not Covered
Included
Not Covered
Primary Physician Office Visit
$20 copay;
deductible waived
50% after deductible
$20 copay;
deductible waived
50% after deductible
Specialist Office Visit
$40 copay;
deductible waived
50% after deductible
$40 copay;
deductible waived
50% after deductible
Lab
$0 copay;
deductible waived
50% after deductible
$0 copay;
deductible waived
50% after deductible
X-Ray
$40 copay;
deductible waived
50% after deductible
$40 copay;
deductible waived
50% after deductible
Outpatient Complex Imaging
(MRA/MRS, MRI, PET and CAT scans)
20%; deductible waived
50% after deductible
20%; deductible waived
50% after deductible
Chiropractic Services
$10 copay;
deductible waived
25% after deductible
$10 copay;
deductible waived
25% after deductible
Outpatient Rehabilitation Therapy
(60 combined visits per calendar-year for physical, occupational
and speech therapy)
$20 copay;
deductible waived
50% after deductible
$20 copay;
deductible waived
50% after deductible
Durable Medical Equipment
($2,500 calendar-year maximum)
50%; deductible waived
50% after deductible
50%; deductible waived
50% after deductible
Inpatient Hospital
(Including inpatient mental health and substance abuse)
10% after deductible
50% after deductible
10% after deductible
50% after deductible
Hospital Outpatient Facility
10% after deductible
50% after deductible
10% after deductible
50% after deductible
Ambulatory Surgical Center or Facility
other than a Hospital Outpatient Facility
10% after deductible
50% after deductible
Maximum benefit of $2,000 per
member per calendar year
10% after deductible
50% after deductible
Maximum benefit of $2,000 per
member per calendar per year
20%; deductible waived
Same as Network
20%; deductible waived
Same as Network
Prescription Drugs: 30-day supply
$5/$20/$40
Not Covered
$15/$35/$60
Not Covered
Retail or Mail Order: 31- to 90-day
$10/$40/$80
Not Covered
$30/$70/$120
Not Covered
Contraceptives and Diabetic Supplies
Included
Not Covered
Included
Not Covered
90-Day Transition of Coverage (TOC) for Prior Authorization†
Included
Not Covered
Included
Not Covered
Outpatient Services
(Network: 30 visits per calendar-year
Non-Network: $1,000 calendar-year maximum)
Outpatient Surgery
Emergency Room
Prescription Drugs (Includes self-injectables)
See page 28 for important plan provisions.
11
NEW JERSEY PLAN GUIDE
Q U A L I T Y P O I N T- O F - S E R V I C E ( Q P O S ) P L A N O P T I O N S *
NJ QPOS CS 1000 80/50 30/30 15/35/60 51+
Plan Options
Member Benefits
NJ QPOS CS 2000 90/50 30/50 15/35/60 51+
Network
Non-Network
Network
PCP Coordinated
No Referral Needed
PCP Coordinated
Non-Network
No Referral Needed
Plan Coinsurance
20% after deductible
50% after deductible
10% after deductible
50% after deductible
Calendar-Year Deductible1
$1,000 per member
$2,000 family
$5,000 per member
$15,000 family
$2,000 per member
$4,000 family
$5,000 per member
$15,000 family
Calendar-Year Maximum Out-of-Pocket1
$3,000 per member
$6,000 family
$30,000 per member
$90,000 family
$5,000 per member
$10,000 family
$30,000 per member
$90,000 family
Lifetime Maximum Benefit
Unlimited
Unlimited
Unlimited
Unlimited
Payment for Non-Network Care4
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
Well-Baby/Child Exams
(Age and frequency schedules apply)
$0 copay;
deductible waived
50%; deductible waived
$0 copay;
deductible waived
50%; deductible waived
Adult Physical Exams
(Age and frequency schedules apply)
$0 copay;
deductible waived
50% after deductible
$0 copay;
deductible waived
50% after deductible
Routine Gyn Exams
(Age and frequency schedules apply)
$0 copay;
deductible waived
50%; deductible waived
$0 copay;
deductible waived
50%; deductible waived
Routine Mammograms
(Age and frequency schedules apply)
$0 copay;
deductible waived
50% after deductible
$0 copay;
deductible waived
50% after deductible
Routine Eye Exams
(Age and frequency schedules apply)
$0 copay;
deductible waived
50% after deductible
$0 copay;
deductible waived
50% after deductible
Preventive Care
Glasses and Contact Lens Reimbursement
Aetna VisionSM Discount Program
$100/24-month period. Network and non-network combined.
$100/24-month period. Network and non-network combined.
Included
Not Covered
Included
Not Covered
Primary Physician Office Visit
$30 copay;
deductible waived
50% after deductible
$30 copay;
deductible waived
50% after deductible
Specialist Office Visit
$30 copay;
deductible waived
50% after deductible
$50 copay;
deductible waived
50% after deductible
Lab
$0 copay;
deductible waived
50% after deductible
$0 copay;
deductible waived
50% after deductible
X-Ray
$30 copay;
deductible waived
50% after deductible
$50 copay;
deductible waived
50% after deductible
Outpatient Complex Imaging
(MRA/MRS, MRI, PET and CAT scans)
20%;
deductible waived
50% after deductible
20%;
deductible waived
50% after deductible
Chiropractic Services
$10 copay;
deductible waived
25% after deductible
$10 copay;
deductible waived
25% after deductible
Outpatient Rehabilitation Therapy
(60 combined visits per calendar-year for physical, occupational
and speech therapy)
$20 copay;
deductible waived
50% after deductible
$20 copay;
deductible waived
50% after deductible
Durable Medical Equipment
($2,500 calendar-year maximum)
50%; deductible waived
50% after deductible
50%; deductible waived
50% after deductible
Inpatient Hospital
(Including inpatient mental health and substance abuse)
20% after deductible
50% after deductible
10% after deductible
50% after deductible
Hospital Outpatient Facility
20% after deductible
50% after deductible
10% after deductible
50% after deductible
Ambulatory Surgical Center or Facility
other than a Hospital Outpatient Facility
20% after deductible
50% after deductible
Maximum benefit of $2,000 per
member per calendar year
10% after deductible
50% after deductible
Maximum benefit of $2,000 per
member per calendar per year
20%; deductible waived
Same as Network
20%; deductible waived
Same as Network
Prescription Drugs: 30-day supply
$15/$35/$60
Not Covered
$15/$35/$60
Not Covered
Retail or Mail Order: 31- to 90-day
$30/$70/$120
Not Covered
$30/$70/$120
Not Covered
Contraceptives and Diabetic Supplies
Included
Not Covered
Included
Not Covered
90-Day Transition of Coverage (TOC) for Prior Authorization†
Included
Not Covered
Included
Not Covered
Outpatient Services
(Network: 30 visits per calendar-year
Non-Network: $1,000 calendar-year maximum)
Outpatient Surgery
Emergency Room
Prescription Drugs (Includes self-injectables)
See page 28 for important plan provisions.
12
MEDICAL
NJ QPOS CS 2000 80/50 30/50 15/35/60 51+
Network
Non-Network
PCP Coordinated
No Referral Needed
20% after deductible
50% after deductible
$2,000 per member
$4,000 family
$5,000 per member
$15,000 family
$5,000 per member
$10,000 family
$30,000 per member
$90,000 family
Unlimited
Unlimited
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
$0 copay; deductible waived
50%; deductible waived
$0 copay; deductible waived
50% after deductible
$0 copay; deductible waived
50%; deductible waived
$0 copay; deductible waived
50% after deductible
$0 copay; deductible waived
50% after deductible
$100/24-month period. Network and non-network combined.
Included
Not Covered
$30 copay; deductible waived
50% after deductible
$50 copay; deductible waived
50% after deductible
$0 copay; deductible waived
50% after deductible
$50 copay; deductible waived
50% after deductible
20%; deductible waived
50% after deductible
$10 copay; deductible waived
25% after deductible
$20 copay; deductible waived
50% after deductible
50%; deductible waived
50% after deductible
20% after deductible
50% after deductible
20% after deductible
50% after deductible
20% after deductible
50% after deductible
Maximum benefit of $2,000 per
member per calendar per year
20%; deductible waived
Same as Network
$15/$35/$60
Not Covered
$30/$70/$120
Not Covered
Included
Not Covered
Included
Not Covered
See page 28 for important plan provisions.
13
NEW JERSEY PLAN GUIDE
H E A LT H N E T W O R K O P T I O N ( H N O P T I O N ) P L A N O P T I O N S * 3
NJ HNOption 20/20/0 100/70 5/20/40 51+
Plan Options
Member Benefits
NJ HNOption 20/20/0 100/70 15/35/60 51+
Network
Non-Network
Network
No Referral Needed
No Referral Needed
No Referral Needed
Non-Network
No Referral Needed
Plan Coinsurance
N/A
30% after deductible
N/A
30% after deductible
Calendar-Year Deductible1
N/A
$1,000 per member
$3,000 family
N/A
$1,000 per member
$3,000 family
Calendar-Year Maximum Out-of-Pocket1
$1,500 per member
$3,000 family
$5,000 per member
$15,000 family
$1,500 per member
$3,000 family
$5,000 per member
$15,000 family
Lifetime Maximum Benefit
Unlimited
Unlimited
Unlimited
Unlimited
Payment for Non-Network Care4
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
Well-Baby/Child Exams
(Age and frequency schedules apply)
$0 copay
30%; deductible waived
$0 copay
30%; deductible waived
Adult Physical Exams
(Age and frequency schedules apply)
$0 copay
30% after deductible
$0 copay
30% after deductible
Routine Gyn Exams
(Age and frequency schedules apply)
$0 copay
30%; deductible waived
$0 copay
30%; deductible waived
Routine Mammograms
(Age and frequency schedules apply)
$0 copay
30% after deductible
$0 copay
30% after deductible
Routine Eye Exams
(Age and frequency schedules apply)
$0 copay
30% after deductible
$0 copay
30% after deductible
Preventive Care
Glasses and Contact Lens Reimbursement
Aetna VisionSM Discount Program
$100/24-month period. Network and non-network combined.
$100/24-month period. Network and non-network combined.
Included
Not Covered
Included
Not Covered
Primary Physician Office Visit
$20 copay
30% after deductible
$20 copay
30% after deductible
Specialist Office Visit
$20 copay
30% after deductible
$20 copay
30% after deductible
$0 copay
30% after deductible
$0 copay
30% after deductible
$20 copay
30% after deductible
$20 copay
30% after deductible
Outpatient Complex Imaging
(MRA/MRS, MRI, PET and CAT scans)
$100 copay
30% after deductible
$100 copay
30% after deductible
Chiropractic Services
$10 copay
25% after deductible
$10 copay
25% after deductible
Outpatient Rehabilitation Therapy
(60 combined visits per calendar-year for physical, occupational
and speech therapy)
$20 copay
30% after deductible
$20 copay
30% after deductible
Durable Medical Equipment
($2,500 calendar-year maximum)
50%
50% after deductible
50%
50% after deductible
Inpatient Hospital
(Including inpatient mental health and substance abuse)
$0 copay
30% after deductible
$0 copay
30% after deductible
Hospital Outpatient Facility
$0 copay
30% after deductible
$0 copay
30% after deductible
Ambulatory Surgical Center or Facility
other than a Hospital Outpatient Facility
$0 copay
30% after deductible
Maximum benefit of $2,000 per
member per calendar year
$0 copay
30% after deductible
Maximum benefit of $2,000 per
member per calendar year
$100 copay
Same as Network
$100 copay
Same as Network
Prescription Drugs: 30-day supply
$5/$20/$40
Not Covered
$15/$35/$60
Not Covered
Retail or Mail Order: 31- to 90-day
$10/$40/$80
Not Covered
$30/$70/$120
Not Covered
Contraceptives and Diabetic Supplies
Included
Not Covered
Included
Not Covered
Included
Not Covered
Included
Not Covered
Outpatient Services
Lab
X-Ray
(Network: 30 visits per calendar-year
Non-Network: $1,000 calendar-year maximum)
Outpatient Surgery
Emergency Room
Prescription Drugs (Includes self-injectables)
90-Day Transition of Coverage (TOC) for Prior Authorization
†
See page 28 for important plan provisions.
14
MEDICAL
NJ HNOption 25/25/500 5/20/40 51+
NJ HNOption 25/25/500 15/35/60 51+
NJ HNOption 20/20/0 100/50 5/20/40 51+
Network
Non-Network
Network
Non-Network
Network
No Referral Needed
No Referral Needed
No Referral Needed
No Referral Needed
No Referral Needed
No Referral Needed
N/A
30% after deductible
N/A
30% after deductible
N/A
50% after deductible
N/A
$2,000 per member
$6,000 family
N/A
$2,000 per member
$6,000 family
N/A
$5,000 per member
$15,000 family
$2,000 per member
$4,000 family
$5,000 per member
$15,000 family
$2,000 per member
$4,000 family
$5,000 per member
$15,000 family
$1,500 per member
$3,000 family
$30,000 per member
$90,000 family
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
$0 copay
30%; deductible waived
$0 copay
30%; deductible waived
$0 copay
50%; deductible waived
$0 copay
30% after deductible
$0 copay
30% after deductible
$0 copay
50% after deductible
$0 copay
30%; deductible waived
$0 copay
30%; deductible waived
$0 copay
50%; deductible waived
$0 copay
30% after deductible
$0 copay
30% after deductible
$0 copay
50% after deductible
$0 copay
30% after deductible
$0 copay
30% after deductible
$0 copay
50% after deductible
$100/24-month period. Network and non-network combined.
$100/24-month period. Network and non-network combined.
Non-Network
$100/24-month period. Network and non-network combined.
Included
Not Covered
Included
Not Covered
Included
Not Covered
$25 copay
30% after deductible
$25 copay
30% after deductible
$20 copay
50% after deductible
$25 copay
30% after deductible
$25 copay
30% after deductible
$20 copay
50% after deductible
$0 copay
30% after deductible
$0 copay
30% after deductible
$0 copay
50% after deductible
$25 copay
30% after deductible
$25 copay
30% after deductible
$20 copay
50% after deductible
$100 copay
30% after deductible
$100 copay
30% after deductible
$100 copay
50% after deductible
$10 copay
25% after deductible
$10 copay
25% after deductible
$10 copay
25% after deductible
$20 copay
30% after deductible
$20 copay
30% after deductible
$20 copay
50% after deductible
50%
50% after deductible
50%
50% after deductible
50%
50% after deductible
$500 copay per admission
30% after deductible
$500 copay per
admission
30% after deductible
$0 copay
50% after deductible
$250 copay
30% after deductible
$250 copay
30% after deductible
$0 copay
50% after deductible
$250 copay
30% after deductible
Maximum benefit of $2,000 per
member per calendar year
$250 copay
30% after deductible
Maximum benefit of $2,000 per
member per calendar year
$0 copay
50% after deductible
Maximum benefit of $2,000 per
member per calendar year
$100 copay
Same as Network
$100 copay
Same as Network
$100 copay
Same as Network
$5/$20/$40
Not Covered
$15/$35/$60
Not Covered
$5/$20/$40
Not Covered
$10/$40/$80
Not Covered
$30/$70/$120
Not Covered
$10/$40/$80
Not Covered
Included
Not Covered
Included
Not Covered
Included
Not Covered
Included
Not Covered
Included
Not Covered
Included
Not Covered
See page 28 for important plan provisions.
15
NEW JERSEY PLAN GUIDE
H E A LT H N E T W O R K O P T I O N ( H N O P T I O N ) P L A N O P T I O N S * 3
NJ HNOption 20/20/0 100/50 15/35/60 51+
Plan Options
Member Benefits
NJ HNOption 20/40/150d 5/20/40 51+
Network
Non-Network
Network
No Referral Needed
No Referral Needed
No Referral Needed
Non-Network
No Referral Needed
Plan Coinsurance
N/A
50% after deductible
N/A
50% after deductible
Calendar-Year Deductible1
N/A
$5,000 per member
$15,000 family
N/A
$5,000 per member
$15,000 family
Calendar-Year Maximum Out-of-Pocket1
$1,500 per member
$3,000 family
$30,000 per member
$90,000 family
$1,500 per member
$3,000 family
$30,000 per member
$90,000 family
Lifetime Maximum Benefit
Unlimited
Unlimited
Unlimited
Unlimited
Payment for Non-Network Care4
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
Well-Baby/Child Exams
(Age and frequency schedules apply)
$0 copay
50%; deductible waived
$0 copay
50%; deductible waived
Adult Physical Exams
(Age and frequency schedules apply)
$0 copay
50% after deductible
$0 copay
50% after deductible
Routine Gyn Exams
(Age and frequency schedules apply)
$0 copay
50%; deductible waived
$0 copay
50%; deductible waived
Routine Mammograms
(Age and frequency schedules apply)
$0 copay
50% after deductible
$0 copay
50% after deductible
Routine Eye Exams
(Age and frequency schedules apply)
$0 copay
50% after deductible
$0 copay
50% after deductible
Preventive Care
Glasses and Contact Lens Reimbursement
Aetna VisionSM Discount Program
$100/24-month period. Network and non-network combined.
$100/24-month period. Network and non-network combined.
Included
Not Covered
Included
Not Covered
Primary Physician Office Visit
$20 copay
50% after deductible
$20 copay
50% after deductible
Specialist Office Visit
$20 copay
50% after deductible
$40 copay
50% after deductible
$0 copay
50% after deductible
$0 copay
50% after deductible
$20 copay
50% after deductible
$40 copay
50% after deductible
Outpatient Complex Imaging
(MRA/MRS, MRI, PET and CAT scans)
$100 copay
50% after deductible
$100 copay
50% after deductible
Chiropractic Services
$10 copay
25% after deductible
$10 copay
25% after deductible
Outpatient Rehabilitation Therapy
(60 combined visits per calendar-year for physical, occupational and
speech therapy)
$20 copay
50% after deductible
$20 copay
50% after deductible
Durable Medical Equipment
($2,500 calendar-year maximum)
50%
50% after deductible
50%
50% after deductible
Inpatient Hospital
(Including inpatient mental health and substance abuse)
$0 copay
50% after deductible
$150 copay per day up to 5
days per admission
50% after deductible
Hospital Outpatient Facility
$0 copay
50% after deductible
$150 copay
50% after deductible
Ambulatory Surgical Center or Facility
other than a Hospital Outpatient Facility
$0 copay
50% after deductible
Maximum benefit of $2,000 per
member per calendar year
$150 copay
50% after deductible
Maximum benefit of $2,000 per
member per calendar year
$100 copay
Same as Network
$100 copay
Same as Network
Prescription Drugs: 30-day supply
$15/$35/$60
Not Covered
$5/$20/$40
Not Covered
Outpatient Services
Lab
X-Ray
(Network: 30 visits per calendar-year
Non-Network: $1,000 calendar-year maximum)
Outpatient Surgery
Emergency Room
Prescription Drugs (Includes self-injectables)
Retail or Mail Order: 31- to 90-day
$30/$70/$120
Not Covered
$10/$40/$80
Not Covered
Contraceptives and Diabetic Supplies
Included
Not Covered
Included
Not Covered
90-Day Transition of Coverage (TOC) for Prior Authorization†
Included
Not Covered
Included
Not Covered
See page 28 for important plan provisions.
16
MEDICAL
NJ HNOption 20/40/150d 15/35/60 51+
NJ HNOption 20/40/250d 5/20/40 51+
NJ HNOption 20/40/250d 15/35/60 51+
Network
Non-Network
Network
Non-Network
Network
No Referral Needed
No Referral Needed
No Referral Needed
No Referral Needed
No Referral Needed
No Referral Needed
N/A
50% after deductible
N/A
30% after deductible
N/A
30% after deductible
N/A
$5,000 per member
$15,000 family
N/A
$4,000 per member
$12,000 family
N/A
$4,000 per member
$12,000 family
$1,500 per member
$3,000 family
$30,000 per member
$90,000 family
$4,000 per member
$8,000 family
$10,000 per member
$30,000 family
$4,000 per member
$8,000 family
$10,000 per member
$30,000 family
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
$0 copay
50%; deductible waived
$0 copay
30%; deductible waived
$0 copay
30%; deductible waived
$0 copay
50% after deductible
$0 copay
30% after deductible
$0 copay
30% after deductible
$0 copay
50%; deductible waived
$0 copay
30%; deductible waived
$0 copay
30%; deductible waived
$0 copay
50% after deductible
$0 copay
30% after deductible
$0 copay
30% after deductible
$0 copay
50% after deductible
$0 copay
30% after deductible
$0 copay
30% after deductible
$100/24-month period. Network and non-network combined.
$100/24-month period. Network and non-network combined.
Non-Network
$100/24-month period. Network and non-network combined.
Included
Not Covered
Included
Not Covered
Included
Not Covered
$20 copay
50% after deductible
$20 copay
30% after deductible
$20 copay
30% after deductible
$40 copay
50% after deductible
$40 copay
30% after deductible
$40 copay
30% after deductible
$0 copay
50% after deductible
$0 copay
30% after deductible
$0 copay
30% after deductible
$40 copay
50% after deductible
$40 copay
30% after deductible
$40 copay
30% after deductible
$100 copay
50% after deductible
$100 copay
30% after deductible
$100 copay
30% after deductible
$10 copay
25% after deductible
$10 copay
25% after deductible
$10 copay
25% after deductible
$20 copay
50% after deductible
$20 copay
30% after deductible
$20 copay
30% after deductible
50%
50% after deductible
50%
50% after deductible
50%
50% after deductible
$150 copay per day up to 5 days
per admission
50% after deductible
$250 copay per day up to 5 days
per admission
30% after deductible
$250 copay per day up to 5 days
per admission
30% after deductible
$150 copay
50% after deductible
$250 copay
30% after deductible
$250 copay
30% after deductible
$150 copay
50% after deductible
Maximum benefit of $2,000 per
member per calendar year
$250 copay
30% after deductible
Maximum benefit of $2,000 per
member per calendar year
$250 copay
30% after deductible
Maximum benefit of $2,000 per
member per calendar year
$100 copay
Same as Network
$100 copay
Same as network
$100 copay
Same as Network
$15/$35/$60
Not Covered
$5/$20/$40
Not Covered
$15/$35/$60
Not Covered
$30/$70/$120
Not Covered
$10/$40/$80
Not Covered
$30/$70/$120
Not Covered
Included
Not Covered
Included
Not Covered
Included
Not Covered
Included
Not Covered
Included
Not Covered
Included
Not Covered
See page 28 for important plan provisions.
17
NEW JERSEY PLAN GUIDE
H E A LT H N E T W O R K O P T I O N ( H N O P T I O N ) P L A N O P T I O N S * 3
NJ HNOption 20/20/400d 5/20/40 51+
Plan Options
Member Benefits
NJ HNOption 20/20/400d 15/35/60 51+
Network
Non-Network
Network
No Referral Needed
No Referral Needed
No Referral Needed
Non-Network
No Referral Needed
Plan Coinsurance
N/A
50% after deductible
N/A
50% after deductible
Calendar-Year Deductible1
N/A
$5,000 per member
$15,000 family
N/A
$5,000 per member
$15,000 family
Calendar-Year Maximum Out-of-Pocket1
$4,000 per member
$8,000 family
$30,000 per member
$90,000 family
$4,000 per member
$8,000 family
$30,000 per member
$90,000 family
Lifetime Maximum Benefit
Unlimited
Unlimited
Unlimited
Unlimited
Payment for Non-Network Care4
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
Well-Baby/Child Exams
(Age and frequency schedules apply)
$0 copay
50%; deductible waived
$0 copay
50%; deductible waived
Adult Physical Exams
(Age and frequency schedules apply)
$0 copay
50% after deductible
$0 copay
50% after deductible
Routine Gyn Exams
(Age and frequency schedules apply)
$0 copay
50%; deductible waived
$0 copay
50%; deductible waived
Routine Mammograms
(Age and frequency schedules apply)
$0 copay
50% after deductible
$0 copay
50% after deductible
Routine Eye Exams
(Age and frequency schedules apply)
$0 copay
50% after deductible
$0 copay
50% after deductible
Preventive Care
Glasses and Contact Lens Reimbursement
Aetna VisionSM Discount Program
$100/24-month period. Network and non-network combined.
$100/24-month period. Network and non-network combined.
Included
Not Covered
Included
Not Covered
Primary Physician Office Visit
$20 copay
50% after deductible
$20 copay
50% after deductible
Specialist Office Visit
$20 copay
50% after deductible
$20 copay
50% after deductible
$0 copay
50% after deductible
$0 copay
50% after deductible
$20 copay
50% after deductible
$20 copay
50% after deductible
Outpatient Complex Imaging
(MRA/MRS, MRI, PET and CAT scans)
$100 copay
50% after deductible
$100 copay
50% after deductible
Chiropractic Services
$10 copay
25% after deductible
$10 copay
25% after deductible
Outpatient Rehabilitation Therapy
(60 combined visits per calendar-year for physical, occupational and
speech therapy)
$20 copay
50% after deductible
$20 copay
50% after deductible
Durable Medical Equipment
($2,500 calendar-year maximum)
50%
50% after deductible
50%
50% after deductible
Inpatient Hospital
(Including inpatient mental health and substance abuse)
$400 copay per day up to 5
days per admission
50% after deductible
$400 copay per day up to 5
days per admission
50% after deductible
Hospital Outpatient Facility
$400 copay
50% after deductible
$400 copay
50% after deductible
Ambulatory Surgical Center or Facility
other than a Hospital Outpatient Facility
$400 copay
50% after deductible
Maximum benefit of $2,000 per
member per calendar year
$400 copay
50% after deductible
Maximum benefit of $2,000 per
member per calendar year
$100 copay
Same as Network
$100 copay
Same as Network
Prescription Drugs: 30-day supply
$5/$20/$40
Not Covered
$15/$35/$60
Not Covered
Outpatient Services
Lab
X-Ray
(Network: 30 visits per calendar-year
Non-Network: $1,000 calendar-year maximum)
Outpatient Surgery
Emergency Room
Prescription Drugs (Includes self-injectables)
Retail or Mail Order: 31- to 90-day
$10/$40/$80
Not Covered
$30/$70/$120
Not Covered
Contraceptives and Diabetic Supplies
Included
Not Covered
Included
Not Covered
90-Day Transition of Coverage (TOC) for Prior Authorization†
Included
Not Covered
Included
Not Covered
See page 28 for important plan provisions.
18
MEDICAL
NJ HNOption 30/50/500d 5/20/40 51+
NJ HNOption 30/50/500d 15/35/50 51+
Network
Non-Network
Network
No Referral Needed
No Referral Needed
No Referral Needed
No Referral Needed
N/A
50% after deductible
N/A
50% after deductible
N/A
$5,000 per member
$15,000 family
N/A
$5,000 per member
$15,000 family
$5,000 per member
$10,000 family
$30,000 per member
$90,000 family
$5,000 per member
$10,000 family
$30,000 per member
$90,000 family
Unlimited
Unlimited
Unlimited
Unlimited
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
$0 copay
50%; deductible waived
$0 copay
50%; deductible waived
$0 copay
50% after deductible
$0 copay
50% after deductible
$0 copay
50%; deductible waived
$0 copay
50%; deductible waived
$0 copay
50% after deductible
$0 copay
50% after deductible
$0 copay
50% after deductible
$0 copay
50% after deductible
$100/24-month period. Network and non-network combined.
Non-Network
$100/24-month period. Network and non-network combined.
Included
Not Covered
Included
Not Covered
$30 copay
50% after deductible
$30 copay
50% after deductible
$50 copay
50% after deductible
$50 copay
50% after deductible
$0 copay
50% after deductible
$0 copay
50% after deductible
$50 copay
50% after deductible
$50 copay
50% after deductible
$100 copay
50% after deductible
$100 copay
50% after deductible
$10 copay
25% after deductible
$10 copay
25% after deductible
$20 copay
50% after deductible
$20 copay
50% after deductible
50%
50% after deductible
50%
50% after deductible
$500 copay per day up to 5
days per admission
50% after deductible
$500 copay per day up to 5
days per admission
50% after deductible
$500 copay
50% after deductible
$500 copay
50% after deductible
$500 copay
50% after deductible
Maximum benefit of $2,000 per
member per calendar year
$500 copay
50% after deductible
Maximum benefit of $2,000 per
member per calendar year
$100 copay
Same as Network
$100 copay
Same as Network
$5/$20/$40
Not Covered
$15/$35/$60
Not Covered
$10/$40/$80
Not Covered
$30/$70/$120
Not Covered
Included
Not Covered
Included
Not Covered
Included
Not Covered
Included
Not Covered
See page 28 for important plan provisions.
19
H E A LT H N E T W O R K O P T I O N ( H N O P T I O N ) P L A N O P T I O N S * 3
NJ HNOption CS 500 90/70 20/40 5/20/40 51+
Plan Options
Member Benefits
NJ HNOption CS 500 90/70 20/40 15/35/60 51+
Network
Non-Network
Network
No Referral Needed
No Referral Needed
No Referral Needed
Non-Network
No Referral Needed
Plan Coinsurance
10% after deductible
30% after deductible
10% after deductible
30% after deductible
Calendar-Year Deductible1
$500 per member
$1,000 family
$2,500 per member
$7,500 family
$500 per member
$1,000 family
$2,500 per member
$7,500 family
Calendar-Year Maximum Out-of-Pocket1
$1,500 per member
$3,000 family
$5,000 per member
$15,000 family
$1,500 per member
$3,000 family
$5,000 per member
$15,000 family
Lifetime Maximum Benefit
Unlimited
Unlimited
Unlimited
Unlimited
Payment for Non-Network Care4
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
Well-Baby/Child Exams
(Age and frequency schedules apply)
$0 copay;
deductible waived
30%; deductible waived
$0 copay;
deductible waived
30%; deductible waived
Adult Physical Exams
(Age and frequency schedules apply)
$0 copay;
deductible waived
30% after deductible
$0 copay;
deductible waived
30% after deductible
Routine Gyn Exams
(Age and frequency schedules apply)
$0 copay;
deductible waived
30%; deductible waived
$0 copay;
deductible waived
30%; deductible waived
Routine Mammograms
(Age and frequency schedules apply)
$0 copay;
deductible waived
30% after deductible
$0 copay;
deductible waived
30% after deductible
Routine Eye Exams
(Age and frequency schedules apply)
$0 copay;
deductible waived
30% after deductible
$0 copay;
deductible waived
30% after deductible
Preventive Care
Glasses and Contact Lens Reimbursement
Aetna VisionSM Discount Program
$100/24-month period. Network and non-network combined.
$100/24-month period. Network and non-network combined.
Included
Not Covered
Included
Not Covered
Primary Physician Office Visit
$20 copay;
deductible waived
30% after deductible
$20 copay;
deductible waived
30% after deductible
Specialist Office Visit
$40 copay;
deductible waived
30% after deductible
$40 copay;
deductible waived
30% after deductible
Lab
$0 copay;
deductible waived
30% after deductible
$0 copay;
deductible waived
30% after deductible
X-Ray
$40 copay;
deductible waived
30% after deductible
$40 copay;
deductible waived
30% after deductible
Outpatient Complex Imaging
(MRA/MRS, MRI, PET and CAT scans)
20%; deductible waived
30% after deductible
20%; deductible waived
30% after deductible
Chiropractic Services
$10 copay;
deductible waived
25% after deductible
$10 copay;
deductible waived
25% after deductible
Outpatient Rehabilitation Therapy
(60 combined visits per calendar-year for physical, occupational and
speech therapy)
$20 copay;
deductible waived
30% after deductible
$20 copay;
deductible waived
30% after deductible
Durable Medical Equipment
($2,500 calendar-year maximum)
50%; deductible waived
50% after deductible
50%; deductible waived
50% after deductible
Inpatient Hospital
(Including inpatient mental health and substance abuse)
10% after deductible
30% after deductible
10% after deductible
30% after deductible
Hospital Outpatient Facility
10% after deductible
30% after deductible
10% after deductible
30% after deductible
Ambulatory Surgical Center or Facility
other than a Hospital Outpatient Facility
10% after deductible
30% after deductible
Maximum benefit of $2,000 per
member per calendar year
10% after deductible
30% after deductible
Maximum benefit of $2,000 per
member per calendar year
20%; deductible waived
Same as Network
20%; deductible waived
Same as Network
Prescription Drugs: 30-day supply
$5/$20/$40
Not Covered
$15/$35/$60
Not Covered
Retail or Mail Order: 31- to 90-day
$10/$40/$80
Not Covered
$30/$70/$120
Not Covered
Contraceptives and Diabetic Supplies
Included
Not Covered
Included
Not Covered
90-Day Transition of Coverage (TOC) for Prior Authorization†
Included
Not Covered
Included
Not Covered
Outpatient Services
(Network: 30 visits per calendar-year
Non-Network: $1,000 calendar-year maximum)
Outpatient Surgery
Emergency Room
Prescription Drugs (Includes self-injectables)
See page 28 for important plan provisions.
20
MEDICAL
NJ HNOption CS 1000 80/50 30/30 15/35/60 51+
NJ HNOption CS 1000 80/60 30/50 15/35/60 51+
Network
Non-Network
Network
Non-Network
Network
No Referral Needed
No Referral Needed
No Referral Needed
No Referral Needed
No Referral Needed
No Referral Needed
20% after deductible
50% after deductible
20% after deductible
40% after deductible
10% after deductible
50% after deductible
$1,000 per member
$2,000 family
$5,000 per member
$15,000 family
$1,000 per member
$2,000 family
$4,000 per member
$12,000 family
$2,000 per member
$4,000 family
$5,000 per member
$15,000 family
$3,000 per member
$6,000 family
$30,000 per member
$90,000 family
$4,000 per member
$8,000 family
$15,000 per member
$45,000 family
$5,000 per member
$10,000 family
$30,000 per member
$90,000 family
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
$0 copay;
deductible waived
50%; deductible waived
$0 copay;
deductible waived
40%; deductible waived
$0 copay;
deductible waived
50%; deductible waived
$0 copay;
deductible waived
50% after deductible
$0 copay;
deductible waived
40% after deductible
$0 copay;
deductible waived
50% after deductible
$0 copay;
deductible waived
50%; deductible waived
$0 copay;
deductible waived
40%; deductible waived
$0 copay;
deductible waived
50%; deductible waived
$0 copay;
deductible waived
50% after deductible
$0 copay;
deductible waived
40% after deductible
$0 copay;
deductible waived
50% after deductible
$0 copay;
deductible waived
50% after deductible
$0 copay;
deductible waived
40% after deductible
$0 copay;
deductible waived
50% after deductible
$100/24-month period. Network and non-network combined.
$100/24-month period. Network and non-network combined.
NJ HNOption CS 2000 90/50 30/50 15/35/60 51+
Non-Network
$100/24-month period. Network and non-network combined.
Included
Not Covered
Included
Not Covered
Included
Not Covered
$30 copay;
deductible waived
50% after deductible
$30 copay;
deductible waived
40% after deductible
$30 copay;
deductible waived
50% after deductible
$30 copay;
deductible waived
50% after deductible
$50 copay;
deductible waived
40% after deductible
$50 copay;
deductible waived
50% after deductible
$0 copay;
deductible waived
50% after deductible
$0 copay;
deductible waived
40% after deductible
$0 copay;
deductible waived
50% after deductible
$30 copay;
deductible waived
50% after deductible
$50 copay;
deductible waived
40% after deductible
$50 copay;
deductible waived
50% after deductible
20%; deductible waived
50% after deductible
20%; deductible waived
40% after deductible
20%; deductible waived
50% after deductible
$10 copay;
deductible waived
25% after deductible
$10 copay;
deductible waived
25% after deductible
$10 copay;
deductible waived
25% after deductible
$20 copay;
deductible waived
50% after deductible
$20 copay;
deductible waived
40% after deductible
$20 copay;
deductible waived
50% after deductible
50%; deductible waived
50% after deductible
50%; deductible waived
50% after deductible
50%; deductible waived
50% after deductible
20% after deductible
50% after deductible
20% after deductible
40% after deductible
10% after deductible
50% after deductible
20% after deductible
50% after deductible
20% after deductible
40% after deductible
10% after deductible
50% after deductible
20% after deductible
50% after deductible
Maximum benefit of $2,000 per
member per calendar year
20% after deductible
40% after deductible
Maximum benefit of $2,000 per
member per calendar year
10% after deductible
50% after deductible
Maximum benefit of $2,000 per
member per calendar year
20%; deductible waived
Same as Network
20%; deductible waived
Same as Network
20%; deductible waived
Same as Network
$15/$35/$60
Not Covered
$15/$35/$60
Not Covered
$15/$35/$60
Not Covered
$30/$70/$120
Not Covered
$30/$70/$120
Not Covered
$30/$70/$120
Not Covered
Included
Not Covered
Included
Not Covered
Included
Not Covered
Included
Not Covered
Included
Not Covered
Included
Not Covered
See page 28 for important plan provisions.
21
NEW JERSEY PLAN GUIDE
H E A LT H N E T W O R K O P T I O N ( H N O P T I O N ) H S A C O M PAT I B L E P L A N O P T I O N S * 3
NJ HNOption HSA 1500 100/70 15/35/60 51+
Plan Options
Member Benefits
NJ HNOption HSA 2000 100/50 15/35/60 51+
Network
Non-Network
Network
No Referral Needed
No Referral Needed
No Referral Needed
Non-Network
No Referral Needed
Plan Coinsurance
0% after deductible
30% after deductible
0% after deductible
50% after deductible
Calendar Year Deductible2
$1,500 individual
$3,000 family
$3,000 individual
$9,000 family
$2,000 individual
$4,000 family
$5,000 individual
$15,000 family
Calendar Year Maximum Out-of-Pocket2
$3,000 individual
$6,000 family
$6,000 individual
$18,000 family
$4,000 individual
$8,000 family
$30,000 individual
$90,000 family
Lifetime Maximum Benefit
Unlimited
Unlimited
Unlimited
Unlimited
Payment for Non-Network Care4
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
Well-Baby/Child Exams
(Age and frequency schedules apply)
$0 copay;
deductible waived
30%; deductible waived
$0 copay;
deductible waived
50%; deductible waived
Adult Physical Exams
(Age and frequency schedules apply)
$0 copay;
deductible waived
30% after deductible
$0 copay;
deductible waived
50% after deductible
Routine Gyn Exams
(Age and frequency schedules apply)
$0 copay;
deductible waived
30%; deductible waived
$0 copay;
deductible waived
50%; deductible waived
Routine Mammograms
(Age and frequency schedules apply)
$0 copay;
deductible waived
30% after deductible
$0 copay;
deductible waived
50% after deductible
Routine Eye Exams
(Age and frequency schedules apply)
$0 copay;
deductible waived
30% after deductible
$0 copay;
deductible waived
50% after deductible
Preventive Care
Glasses and Contact Lens Reimbursement
Aetna VisionSM Discount Program
$100/24-month period. Network and non-network combined.
$100/24-month period. Network and non-network combined.
Included
Not Covered
Included
Not Covered
Primary Physician Office Visit
0% after deductible
30% after deductible
0% after deductible
50% after deductible
Specialist Office Visit
0% after deductible
30% after deductible
0% after deductible
50% after deductible
Lab
0% after deductible
30% after deductible
0% after deductible
50% after deductible
X-Ray
0% after deductible
30% after deductible
0% after deductible
50% after deductible
Outpatient Complex Imaging
(MRA/MRS, MRI, PET and CAT scans)
20% after deductible
30% after deductible
20% after deductible
50% after deductible
Chiropractic Services
0% after deductible
25% after deductible
0% after deductible
25% after deductible
Outpatient Rehabilitation Therapy
(60 combined visits per calendar-year for physical, occupational
and speech therapy)
0% after deductible
30% after deductible
0% after deductible
50% after deductible
Durable Medical Equipment
($2,500 calendar-year maximum)
50% after deductible
50% after deductible
50% after deductible
50% after deductible
Inpatient Hospital
(Including inpatient mental health and substance abuse)
0% after deductible
30% after deductible
0% after deductible
50% after deductible
Hospital Outpatient Facility
0% after deductible
30% after deductible
0% after deductible
50% after deductible
Ambulatory Surgical Center or Facility
other than a Hospital Outpatient Facility
0% after deductible
30% after deductible
Maximum benefit of $2,000 per
member per calendar year
0% after deductible
50% after deductible
Maximum benefit of $2,000 per
member per calendar year
20% after deductible
Same as Network
20% after deductible
Same as Network
Prescription Drug Deductible
Integrated Medical/Pharmacy
Deductible
Not Covered
Integrated Medical/Pharmacy
Deductible
Not Covered
Prescription Drugs: 30-day supply
$15/$35/$60
Not Covered
$15/$35/$60
Not Covered
Retail or Mail Order: 31- to 90-day
$30/$70/$120
Not Covered
$30/$70/$120
Not Covered
Contraceptives and Diabetic Supplies
Included
Not Covered
Included
Not Covered
Included
Not Covered
Included
Not Covered
Outpatient Services
(Network: 30 visits per calendar-year
Non-Network: $1,000 calendar-year maximum)
Outpatient Surgery
Emergency Room
Prescription Drugs (Includes self-injectables)
90-Day Transition of Coverage (TOC) for Prior Authorization
†
See page 28 for important plan provisions.
22
MEDICAL
NJ HNOption HSA 2000 90/70 15/35/60 51+
NJ HNOption HSA 2000 90/50 15/35/60 51+
Network
Non-Network
Network
No Referral Needed
No Referral Needed
No Referral Needed
No Referral Needed
10% after deductible
30% after deductible
10% after deductible
50% after deductible
$2,000 individual
$4,000 family
$4,000 individual
$12,000 family
$2,000 individual
$4,000 family
$5,000 individual
$15,000 family
$4,000 individual
$8,000 family
$7,500 individual
$22,500 family
$4,000 individual
$8,000 family
$30,000 individual
$90,000 family
Unlimited
Unlimited
Unlimited
Unlimited
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
$0 copay;
deductible waived
30%; deductible waived
$0 copay;
deductible waived
50%; deductible waived
$0 copay;
deductible waived
30% after deductible
$0 copay;
deductible waived
50% after deductible
$0 copay;
deductible waived
30%; deductible waived
$0 copay;
deductible waived
50%; deductible waived
$0 copay;
deductible waived
30% after deductible
$0 copay;
deductible waived
50% after deductible
$0 copay;
deductible waived
30% after deductible
$0 copay;
deductible waived
50% after deductible
$100/24-month period. Network and non-network combined.
Non-Network
$100/24-month period. Network and non-network combined.
Included
Not Covered
Included
Not Covered
10% after deductible
30% after deductible
10% after deductible
50% after deductible
10% after deductible
30% after deductible
10% after deductible
50% after deductible
10% after deductible
30% after deductible
10% after deductible
50% after deductible
10% after deductible
30% after deductible
10% after deductible
50% after deductible
20% after deductible
30% after deductible
20% after deductible
50% after deductible
10% after deductible
25% after deductible
10% after deductible
25% after deductible
10% after deductible
30% after deductible
10% after deductible
50% after deductible
50% after deductible
50% after deductible
50% after deductible
50% after deductible
10% after deductible
30% after deductible
10% after deductible
50% after deductible
10% after deductible
30% after deductible
10% after deductible
50% after deductible
10% after deductible
30% after deductible
Maximum benefit of $2,000 per
member per calendar year
10% after deductible
50% after deductible
Maximum benefit of $2,000 per
member per calendar year
20% after deductible
Same as Network
20% after deductible
Same as Network
Integrated Medical/Pharmacy
Deductible
Not Covered
Integrated Medical/
Pharmacy Deductible
Not Covered
$15/$35/$60
Not Covered
$15/$35/$60
Not Covered
$30/$70/$120
Not Covered
$30/$70/$120
Not Covered
Included
Not Covered
Included
Not Covered
Included
Not Covered
Included
Not Covered
See page 28 for important plan provisions.
23
NEW JERSEY PLAN GUIDE
H E A LT H N E T W O R K O P T I O N ( H N O P T I O N ) H S A C O M PAT I B L E P L A N O P T I O N S * 3
NJ HNOption HSA 2000 80/50 15/35/60 51+
Plan Options
Member Benefits
NJ HNOption HSA 2500 90/50 15/35/60 51+
Network
Non-Network
Network
No Referral Needed
No Referral Needed
No Referral Needed
Non-Network
No Referral Needed
Plan Coinsurance
20% after deductible
50% after deductible
10% after deductible
50% after deductible
Calendar Year Deductible2
$2,000 individual
$4,000 family
$5,000 individual
$15,000 family
$2,500 individual
$5,000 family
$5,000 individual
$15,000 family
Calendar Year Maximum Out-of-Pocket2
$4,000 individual
$8,000 family
$30,000 individual
$90,000 family
$5,000 individual
$10,000 family
$30,000 individual
$90,000 family
Lifetime Maximum Benefit
Unlimited
Unlimited
Unlimited
Unlimited
Payment for Non-Network Care4
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
Well-Baby/Child Exams
(Age and frequency schedules apply)
$0 copay;
deductible waived
50%; deductible waived
$0 copay;
deductible waived
50%; deductible waived
Adult Physical Exams
(Age and frequency schedules apply)
$0 copay;
deductible waived
50% after deductible
$0 copay;
deductible waived
50% after deductible
Routine Gyn Exams
(Age and frequency schedules apply)
$0 copay;
deductible waived
50%; deductible waived
$0 copay;
deductible waived
50%; deductible waived
Routine Mammograms
(Age and frequency schedules apply)
$0 copay;
deductible waived
50% after deductible
$0 copay;
deductible waived
50% after deductible
Routine Eye Exams
(Age and frequency schedules apply)
$0 copay;
deductible waived
50% after deductible
$0 copay;
deductible waived
50% after deductible
Preventive Care
Glasses and Contact Lens Reimbursement
Aetna VisionSM Discount Program
$100/24-month period. Network and non-network combined.
$100/24-month period. Network and non-network combined.
Included
Not Covered
Included
Not Covered
Primary Physician Office Visit
20% after deductible
50% after deductible
10% after deductible
50% after deductible
Specialist Office Visit
20% after deductible
50% after deductible
10% after deductible
50% after deductible
Lab
20% after deductible
50% after deductible
10% after deductible
50% after deductible
X-Ray
20% after deductible
50% after deductible
10% after deductible
50% after deductible
Outpatient Complex Imaging
(MRA/MRS, MRI, PET and CAT scans)
20% after deductible
50% after deductible
20% after deductible
50% after deductible
Chiropractic Services
20% after deductible
25% after deductible
10% after deductible
25% after deductible
Outpatient Rehabilitation Therapy
(60 combined visits per calendar-year for physical, occupational and
speech therapy)
20% after deductible
50% after deductible
10% after deductible
50% after deductible
Durable Medical Equipment
($2,500 calendar-year maximum)
50% after deductible
50% after deductible
50% after deductible
50% after deductible
Inpatient Hospital
(Including inpatient mental health and substance abuse)
20% after deductible
50% after deductible
10% after deductible
50% after deductible
Hospital Outpatient Facility
20% after deductible
50% after deductible
10% after deductible
50% after deductible
Ambulatory Surgical Center or Facility
other than a Hospital Outpatient Facility
20% after deductible
50% after deductible
Maximum benefit of $2,000 per
member per calendar year
10% after deductible
50% after deductible
Maximum benefit of $2,000 per
member per calendar year
20% after deductible
Same as Network
20% after deductible
Same as Network
Prescription Drug Deductible
Integrated Medical/Pharmacy
Deductible
Not Covered
Integrated Medical/Pharmacy
Deductible
Not Covered
Prescription Drugs: 30-day supply
$15/$35/$60
Not Covered
$15/$35/$60
Not Covered
Retail or Mail Order: 31- to 90-day
$30/$70/$120
Not Covered
$30/$70/$120
Not Covered
Contraceptives and Diabetic Supplies
Included
Not Covered
Included
Not Covered
Included
Not Covered
Included
Not Covered
Outpatient Services
(Network: 30 visits per calendar-year
Non-Network: $1,000 calendar-year maximum)
Outpatient Surgery
Emergency Room
Prescription Drugs (Includes self-injectables)
90-Day Transition of Coverage (TOC) for Prior Authorization
†
See page 28 for important plan provisions.
24
MEDICAL
25
NEW JERSEY PLAN GUIDE
OPEN ACCESS MA N A G E D C H O I C E ® ( O A M C ) A N D I N D E M N I T Y P L A N OPTIONS * 3
NJ OA MC 20/20/0 15/35/60 51+
Plan Options
Member Benefits
NJ OA MC 1000 90/70 30/30 15/35/60 51+
Network
Non-Network
Network
No Referral Needed
No Referral Needed
No Referral Needed
Non-Network
No Referral Needed
Plan Coinsurance
N/A
30% after deductible
10% after deductible
30% after deductible
Calendar-Year Deductible1
N/A
$1,000 per member
$3,000 family
$1,000 per member
$2,000 family
$3,000 per member
$9,000 family
Calendar-Year Maximum Out-of-Pocket1
$1,500 per member
$3,000 family
$5,000 per member
$15,000 family
$3,000 per member
$6,000 family
$10,000 per member
$30,000 family
Lifetime Maximum Benefit
Unlimited
Unlimited
Unlimited
Unlimited
Payment for Non-Network Care4
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
Well-Baby/Child Exams
(Age and frequency schedules apply)
$0 copay
30%; deductible waived
$0 copay;
deductible waived
30%; deductible waived
Adult Physical Exams
(Age and frequency schedules apply)
$0 copay
30% after deductible
$0 copay;
deductible waived
30% after deductible
Routine Gyn Exams
(Age and frequency schedules apply)
$0 copay
30%; deductible waived
$0 copay;
deductible waived
30%; deductible waived
Routine Mammograms
(Age and frequency schedules apply)
$0 copay
30% after deductible
$0 copay;
deductible waived
30% after deductible
Routine Eye Exams
(Age and frequency schedules apply)
$0 copay
30% after deductible
$0 copay;
deductible waived
30% after deductible
Preventive Care
Glasses and Contact Lens Reimbursement
Aetna VisionSM Discount Program
$100/24-month period. Network and non-network combined.
$100/24-month period. Network and non-network combined.
Included
Not Covered
Included
Not Covered
Primary Physician Office Visit
$20 copay
30% after deductible
$30 copay;
deductible waived
30% after deductible
Specialist Office Visit
$20 copay
30% after deductible
$30 copay;
deductible waived
30% after deductible
$0 copay
30% after deductible
$0 copay;
deductible waived
30% after deductible
$20 copay
30% after deductible
$30 copay;
deductible waived
30% after deductible
Outpatient Complex Imaging
(MRA/MRS, MRI, PET and CAT scans)
$100 copay
30% after deductible
$100 copay;
deductible waived
30% after deductible
Chiropractic Services
$10 copay
25% after deductible
$10 copay;
deductible waived
25% after deductible
Outpatient Rehabilitation Therapy
(60 combined visits per calendar-year for physical, occupational and
speech therapy)
$20 copay
30% after deductible
$20 copay;
deductible waived
30% after deductible
Durable Medical Equipment
($2,500 calendar-year maximum)
50%
50% after deductible
50%; deductible waived
50% after deductible
Inpatient Hospital
(Including inpatient mental health and substance abuse)
$0 copay
30% after deductible
10% after deductible
30% after deductible
Outpatient Surgery
$0 copay
30% after deductible
10% after deductible
30% after deductible
Emergency Room
$100 copay
Same as Network
$100 copay;
deductible waived
Same as Network
Prescription Drug Deductible
None
None
None
None
Prescription Drugs: 30-day supply
$15/$35/$60
$15/$35/$60 plus 30%
$15/$35/$60
$15/$35/$60 plus 30%
Retail or Mail Order: 31- to 90-day
$30/$70/$120
$30/$70/$120 plus 30%
$30/$70/$120
$30/$70/$120 plus 30%
Contraceptives and Diabetic Supplies
Included
Included
Included
Included
90-Day Transition of Coverage (TOC) for Prior Authorization†
Included
Included
Included
Included
Outpatient Services
Lab
X-Ray
(Network: 30 visits per calendar-year
Non-Network: $1,000 calendar-year maximum)
Prescription Drugs (Includes self-injectables)
See page 28 for important plan provisions.
26
MEDICAL
NJ OA MC HSA 2500 90/50 15/35/60 51+
Network
NJ Indemnity 1000 80 15/35/60 51+
Non-Network
No Referral Needed
No Referral Needed
No Referral Needed
10% after deductible
50% after deductible
20% after deductible
$2,500 individual
$5,000 family
$5,000 individual
$15,000 family
$1,000 per member
$2,000 family
$5,000 individual
$10,000 family
$30,000 individual
$90,000 family
$5,000 per member
$10,000 family
Unlimited
Unlimited
Unlimited
N/A
Professional:
Medicare 110%
Facility:
Medicare 140%
N/A
$0 copay;
deductible waived
50%; deductible waived
$0 copay; deductible waived
$0 copay;
deductible waived
50% after deductible
$0 copay; deductible waived
$0 copay;
deductible waived
50%; deductible waived
$0 copay; deductible waived
$0 copay;
deductible waived
50% after deductible
$0 copay; deductible waived
$0 copay;
deductible waived
50% after deductible
$0 copay; deductible waived
$100/24-month period. Network and non-network combined.
$100/24 month period.
Included
Not Covered
Included
10% after deductible
50% after deductible
20% after deductible
10% after deductible
50% after deductible
20% after deductible
10% after deductible
50% after deductible
20% after deductible
10% after deductible
50% after deductible
20% after deductible
20% after deductible
50% after deductible
20% after deductible
10% after deductible
25% after deductible
20% after deductible
10% after deductible
50% after deductible
20% after deductible
50% after deductible
50% after deductible
50% after deductible
10% after deductible
50% after deductible
20% after deductible
10% after deductible
50% after deductible
20% after deductible
20% after deductible
Same as Network
20% after deductible
Integrated Medical/Pharmacy
Deductible
Integrated Medical/Pharmacy
Deductible
None
$15/$35/$60
$15/$35/$60 plus 30%
$15/$35/$60
$30/$70/$120
$30/$70/$120 plus 30%
$30/$70/$120
Included
Included
Included
Included
Included
Included
See page 28 for important plan provisions.
27
NEW JERSEY PLAN GUIDE
I M P O R TA N T P L A N P R O V I S I O N S
This is a partial description of benefits available; for more information, refer to the specific plan design summary. The dollar amount copayments and percentage
amounts indicate what the member is required to pay.
*
Some benefits are subject to limitations or visit maximums. Members or providers may be required to pre-certify or obtain prior approval for certain services.
All covered expenses, excluding prescription drugs, accumulate separately toward the network and non-network deductible and maximum out-of-pocket; only those
out-of-pocket expenses resulting from the application of deductible, coinsurance percentage and copays (excluding prescription drug copays) may be used to satisfy
the maximum out-of-pocket; and certain services may not apply toward the deductible. Once the family deductible/maximum out-of-pocket is met, all family members
will be considered as having met their deductible/maximum out-of-pocket for the remainder of the calendar year. No one family member may contribute more than the
individual deductible/maximum out-of-pocket amount to the family deductible/maximum out-of-pocket.
1
All covered expenses, including prescription drugs, accumulate separately toward the network and non-network deductible and maximum out-of-pocket; only those
out-of-pocket expenses resulting from the application of deductible, coinsurance percentage and copays, including prescription drug copays, may be used to satisfy
the maximum out-of-pocket. The individual deductible/maximum out-of-pocket can only be met when a member is enrolled for self-only coverage with no dependent
coverage. The family deductible/maximum out-of-pocket can be met by a combination of family members or by any single individual within the family. Once the family
deductible/maximum out-of-pocket is met, all family members will be considered as having met their deductible/maximum out-of-pocket for the remainder of the
calendar year.
2
No referral provision: A member will pay the primary physician office visit cost share when the member obtains covered benefits from any participating primary care
physician. Members will pay the specialist office visit cost share when the member obtains covered benefits from any participating specialist.
3
We cover the cost of services based on whether doctors are “in network” or “out of network.” We want to help you understand how much Aetna pays for your outof-network care. At the same time, we want to make it clear how much more you will need to pay for this “out-of-network” care.
4
You may choose a provider (doctor or hospital) in the Aetna network. You may choose to visit an out-of-network provider. If you choose a doctor who is out of
network, your Aetna health plan may pay some of that doctor’s bill. Most of the time, you will pay a lot more money out of your own pocket if you choose to use an
out-of-network doctor or hospital.
When you choose out-of-network care, Aetna limits the amount it will pay. This limit is called the “recognized” or “allowed” amount. When you choose out-ofnetwork care, Aetna “recognizes” an amount based on what Medicare pays for these services. The government sets the Medicare rate.
Your doctor sets his or her own rate to charge you. It may be higher – sometimes much higher – than what your Aetna plan “recognizes.” Your doctor may bill you
for the dollar amount that Aetna doesn’t “recognize.” You must also pay any copayments, coinsurance and deductibles under your plan. No dollar amount above the
“recognized charge” counts toward your deductible or out-of-pocket maximums. To learn more about how we pay out-of-network benefits, visit www.aetna.com.
Type “how Aetna pays” in the search box.
You can avoid these extra costs by getting your care from Aetna’s broad network of health care providers. Go to www.aetna.com and click on “Find a Doctor” on
the left side of the page. If you are already a member, log in to your secure Aetna Navigator member site.
This applies when you choose to get care out of network. When you have no choice (for example: emergency room visit after a car accident, or for other emergency
services), we will pay the bill as if you got care in network. You pay cost sharing and deductibles for your in-network level of benefits. Contact Aetna if your provider
asks you to pay more. You are not responsible for any outstanding balance billed by your providers for emergency services beyond your cost sharing and deductibles.
Transition of coverage for prior authorizations helps members of new groups to transition to Aetna by providing a 90-calendar-day opportunity, beginning on the
group’s initial effective date, during which time prior authorization requirements will not apply to certain drugs. Once the 90 calendar days have expired, prior
authorization edits will apply to all drugs requiring prior authorization as listed in the formulary guide. Members, who have claims paid for a drug requiring prior
authorization during the transition of coverage period, may continue to receive this drug after the 90 calendar days and will not be required to obtain a prior
authorization for this drug.
†
Note: For a summary list of limitations and exclusions, refer to page 38. Please refer to Aetna’s Producer World website via www.aetna.com for more detailed business
benefits descriptions. Or for more information, please contact your licensed agent or Aetna sales representative.
28
MEDICAL
29
NEW JERSEY PLAN GUIDE
D E N TA L O V E R V I E W
A E T N A D E N TA L ® P L A N S
Business decision makers can choose from a variety of plan
design options that help you offer a dental benefits and
dental insurance plan that’s just right for your employees.
The Mouth MattersSM
Research suggests that serious gum
disease, known as periodontitis, may be
associated with many health problems. This
is especially true if gum disease continues
without treatment.1,2 Now, here’s the good
news. Researchers are discovering that a
healthy mouth may be important to your
overall health.1,2
The Aetna Dental/Medical IntegrationSM
program,* available at no additional
charge to plan sponsors that have both
medical and dental coverages with Aetna,
focuses on those who are pregnant or
have diabetes, coronary artery disease
(heart disease) or cerebrovascular disease
(stroke) and have not had a recent dental
visit. We proactively educate those at-risk
members about the impact oral health care
can have on their condition. Our member
outreach has been proven to successfully
motivate those at-risk members who do
not normally seek dental care to visit the
dentist. Once at the dentist, these at-risk
members will receive enhanced dental
benefits, including an extra cleaning
and full coverage for certain periodontal
services.
The Dental Maintenance
Organization (DMO®)
Members select a primary care dentist to
coordinate their care from the available
managed dental network. Each family
member may choose a different primary
care dentist and may switch dentists at
any time via Aetna Navigator or with
a call to Member Services. If specialty
care is needed, a member’s primary
care dentist can refer the member to
a participating specialist. However,
members may visit orthodontists without
a referral. There are virtually no claim
forms to file, and benefits are not subject
to deductibles or annual maximums.
MayoClinic.com. “Oral health: A window to your overall health.” Available online at
www.mayoclinic.com/health/dental/DE00001. Accessed May 2010.
1
.C. Williams, A.H. Barnett, N. Claffey, M. Davis, R. Gadsby, M. Kellett, G.Y.H. Lip, and S. Thackray. “The potential impact
R
of periodontal disease on general health: a consensus view.” Current Medical Research and Opinion, Vol. 24, No. 6,
2008, 1635-1643.
2
*DMI may not be available in all states.
30
D E N TA L
Preferred Provider Organization
(PPO) plan
Freedom-of-Choice plan
design option
Members can choose a dentist who
participates in the network or choose a
licensed dentist who does not. Participating
dentists have agreed to offer our members
covered services at a negotiated rate
and will not balance bill members.
Get maximum flexibility with our twoin-one dental plan design. The Freedomof-Choice plan design option provides
the administrative ease of one plan, yet
members get to choose between the DMO
and PPO plans on a monthly basis. One
blended rate is paid. Members may switch
between the plans on a monthly basis by
calling Member Services. Plan changes
must be made by the 15th of the month to
be effective the following month.
PPO Max plan
While the PPO Max plan uses the
PPO network, when members use
out-of-network dentists, the service
will be covered based on the PPO fee
schedule, rather than the usual and
customary charge. The member will
share in more of the costs and may
be balance billed. This plan offers
members a quality dental insurance
plan with a significantly lower premium
that encourages in-network usage.
Voluntary Dental option
The Voluntary Dental option is entirely
member paid and provides a solution to
meet the individual needs of members
in the face of rising health care costs.
Administration is easy, and members
benefit from low group rates and the
convenience of payroll deductions.
Dual Option plan
In the Dual Option plan design, the
DMO must be packaged with any
one of the PPO plans. Employees may
choose between the DMO and PPO
offerings at annual enrollment.
31
NEW JERSEY PLAN GUIDE
S TA N D A R D A N D V O L U N TA R Y D E N TA L P L A N S
Option 1A
DMO Fixed
Copay 42
Option 2A
DMO 100/80/50
Option 3A
DMO Fixed
Copay 64
Option 4A
DMO 100/100/60
Option 5A
DMO Fixed
Copay 56
Plan code 42
DMO Plan 100/80/50
Plan code 64
DMO Plan 100/100/60
Plan code 56
Office Visit Copay
$5
$5
$5
$5
$5
Annual Deductible per Member
(Does not apply to diagnostic & preventive services)
None
None
None
None
None
Annual Maximum Benefit
None
None
None
None
None
Periodic oral exam
No Charge
100%
No Charge
100%
No Charge
Comprehensive oral exam
No Charge
100%
No Charge
100%
No Charge
Problem-focused oral exam
No Charge
100%
No Charge
100%
No Charge
Bitewing — single film
No Charge
100%
No Charge
100%
No Charge
Complete series
No Charge
100%
No Charge
100%
No Charge
Adult cleaning
No Charge
100%
No Charge
100%
No Charge
Child cleaning
No Charge
100%
No Charge
100%
No Charge
Sealants — per tooth
$10
100%
No Charge
100%
No Charge
Fluoride application — with cleaning
No Charge
100%
No Charge
100%
No Charge
Space maintainers
$100
100%
$75
100%
No Charge
Amalgam filling — 2 surfaces
$32
80%
$12
100%
No Charge
Resin filling — 2 surfaces, anterior
$55
80%
$21
100%
No Charge
$195
80%
$109
100%
No Charge
$65
80%
$51
100%
$25
Extraction — exposed root or erupted tooth
$30
80%
$11
100%
No Charge
Extraction of impacted tooth — soft tissue
$80
80%
$46
100%
No Charge
Complete upper denture
$500
50%
$275
60%
$185
Crown — Porcelain with noble metal1
$488
50%
$255
60%
$150
Pontic — Porcelain with noble metal1
$488
50%
$255
60%
$150
Inlay — metallic (3 or more surfaces)
$463
50%
$195
60%
$150
$175**
50%
$58
60%
$45
$435**
50%
$280
60%
$125
Osseous surgery — per quadrant
$445**
50%
$300
60%
$140
ORTHODONTIC SERVICES*
$2,300 copay
$2,300 copay
$2,300 copay
$2,300 copay
$2,300 copay
Orthodontic Lifetime Maximum
Does not apply
Does not apply
Does not apply
Does not apply
Does not apply
DIAGNOSTIC SERVICES
Oral Exams
X-rays
PREVENTIVE SERVICES
BASIC SERVICES
Endodontic Services
Bicuspid root canal therapy
Periodontic Services
Scaling and root planing — per quadrant
Oral Surgery
MAJOR SERVICES*
Oral Surgery
Removal of impacted tooth — partially bony
Endodontic Services
Molar root canal therapy
Periodontic Services
See page 36 for footnotes.
32
D E N TA L
S TA N D A R D A N D V O L U N TA R Y D E N TA L P L A N S
Option 6A
Freedom of Choice - PPO Max Low
Monthly selection between the DMO and PPO Max
Option 7A
Freedom-of-Choice - PPO Max High
Monthly selection between the DMO and PPO Max
Option 8A
Freedom-of-Choice - PPO Low 80th
Monthly selection between the DMO and PPO
DMO Plan 100/90/60
PPO Max Plan 100/70/40
DMO Plan 100/100/60
PPO Max Plan 100/80/50
DMO Plan 100/100/60
PPO Plan 100/80/50
$5
None
$5
None
$5
None
None
$50; 3X Family Maximum
None
$50; 3X Family Maximum
None
$50; 3X Family Maximum
None
$1,000
None
$1,000
None
$1,000
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
90%
70%
100%
80%
100%
80%
90%
70%
100%
80%
100%
80%
90%
70%
100%
80%
100%
80%
90%
70%
100%
80%
100%
80%
90%
70%
100%
80%
100%
80%
90%
70%
100%
80%
100%
80%
60%
40%
60%
50%
60%
50%
60%
40%
60%
50%
60%
50%
60%
40%
60%
50%
60%
50%
60%
40%
60%
50%
60%
50%
60%
40%
60%
50%
60%
50%
60%
40%
60%
50%
60%
50%
60%
40%
60%
50%
60%
50%
$2,300 copay
40%
$2,300 copay
50%
$2,300 copay
50%
Does not apply
$1,000
Does not apply
$1,000
Does not apply
$1,000
See page 36 for footnotes.
33
NEW JERSEY PLAN GUIDE
S TA N D A R D A N D V O L U N TA R Y D E N TA L P L A N S
Option 9A
Freedom-of-Choice - PPO 1000 80th
Monthly selection between the DMO and PPO
Option 10A
Freedom-of-Choice - PPO 2000 80th
Monthly selection between the DMO and PPO
Plan code 56
PPO Plan 100/80/50
DMO Plan 100/100/60
PPO Plan 100/80/50
Office Visit Copay
$5
None
$5
None
Annual Deductible per Member
(Does not apply to diagnostic & preventive services)
None
$50; 3X Family Maximum
None
$50; 3X Family Maximum
Annual Maximum Benefit
None
$1,000
None
$2,000
Periodic oral exam
No Charge
100%
100%
100%
Comprehensive oral exam
No Charge
100%
100%
100%
Problem-focused oral exam
No Charge
100%
100%
100%
Bitewing — single film
No Charge
100%
100%
100%
Complete series
No Charge
100%
100%
100%
Adult cleaning
No Charge
100%
100%
100%
Child cleaning
No Charge
100%
100%
100%
Sealants — per tooth
No Charge
100%
100%
100%
Fluoride application — with cleaning
No Charge
100%
100%
100%
Space maintainers
No Charge
100%
100%
100%
Amalgam filling — 2 surfaces
No Charge
80%
100%
80%
Resin filling — 2 surfaces, anterior
No Charge
80%
100%
80%
No Charge
80%
100%
80%
$25
80%
100%
80%
Extraction — exposed root or erupted tooth
No Charge
80%
100%
80%
Extraction of impacted tooth — soft tissue
No Charge
80%
100%
80%
Complete upper denture
$185
50%
60%
50%
Crown — Porcelain with noble metal1
$150
50%
60%
50%
Pontic — Porcelain with noble metal1
$150
50%
60%
50%
Inlay — metallic (3 or more surfaces)
$150
50%
60%
50%
$45
50%
60%
80%
$125
50%
60%
80%
Osseous surgery — per quadrant
$140
50%
60%
80%
ORTHODONTIC SERVICES*
$2,300 copay
50%
$2,300 copay
50%
Orthodontic Lifetime Maximum
Does not apply
$1,000
Does not apply
$1,000
DIAGNOSTIC SERVICES
Oral Exams
X-rays
PREVENTIVE SERVICES
BASIC SERVICES
Endodontic Services
Bicuspid root canal therapy
Periodontic Services
Scaling and root planing — per quadrant
Oral Surgery
MAJOR SERVICES*
Oral Surgery
Removal of impacted tooth — partially bony
Endodontic Services
Molar root canal therapy
Periodontic Services
See page 36 for footnotes.
34
D E N TA L
S TA N D A R D A N D V O L U N TA R Y D E N TA L P L A N S
Option 11A
PPO Max 1500
Option 12A
PPO 1000 80th
Option 13A
PPO 1500 80th
Option 14A
PPO 2000 90th
PPO Max 1500 Plan 100/80/50
PPO 1000 Plan 100/80/50
PPO 1500 Plan 100/80/50
PPO 2000 Plan 100/80/50
None
None
None
None
$50; 3X Family Maximum
$50; 3X Family Maximum
$50; 3X Family Maximum
$50; 3X Family Maximum
$1,500
$1,000
$1,500
$2,000
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
80%
80%
80%
50%
80%
80%
80%
50%
80%
80%
80%
50%
50%
50%
50%
$1,000
$1,000
$1,000
$1,500
See page 36 for footnotes.
35
NEW JERSEY PLAN GUIDE
FOOTNOTES
*Coverage Waiting Period applies to Voluntary PPO & PPO Max plans in Options 6A – 12A: Must be an enrolled member of the Plan for 12 months before becoming eligible for
coverage of any major service including Orthodontic Services. Does not apply to DMO in Plan Options 1A – 10A or Standard plans.
**Specialist procedures are not covered by the plan when performed by a participating specialist. However, the service is available to the member at a discount.
There will be an additional patient charge for the actual cost for gold/high noble metal for these procedures for the DMO in plan options 1A, 2A, 5A and 9A.
1
Fixed dollar copay amounts on the DMO, including office visit and ortho copays, are member responsibility.
Note: For New Jersey groups with 50 or more eligible employees, the DMO in plan options 1A - 5A cannot be sold on a standalone basis to a customer with primary business
location in New Jersey. It must be part of a Dual Option sale packaged with either one of the PPO plans in plan options 11A - 14A.
Most oral surgery, endodontic and periodontic services are covered as basic services on the DMO in plan options 1A - 10A, and on the PPO in plan options 6A - 9A and 11A. All
oral surgery, endodontic and periodontic services are covered as basic services on the PPO in Plan Option 13A. General anesthesia along with all oral surgery, endodontic and
periodontic services are covered as basic services on the PPO in plan options 10A, 12A and 14A.
Coverage for implants is included as a major service on the PPO in Plan Option 10A and 14A.
Out-of-network plan payments are limited by geographic area on the PPO in plan options 8A - 10A, 12A and 13A to the prevailing fees at the 80th percentile and the 90th
percentile on Plan Option 14A.
Plan Options 6A, 7A and 11A; PPO Max non-preferred (out-of-network) coverage is limited to a maximum of the plan’s payment, which is based on the contracted maximum fee
for participating providers in the particular geographic area.
Plan features and availability may vary by location and are subject to change. Information is believed to be accurate as of the production date; however, it is subject to change.
Voluntary plans: If there is a lapse in coverage, members may not re-enroll in the plan for a period of two years from the date of termination. If they are eligible for coverage at
that time, they may re-enroll, subject to all provisions of the plan, including, but not limited to, the coverage waiting period.
Orthodontic coverage is available for dependent children only.
DMO access: Apart from the DMO network and DMO plan of benefits, members under this plan also have access to the Aetna Dental AccessSM network. This network provides
access to providers who participate in the Aetna Dental Access network and have agreed to charge a negotiated discounted fee. Members can access this network for any service.
However, the DMO benefits do not apply. In situations where the dentist participates in both the Aetna Dental Access network and the Aetna DMO network, DMO benefits take
precedence over all other discounts including discounts through the Aetna Dental Access network.
Aetna Dental Access network is not insurance or a benefits plan. It only provides access to discounted fees for dental services obtained from providers who participate in the Aetna
Dental Access network. Members are solely responsible for all charges incurred using this access, and are expected to make payment to the provider at the time of treatment.
Above list of covered services is representative. Full list with limitations, as determined by Aetna appears on the plan booklet/certificate. For a summary list of Limitations and
Exclusions, refer to page 39.
36
D E N TA L
37
NEW JERSEY PLAN GUIDE
L I M I TAT I O N S A N D E X C L U S I O N S
MEDICAL
These plans do not cover all health
care expenses and include exclusions
and limitations. Members should refer
to their plan documents to determine
which health care services are covered
and to what extent. The following is a
partial list of services and supplies that
are generally not covered. However, the
plan documents may contain exceptions
to this list based on state mandates
or the plan design purchased.
Aetna QPOS, Health Network Option,
OA MC and Indemnity
ƒƒAll medical and hospital services not
specifically covered in, or that are limited
or excluded by the plan documents,
including costs of services before coverage
begins and after coverage terminates.
ƒƒCosmetic surgery
ƒƒCustodial care
ƒƒDental care and dental X-rays
ƒƒDonor egg retrieval
ƒƒExperimental and investigational
procedures (except for coverage for
medically necessary routine patient
care costs for members participating
in a cancer clinical trial)
ƒƒHearing aids
ƒƒHome births
ƒƒImmunizations for travel or work
ƒƒImplantable drugs and certain injectable
drugs, including injectable infertility drugs
38
ƒƒInfertility services, including
artificial insemination and advanced
reproductive technologies such as
IVF, ZIFT, GIFT, ICSI and other related
services, unless specifically listed as
covered in the plan documents
ƒƒNonmedically necessary services
or supplies
ƒƒOrthotics
ƒƒOver-the-counter medications
and supplies
ƒƒRadial keratotomy or related procedures
ƒƒReversal of sterilization
ƒƒServices for the treatment of sexual
dysfunction or inadequacies, including
therapy, supplies or counseling, or
prescription drugs
ƒƒSpecial-duty nursing
ƒƒTherapy or rehabilitation, other than those
listed as covered in the plan documents
D E N TA L
Listed below are some of the charges
and services for which these dental plans
do not provide coverage. For a complete
list of exclusions and limitations, refer to
the plan documents.
ƒƒDental services or supplies that are
primarily used to alter, improve or
enhance appearance
ƒƒExperimental services, supplies
or procedures
ƒƒTreatment of any jaw joint disorder, such
as temporomandibular joint disorder
ƒƒReplacement of lost, missing or stolen
appliances and certain damaged
appliances
ƒƒThose services that Aetna defines as
not necessary for the diagnosis, care
or treatment of a condition involved
Specific service limitations
ƒƒDMO plans: Oral exams (4 per year)
ƒƒPPO plans: Oral exams (2 routine and
2 problem-focused per year)
ƒƒAll plans:
−−Bitewing X-rays (1 set per year)
−−Complete series X-rays (1 set every
3 years)
−−Cleanings (2 per year)
−−Fluoride (1 per year; children under 16)
−−Sealants (1 treatment per tooth,
every 3 years on permanent molars;
children under 16)
−−Scaling and root planing (4 quadrants
every 2 years)
−−Osseous surgery (1 per quadrant
every 3 years)
ƒƒAll other limitations and exclusions
in the plan documents
39
Aetna Avenue® — Your Destination for Small Business Solutions®
This material is for information only and is not an offer or invitation to contract. An application
must be completed to obtain coverage. Rates and benefits may vary by location. Health/Dental
benefits, health/dental insurance, life and disability insurance plans/policies contain exclusions
and limitations. Health information programs provide general health information and are not a
substitute for diagnosis or treatment by a physician or other health care professional. Plan features
and availability may vary by location and group size. Investment services are independently offered
through HealthEquity, Inc. Discount programs provide access to discounted prices and are NOT
insured benefits. The member is responsible for the full cost of the discounted services. Plan
for Your Health is a public education program from Aetna and The Financial Planning Association.
Providers are independent contractors and not agents of Aetna. Provider participation may change
without notice. Aetna does not provide care or guarantee access to health services. Not all health,
dental and disability services are covered. See plan documents for a complete description of
benefits, exclusions, limitations and conditions of coverage. Plan features are subject to change.
Aetna receives rebates from drug manufacturers that may be taken into account in determining
Aetna’s Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for
covered prescriptions. The Aetna Personal Health Record should not be used as the sole source of
information about the member’s medical history. Information is believed to be accurate as of the
production date; however, it is subject to change. For more information about Aetna plans, refer
to www.aetna.com.
64.10.301.1-NJ A (11/11)
©2011 Aetna Inc.