1. Take charge
of your health.
We’re here to help.
AetnA AdvAntAge plAns for
individuAls, fAmilies And the
self-employed in texAs
AA.02.311.1-TX (4/10) G

2. it’s easy to establish a health savings Account…
Aetna Advantage Simply enroll in an Aetna HSA Compatible High Deductible
Health Plan and you will automatically have an HSA opened
plan choices through Bank of America. You will also receive a debit card
and a welcome package with additional information to get
you started.
If you do not wish to set up an HSA, you can opt out
by calling Bank of America – or the account will be
Our health insurance plans are designed to automatically canceled after 90 days if the debit card is not
offer you quality coverage at an excellent activated or if you do not enroll online.
value. Coverage can include prescription drugs,
doctor visits, hospitalization and preventive Why choose an Aetna HealthFund HSA?
care services.
n No set-up fees
Generally speaking, the lower your “premiums,” or n No monthly administration fee
monthly payments, the higher your “deductible,” which is n No withdrawal forms required
the amount you pay out of pocket before the plan begins n Convenient access to HSA funds via debit card or online
paying for expenses. n Track HSA activity online
You’ll pay less by using “in-network” doctors, hospitals,
pharmacies and other health care providers who Is your doctor in the Aetna network?
participate in Aetna’s nationwide network than by using
Which local physicians, hospitals, pharmacies and eyewear
“out-of-network” doctors.
providers participate in the nationwide Aetna Advantage
Visit www.planforyourhealth.com for an in-depth list Plan network? Visit www.aetna.com/docfind/custom/
of terms in this brochure and what they mean. advplans. Or call 1-800-694-3258 and ask for a directory
of providers.
About HSAs
Get more from your Aetna plan
Many of our high-deductible plans are Health Savings
Account (HSA) Compatible, offering you lower premiums Cover just your children
and tax advantaged savings. An HSA is a personal
Aetna Advantage Plans are also available for children only,
account that lets you pay for qualified medical expenses
which means you can enroll your child even if no other
with tax advantaged funds. You or an eligible family
family member enrolls. Coverage includes immunizations,
member make contributions to your HSA tax-free, and
well-child visits, emergency room and dental preventive
those dollars earn interest tax-free. Then, when you make
services (if a dental plan is selected).
withdrawals from your account to pay for qualified health
care expenses, they’re tax-free, too. Note: when an HSA Compatible plan is selected for child only
enrollment, an HSA account is not available for the child.
Add dental pdn max
With the Aetna Advantage Dental PDN Max insurance
plan, you can obtain services from either a participating or
non-participating dentist. Participating dentists have agreed
to provide services at a negotiated rate for both covered
Aetna Advantage Plans for Individuals, Families and the
services, as well as non-covered services such as cosmetic
Self-Employed are underwritten by Aetna Life Insurance tooth whitening and orthodontic care, so you generally
Company (Aetna) directly and/or through an out-of-state pay less out-of-pocket. You also have the flexibility to visit a
blanket trust. In some states, individuals may qualify as a
business group of one and may be eligible for guaranteed
dentist who does not participate in Aetna’s network, though
issue, small group health plans. These plans are medically you will not have access to negotiated fees. Dental coverage
underwritten and you may be declined coverage in accordance is offered only if medical coverage is obtained.
with your health condition.
1

3. Plan Details 4) Managed Choice Open Access
and Preferred Provider Benefits
Plans (PPO) Value plan options
1)
Affordability — a balance of lower monthly
First Dollar Managed Choice Open
premiums and quality coverage…where you
Access and Preferred Provider Benefits
want to cap the amount you’ll spend on total
Plans (PPO) plan options
medical expenses each year
robust coverage and lower out-of-pocket featuring:
expenses with no deductibles when you n Lower monthly premiums (that’s the “Value” part)
choose a network provider n No deductible for generic prescription drugs
featuring:
5)
n Lower copay for in-network provider visits Preventive and Hospital Care
n No deductible for generic prescription drugs plan options
Affordability is one of your top priorities and
2) Managed Choice Open Access
and Preferred Provider Benefits Plans
(PPO) plan options
you use only basic health care services…and
want to keep your monthly premiums lower
featuring:
robust coverage and lower monthly payments n Health insurance coverage with lower monthly
balanced with a deductible…where you don’t premiums and varying deductible levels
want to pay a lot for frequent doctor visits
featuring:
n Health insurance coverage with lower monthly premiums
and varying deductible levels
6) Managed Choice Open Access
and Preferred Provider Benefits
Plans (PPO) with Limited Rx
robust medical coverage with limited
3) Managed Choice Open Access
and Preferred Provider Benefits Plans
(PPO) High Deductible plan options
pharmacy benefits…with lower costs for
smart consumers
featuring:
lower premium costs…and an hsA-compatible n Health insurance coverage with lower monthly
plan that offers tax advantaged savings premiums
featuring:
n 0% coinsurance in network after your deductible is met
n Lower monthly premiums, higher annual deductibles
(at least $3,000 for individuals and $6,000 for families)
n Can be paired with a tax-advantaged Health
Savings Account (HSA)
2 3

4. Ae t nA’ s t e x As
plus ... these benefits Are r At i ngs Ar e As *
inCluded with most of your rates will depend on the area in
our plAns. which your county is located.
for more information or a quote on what your
n Coverage for office visits to your primary care rate would be, call your broker.
physician and specialists
n No claim forms to fill out when you visit Area 1 Counties+
a network provider Blanco
Bosque
De Witt
Dimmit
Jim Hogg
Jones
Lavaca
Llano (except
Milam
Mills
Washington
Webb
Brazos Edwards Karnes Horseshoe Real Zapata
n No referrals required to see a specialist* Brooks Frio Kenedy Bay) Refugio Zavala
Brown Gillespie Kerr Madison Robertson
n No waiting period for routine physical exams Burleson
Coleman
Goliad
Gonzales
Kimble
Kinney
Mason
Maverick
San Saba
Taylor
Comanche Hamilton La Salle McMullen Uvalde
n 100% annual routine GYN exam coverage —
no waiting period, no dollar maximum and Area 2 Counties+
no copay or deductible when you visit a Ector Jasper Lubbock Midland Wichita
(Brookeland) McLennan Tom Green
network provider
n Coverage for prescription drugs* Area 3 Counties+
Aransas Castro Gray Jackson Ochiltree Sherman
n Coverage for routine physicals including lab work Armstrong Childress Hall Jim Wells Oldham Starr
Bee Collingsworth Hansford Kleberg Parmer Swisher
and X-rays Briscoe Dallam Hartley Lipscomb Potter Victoria
Calhoun Deaf Smith Hemphill Live Oak Randall Wheeler
n 100% coverage for in-network childhood Cameron
Carson
Donley
Duval
Hidalgo
Hutchinson
Moore
Nueces
Roberts
San Patricio
Willacy
immunizations Area 4 Counties+
Anderson Cottle Hale Knox Polk Sutton
* These benefits are not applicable to Preventive and Hospital Care plans Andrews Crane Hardeman Lamb Presidio Terrell
Angelina Crockett Haskell Leon Reagan Terry
Archer Crosby Henderson Limestone Reeves Throckmorton
Bailey Culberson (except Loving Runnels Trinity
Baylor Dawson Mabank) Lynn Rusk Upton
Borden Dickens Hockley Martin Sabine Val Verde
Bowie Eastland Houston McCulloch San Augustine Ward
Brewster Falls Howard Menard Schleicher Wilbarger
Callahan Fisher Hudspeth Mitchell Scurry Winkler
Cass Floyd Irion Motley Shackelford Yoakum
Clay Foard Jack Nacogdoches Shelby Young
Cochran Gaines Jeff Davis Nolan Stephens
Coke Garza Kent Panola Sterling
Concho Glasscock King Pecos Stonewall
Area 5 Counties+ Aexcel specialist network**
Camp Ellis Harrison Johnson Palo Pinto Tarrant
Cherokee Erath Henderson Kaufman Parker Titus
Collin Fannin (Mabank) Lamar Rains Upshur
Cooke Franklin Hill Marion Red River Van Zandt
Dallas Freestone Hood Montague Rockwall Wise
Delta Grayson Hopkins Morris Smith Wood
Denton Gregg Hunt Navarro Somervell
Area 6 Counties++ Aexcel specialist network**
Austin Fort Bend Harris Liberty Orange Waller
Brazoria Galveston Jasper (except Matagorda San Jacinto Wharton
Chambers Grimes Brookeland) Montgomery Tyler
Colorado Hardin Jefferson Newton Walker
Area 7 Counties+ Aexcel specialist network**
Atascosa Bexar Guadalupe Medina
Bandera Comal Kendall Wilson
Area 8 Counties++ Aexcel specialist network**
Bastrop Caldwell Hays Llano (Horseshoe Travis
Bell Coryell Lampasas Bay) Williamson
Burnet Fayette Lee
Area 9 Counties++
El Paso
* All products not available in all counties. Please refer to the county in which you reside for the
available product.
** The Aetna Performance Network® features Aexcel-designated specialists who have demonstrated
cost-effectiveness in the delivery of care and met certain clinical performance measures. The Aexcel
designation applies to select specialists in 12 specialty areas: Cardiology, Cardiothoracic Surgery,
Gastroenterology, General Surgery, Obstetrics and Gynecology, Orthopedics, Otolaryngology/ENT,
Neurology, Neurosurgery, Plastic Surgery, Urology, and Vascular Surgery. Aetna members in the
designated counties must choose Aexcel designated specialists or they will incur out-of-
network charges. There is no additional cost when members use Aexcel specialists. You’ll
find them by looking for the star next to the doctors’ names at www.aetna.com/docfind/custom/
advplans or in your printed directory.
+ Areas 1-5, and Area 7 are Preferred Provider Benefits Plans.
4 ++ Area 6, and Area 8-9 are Managed Choice Open Access Plans. 5

5. 1) 2)
first dollar managed Choice managed Choice open Access
open Access and preferred and preferred provider benefits
provider benefits plans (ppo) 30 plans (ppo) 2500
member benefits in-network out-of-network+ member benefits in-network out-of-network+
Deductible Deductible
Individual $0 $5,000 Individual $2,500 $5,000
Family $0 $10,000 Family $5,000 $10,000
Coinsurance 30% up to 50% after Coinsurance 20% after 50% after
(Member’s responsibility) out-of-pocket max. deductible up to (Member’s responsibility) deductible up to deductible up to
out-of-pocket max. out-of-pocket max. out-of-pocket max.
$0 once out-of-pocket max. is satisfied $0 once out-of-pocket max. is satisfied
Coinsurance Maximum Coinsurance Maximum
Individual $7,500 $7,500 Individual $2,500 $5,000
Family $15,000 $15,000 Family $5,000 $10,000
Out-of-Pocket Maximum Out-of-Pocket Maximum
Individual $7,500 $12,500 Individual $5,000 $10,000
Family $15,000 $25,000 Family $10,000 $20,000
Includes deductible Includes deductible
Lifetime Maximum* per insured $5,000,000 Lifetime Maximum* per insured $5,000,000
Non-Specialist Office Visit $30 copay 30% Non-Specialist Office Visit $30 copay 30%
Unlimited visits after deductible Unlimited visits deductible waived after deductible
General Physician, Family Practitioner, General Physician, Family Practitioner,
Pediatrician or Internist Pediatrician or Internist
Specialist Visit $40 copay 30% Specialist Visit $40 copay 30%
Unlimited visits after deductible Unlimited visits deductible waived after deductible
Hospital Admission 30% 50% Hospital Admission 20% 50%
after deductible after deductible after deductible
Outpatient Surgery 30% 50% Outpatient Surgery 20% 50%
after deductible after deductible after deductible
Urgent Care Facility $50 copay 50% Urgent Care Facility $50 copay 50%
after deductible deductible waived after deductible
Emergency Room $100 copay** (waived if admitted) Emergency Room $100 copay** (waived if admitted)
30% coinsurance 20% coinsurance after deductible
Annual Routine Gyn Exam $0 copay 30% Annual Routine Gyn Exam $0 copay 30%
No waiting period, after deductible No waiting period, deductible waived after deductible
no calendar year max. no calendar year max.
Annual Pap/Mammogram Annual Pap/Mammogram
Maternity Not covered Maternity Not covered
(except for pregnancy complications) (except for pregnancy complications)
Preventive Health — $30 copay 30% Preventive Health — $30 copay 30%
Routine Physical after deductible Routine Physical deductible waived after deductible
Aetna will pay up to $200 per exam* Includes lab work and X-rays Aetna will pay up to $200 per exam* Includes lab work and X-rays
No waiting period No waiting period
Lab/X-Ray 30% 50% Lab/X-Ray 20% 50%
after deductible after deductible after deductible
Skilled Nursing — in lieu of hospital 30% 50% Skilled Nursing — in lieu of hospital 20% 50%
30 days per calendar year* after deductible 30 days per calendar year* after deductible after deductible
Physical/Occupational Therapy 30% 50% Physical/Occupational Therapy 20% 50%
and Chiropractic Care after deductible and Chiropractic Care after deductible after deductible
24 visits per calendar year* 24 visits per calendar year* Aetna will pay a max. of $25 per visit*
Aetna will pay a max. of $25 per visit*
Home Health Care — 30% 50% Home Health Care — 20% 50%
in lieu of hospital after deductible in lieu of hospital after deductible after deductible
30 visits per calendar year* 30 visits per calendar year*
Durable Medical Equipment 30% 50% Durable Medical Equipment 20% 50%
Aetna will pay up to $2000 per after deductible Aetna will pay up to $2000 per after deductible after deductible
calendar year* calendar year*
phArmACy phArmACy
Pharmacy Deductible $500 $500 Pharmacy Deductible $500 $500
per individual per individual Does not apply to generic
Does not apply to generic
Generic $15 copay $15 copay plus 30% Generic $15 copay $15 copay plus 30%
Oral Contraceptives Included deductible waived deductible waived Oral Contraceptives Included deductible waived deductible waived
Preferred Brand $40 copay $40 copay plus 30% Preferred Brand $35 copay $35 copay plus 30%
Oral Contraceptives Included after deductible after deductible Oral Contraceptives Included after deductible after deductible
Non-Preferred Brand $60 copay $60 copay plus 30% Non-Preferred Brand $50 copay $50 copay plus 30%
Oral Contraceptives Included after deductible after deductible Oral Contraceptives Included after deductible after deductible
Self-Injectible Drugs 20% Not covered Self-Injectible Drugs 20% Not covered
after deductible after deductible
Calendar Year Maximum Unlimited Unlimited Calendar Year Maximum $5,000 $5,000
per individual* per individual*
+ Payment for out-of-network facility covered expenses is determined based
* Maximum applies to combined in and out-of-network benefits. on Aetna’s Market Fee Schedule. Payment for out-of-network non-facility
** Copay is billed separately and not due at time of service. Copay does covered expenses is determined based on the negotiated charge that would
not count towards coinsurance or out-of-pocket maximum. apply if such services were received from a Network Provider.
6 7

6. managed Choice open Access managed Choice open Access
and preferred provider benefits and preferred provider benefits
plans (ppo) 3500 plans (ppo) 5000
member benefits in-network out-of-network+ member benefits in-network out-of-network+
Deductible Deductible
Individual $3,500 $7,000 Individual $5,000 $10,000
Family $7,000 $14,000 Family $10,000 $20,000
Coinsurance 20% after 50% after Coinsurance 20% after 50% after
(Member’s responsibility) deductible up to deductible up to (Member’s responsibility) deductible up to deductible up to
out-of-pocket max. out-of-pocket max. out-of-pocket max. out-of-pocket max.
$0 once out-of-pocket max. is satisfied $0 once out-of-pocket max. is satisfied
Coinsurance Maximum Coinsurance Maximum
Individual $6,500 $5,500 Individual $5,000 $2,500
Family $13,000 $11,000 Family $10,000 $5,000
Out-of-Pocket Maximum Out-of-Pocket Maximum
Individual $10,000 $12,500 Individual $10,000 $12,500
Family $20,000 $25,000 Family $20,000 $25,000
Includes deductible Includes deductible
Lifetime Maximum* per insured $5,000,000 Lifetime Maximum* per insured $5,000,000
Non-Specialist Office Visit $35 copay 30% Non-Specialist Office Visit $40 copay 30%
Unlimited visits deductible waived after deductible Unlimited visits deductible waived after deductible
General Physician, Family General Physician, Family Practitioner,
Practitioner, Pediatrician or Internist Pediatrician or Internist
Specialist Visit $45 copay 30% Specialist Visit $50 copay 30%
Unlimited visits deductible waived after deductible Unlimited visits deductible waived after deductible
Hospital Admission 20% 50% Hospital Admission 20% 50%
after deductible after deductible after deductible after deductible
Outpatient Surgery 20% 50% Outpatient Surgery 20% 50%
after deductible after deductible after deductible after deductible
Urgent Care Facility $50 copay 50% Urgent Care Facility $50 copay 50%
deductible waived after deductible deductible waived after deductible
Emergency Room $100 copay** (waived if admitted) Emergency Room $100 copay** (waived if admitted)
20% coinsurance after deductible 20% coinsurance after deductible
Annual Routine Gyn Exam $0 copay 30% Annual Routine Gyn Exam $0 copay 30%
No waiting period, deductible waived after deductible No waiting period, deductible waived after deductible
no calendar year max. no calendar year max.
Annual Pap/Mammogram Annual Pap/Mammogram
Maternity Not covered Maternity Not covered
(except for pregnancy complications) (except for pregnancy complications)
Preventive Health — $35 copay 30% Preventive Health — $40 copay 30%
Routine Physical deductible waived after deductible Routine Physical deductible waived after deductible
Aetna will pay up to $200 per exam* Aetna will pay up to $200 per exam*
Includes lab work and X-rays No waiting period Includes lab work and X-rays
No waiting period
Lab/X-Ray 20% 50% Lab/X-Ray 20% 50%
after deductible after deductible after deductible after deductible
Skilled Nursing — in lieu of hospital 20% 50% Skilled Nursing — in lieu of hospital 20% 50%
30 days per calendar year* after deductible after deductible 30 days per calendar year* after deductible after deductible
Physical/Occupational Therapy 20% 50% Physical/Occupational Therapy 20% 50%
and Chiropractic Care after deductible after deductible and Chiropractic Care after deductible after deductible
24 visits per calendar year* 24 visits per calendar year* Aetna will pay a max. of $25 per visit*
Aetna will pay a max. of $25 per visit*
Home Health Care — 20% 50% Home Health Care — 20% 50%
in lieu of hospital after deductible after deductible in lieu of hospital after deductible after deductible
30 visits per calendar year* 30 visits per calendar year*
Durable Medical Equipment 20% 50% Durable Medical Equipment 20% 50%
Aetna will pay up to $2000 per after deductible after deductible Aetna will pay up to $2000 per after deductible after deductible
calendar year* calendar year*
phArmACy phArmACy
Pharmacy Deductible $500 $500 Pharmacy Deductible $500 $500
per individual per individual Does not apply to generic
Does not apply to generic
Generic $15 copay $15 copay plus 30% Generic $15 copay $15 copay plus 30%
Oral Contraceptives Included deductible waived deductible waived Oral Contraceptives Included deductible waived deductible waived
Preferred Brand $35 copay $35 copay plus 30% Preferred Brand $35 copay $35 copay plus 30%
Oral Contraceptives Included after deductible after deductible Oral Contraceptives Included after deductible after deductible
Non-Preferred Brand $50 copay $50 copay plus 30% Non-Preferred Brand $50 copay $50 copay plus 30%
Oral Contraceptives Included after deductible deductible waived Oral Contraceptives Included after deductible after deductible
Self-Injectible Drugs 20% Not covered Self-Injectible Drugs 20% Not covered
after deductible after deductible
Calendar Year Maximum $5,000 $5,000 Calendar Year Maximum $5,000 $5,000
per individual* per individual*
+ Payment for out-of-network facility covered expenses is determined based on
* Maximum applies to combined in and out-of-network benefits. Aetna’s Market Fee Schedule. Payment for out-of-network non-facility covered
** Copay is billed separately and not due at time of service. Copay does expenses is determined based on the negotiated charge that would apply if such
not count towards coinsurance or out-of-pocket maximum. services were received from a Network Provider.
8 9

7. managed Choice open Access
3)
managed Choice open Access and preferred provider benefits
and preferred provider benefits plans (ppo) high deductible
plans (ppo) 7500 3000 (hsA Compatible)
member benefits in-network out-of-network+ member benefits in-network out-of-network+
Deductible Deductible
Individual $7,500 $10,000 Individual $3,000 $6,000
Family $15,000 $20,000 Family $6,000 $12,000
Coinsurance 20% after 50% after Coinsurance 0% after 50% after
(Member’s responsibility) deductible up to deductible up to (Member’s responsibility) deductible up to deductible up to
out-of-pocket max. out-of-pocket max. out-of-pocket max. out-of-pocket max.
$0 once out-of-pocket max. is satisfied $0 once out-of-pocket max. is satisfied
Coinsurance Maximum Coinsurance Maximum
Individual $2,500 $2,500 Individual $0 $6,500
Family $5,000 $5,000 Family $0 $13,000
Out-of-Pocket Maximum Out-of-Pocket Maximum
Individual $10,000 $12,500 Individual $3,000 $12,500
Family $20,000 $25,000 Family $6,000 $25,000
Includes deductible Includes deductible
Lifetime Maximum* per insured $5,000,000 Lifetime Maximum* per insured $5,000,000
Non-Specialist Office Visit $45 copay 30% Non-Specialist Office Visit 0% 30%
Unlimited visits deductible waived after deductible Unlimited visits after deductible after deductible
General Physician, Family Practitioner, General Physician, Family Practitioner,
Pediatrician or Internist Pediatrician or Internist
Specialist Visit $50 copay 30% Specialist Visit 0% 30%
Unlimited visits deductible waived after deductible Unlimited visits after deductible after deductible
Hospital Admission 20% 50% Hospital Admission 0% 50%
after deductible after deductible after deductible after deductible
Outpatient Surgery 20% 50% Outpatient Surgery 0% 50%
after deductible after deductible after deductible after deductible
Urgent Care Facility $50 copay 50% Urgent Care Facility 0% 50%
deductible waived after deductible after deductible after deductible
Emergency Room $100 copay** (waived if admitted) Emergency Room $0 copay after deductible
20% coinsurance after deductible Annual Routine Gyn Exam $0 copay 30%
Annual Routine Gyn Exam $0 copay 30% No waiting period, deductible waived after deductible
No waiting period, deductible waived after deductible no calendar year max.
no calendar year max. Annual Pap/Mammogram
Annual Pap/Mammogram Maternity Not covered
Maternity Not covered (except for pregnancy complications)
Except for pregnancy complications Preventive Health — $20 copay 30%
Preventive Health — $45 copay 30% Routine Physical deductible waived after deductible
Routine Physical deductible waived after deductible Aetna will pay up to $200 per exam*
Aetna will pay up to $200 per exam* No waiting period Includes lab work and X-rays
Includes lab work and X-rays
No waiting period
Lab/X-Ray 0% 50%
Lab/X-Ray 20% 50% after deductible after deductible
after deductible after deductible
Skilled Nursing — in lieu of hospital 0% 50%
Skilled Nursing — in lieu of hospital 20% 50% 30 days per calendar year* after deductible after deductible
30 days per calendar year* after deductible after deductible
Physical/Occupational Therapy 0% 50%
Physical/Occupational Therapy 20% 50%
and Chiropractic Care after deductible after deductible
and Chiropractic Care after deductible after deductible
24 visits per calendar year*
24 visits per calendar year* Aetna will pay a max. of $25 per visit* Aetna will pay a max. of $25 per visit*
Home Health Care — 20% 50% Home Health Care — 0% 50%
in lieu of hospital after deductible after deductible in lieu of hospital after deductible after deductible
30 visits per calendar year* 30 visits per calendar year*
Durable Medical Equipment 20% 50% Durable Medical Equipment 0% 50%
Aetna will pay up to $2000 per after deductible after deductible Aetna will pay up to $2000 per after deductible after deductible
calendar year* calendar year*
phArmACy phArmACy
Pharmacy Deductible $500 $500 Pharmacy Deductible Integrated Medical/Rx Deductible
per individual per individual
Does not apply to generic
Generic 0% after Medical/ 30% after Medical/
Generic $15 copay $15 copay plus 30% Oral Contraceptives Included Rx deductible Rx deductible
Oral Contraceptives Included deductible waived deductible waived
Preferred Brand 0% after Medical/ 30% after Medical/
Preferred Brand $35 copay $35 copay plus 30% Oral Contraceptives Included Rx deductible Rx deductible
Oral Contraceptives Included after deductible after deductible
Non-Preferred Brand $50 copay $50 copay plus 30% Non-Preferred Brand 0% after Medical/ 30% after Medical/
Oral Contraceptives Included after deductible after deductible Oral Contraceptives Included Rx deductible Rx deductible
Self-Injectible Drugs 20% Not covered Self-Injectible Drugs 0% after Medical/ Not covered
after deductible Rx deductible
Calendar Year Maximum $5,000 $5,000 Calendar Year Maximum $5,000 $5,000
per individual* per individual*
+ Payment for out-of-network facility covered expenses is determined based on
* Maximum applies to combined in and out-of-network benefits. Aetna’s Market Fee Schedule. Payment for out-of-network non-facility covered
** Copay is billed separately and not due at time of service. Copay does expenses is determined based on the negotiated charge that would apply if such
not count towards coinsurance or out-of-pocket maximum. services were received from a Network Provider.
10 11

8. managed Choice open Access
4)
and preferred provider benefits managed Choice open Access
plans (ppo) high deductible and preferred provider benefits
5000 (hsA Compatible) plans (ppo) value 1500
member benefits in-network out-of-network+ member benefits in-network out-of-network+
Deductible Deductible
Individual $5,000 $10,000 Individual $1,500 $3,000
Family $10,000 $20,000 Family $3,000 $6,000
Coinsurance 30% after 50% after
Coinsurance 0% after 50% after
(Member’s responsibility) deductible up to deductible up to
(Member’s responsibility) deductible up to deductible up to
out-of-pocket max. out-of-pocket max.
out-of-pocket max. out-of-pocket max.
$0 once out-of-pocket max. is satisfied
$0 once out-of-pocket max. is satisfied
Coinsurance Maximum
Coinsurance Maximum Individual $1,500 $7,000
Individual $0 $2,500 Family $3,000 $14,000
Family $0 $5,000 Out-of-Pocket Maximum
Out-of-Pocket Maximum Individual $3,000 $10,000
Individual $5,000 $12,500 Family $6,000 $20,000
Family $10,000 $25,000 Includes deductible
Includes deductible Lifetime Maximum* per insured $5,000,000
Lifetime Maximum* per insured $5,000,000 Non-Specialist Office Visit Visits 1-2 $30 copay, 30%
Unlimited visits ded. waived; Visit 3+ after deductible
Non-Specialist Office Visit 0% 30% General Physician, Family Practitioner, 30% after deductible.
Unlimited visits after deductible after deductible Pediatrician or Internist Spec. and non- spec
General Physician, Family Practitioner, share visit max
Pediatrician or Internist Specialist Visit Visits 1-2 $30 copay, 30%
Specialist Visit 0% 30% Unlimited visits ded. waived; Visit 3+ after deductible
Unlimited visits after deductible after deductible 30% after deductible.
Spec. and non- spec
Hospital Admission 0% 50% share visit max
after deductible after deductible
Hospital Admission 30% 50%
Outpatient Surgery 0% 50% after deductible after deductible
after deductible after deductible Outpatient Surgery 30% 50%
Urgent Care Facility 0% 50% after deductible after deductible
after deductible after deductible Urgent Care Facility $50 copay 50%
Emergency Room $0 copay after deductible deductible waived after deductible
Annual Routine Gyn Exam $0 copay 30% Emergency Room $100 copay** (waived if admitted)
No waiting period, deductible waived after deductible 30% coinsurance after deductible
no calendar year max. Annual Routine Gyn Exam $0 copay 30%
Annual Pap/Mammogram No waiting period, deductible waived after deductible
no calendar year max.
Maternity Not covered Annual Pap/Mammogram
(except for pregnancy complications)
Maternity Not covered
Preventive Health — $25 copay 30% (except for pregnancy complications)
Routine Physical deductible waived after deductible
Preventive Health — $50 copay 30%
Aetna will pay up to $200 per exam*
Includes lab work and X-rays Routine Physical deductible waived after deductible
No waiting period
Aetna will pay up to $200 per exam*
Lab/X-Ray 0% 50% No waiting period Includes lab work and X-rays
after deductible after deductible Lab/X-Ray 30% 50%
Skilled Nursing — in lieu of hospital 0% 50% after deductible after deductible
30 days per calendar year* after deductible after deductible Skilled Nursing — in lieu of hospital 30% 50%
Physical/Occupational Therapy 0% 50% 30 days per calendar year* after deductible after deductible
and Chiropractic Care after deductible after deductible Physical/Occupational Therapy 30% 50%
24 visits per calendar year* Aetna will pay a max. of $25 per visit* and Chiropractic Care after deductible after deductible
24 visits per calendar year* Aetna will pay a max. of $25 per visit*
Home Health Care — 0% 50%
in lieu of hospital after deductible after deductible Home Health Care — 30% 50%
30 visits per calendar year* in lieu of hospital after deductible after deductible
30 visits per calendar year*
Durable Medical Equipment 0% 50%
Durable Medical Equipment 30% 50%
Aetna will pay up to $2000 per after deductible after deductible
Aetna will pay up to $2000 per after deductible after deductible
calendar year*
calendar year*
phArmACy phArmACy
Pharmacy Deductible Integrated Medical/Rx Deductible Pharmacy Deductible $500 $500
per individual per individual Does not apply to generic
Generic 0% after Medical/ 30% after Medical/ Generic $20 copay $20 copay plus 30%
Oral Contraceptives Included Rx deductible Rx deductible Oral Contraceptives Included deductible waived deductible waived
Preferred Brand 0% after Medical/ 30% after Medical/ Preferred Brand $40 copay $40 copay plus 30%
Oral Contraceptives Included Rx deductible Rx deductible Oral Contraceptives Included after deductible after deductible
Non-Preferred Brand Not covered Not covered
Non-Preferred Brand 0% after Medical/ 30% after Medical/ Oral Contraceptives Included Aetna Discount
Oral Contraceptives Included Rx deductible Rx deductible Applies
Self-Injectible Drugs 0% after Medical/ Not covered Self-Injectible Drugs Not covered Not covered
Rx deductible Aetna Discount
Applies
Calendar Year Maximum $5,000 $5,000 Calendar Year Maximum $5,000 $5,000
per individual* per individual*
+ Payment for out-of-network facility covered expenses is determined based on
* Maximum applies to combined in and out-of-network benefits. Aetna’s Market Fee Schedule. Payment for out-of-network non-facility covered
** Copay is billed separately and not due at time of service. Copay does expenses is determined based on the negotiated charge that would apply if such
not count towards coinsurance or out-of-pocket maximum. services were received from a Network Provider.
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9. managed Choice open Access managed Choice open Access
and preferred provider benefits and preferred provider benefits
plans (ppo) value 2500 plans (ppo) value 5000
member benefits in-network out-of-network+ member benefits in-network out-of-network+
Deductible Deductible
Individual $2,500 $5,000 Individual $5,000 $10,000
Family $5,000 $10,000 Family $10,000 $20,000
Coinsurance 30% after 50% after Coinsurance 30% after 50% after
(Member’s responsibility) deductible up to deductible up to (Member’s responsibility) deductible up to deductible up to
out-of-pocket max. out-of-pocket max. out-of-pocket max. out-of-pocket max.
$0 once out-of-pocket max. is satisfied $0 once out-of-pocket max. is satisfied
Coinsurance Maximum Coinsurance Maximum
Individual $2,500 $5,000 Individual $5,000 $2,500
Family $5,000 $10,000 Family $10,000 $5,000
Out-of-Pocket Maximum
Out-of-Pocket Maximum
Individual $5,000 $10,000
Individual $10,000 $12,500
Family $10,000 $20,000
Family $20,000 $25,000
Includes deductible
Lifetime Maximum* per insured $5,000,000 Includes deductible
Non-Specialist Office Visit Visits 1-2 $30 copay, 30% Lifetime Maximum* per insured $5,000,000
Unlimited visits ded. waived; Visit 3+ after deductible Non-Specialist Office Visit Visits 1-2 $30 copay, 30%
General Physician, Family Practitioner, 30% after deductible. Unlimited visits ded. waived; Visit 3+ after deductible
Pediatrician or Internist Spec. and non- spec General Physician, Family 30% after deductible.
share visit max Spec. and non- spec
Practitioner, Pediatrician or Internist
Specialist Visit Visits 1-2 $30 copay, 30% share visit max
Unlimited visits ded. waived; Visit 3+ after deductible Specialist Visit Visits 1-2 $30 copay, 30%
30% after deductible. Unlimited visits ded. waived; Visit 3+ after deductible
Spec. and non- spec 30% after deductible.
share visit max Spec. and non- spec
Hospital Admission 30% 50% share visit max
after deductible after deductible Hospital Admission 30% 50%
Outpatient Surgery 30% 50% after deductible after deductible
after deductible after deductible Outpatient Surgery 30% 50%
Urgent Care Facility $50 copay 50% after deductible after deductible
deductible waived after deductible Urgent Care Facility $50 copay 50%
Emergency Room $100 copay** (waived if admitted) deductible waived after deductible
30% coinsurance after deductible Emergency Room $100 copay** (waived if admitted)
Annual Routine Gyn Exam $0 copay 30% 30% after deductible
No waiting period, deductible waived after deductible Annual Routine Gyn Exam $0 copay 30%
no calendar year max. No waiting period, deductible waived after deductible
Annual Pap/Mammogram no calendar year max.
Maternity Not covered Annual Pap/Mammogram
(except for pregnancy complications) Maternity Not covered
Preventive Health — $50 copay 30% (except for pregnancy complications)
Routine Physical deductible waived after deductible Preventive Health — $50 copay 30%
Aetna will pay up to $200 per exam* Routine Physical deductible waived after deductible
No waiting period Includes lab work and X-rays Aetna will pay up to $200 per exam* Includes lab work and X-rays
Lab/X-Ray 30% 50% No waiting period
after deductible after deductible Lab/X-Ray 30% 50%
Skilled Nursing — in lieu of hospital 30% 50% after deductible after deductible
30 days per calendar year* after deductible after deductible Skilled Nursing — in lieu of hospital 30% 50%
Physical/Occupational Therapy 30% 50% 30 days per calendar year* after deductible after deductible
and Chiropractic Care after deductible after deductible Physical/Occupational Therapy 30% 50%
24 visits per calendar year* Aetna will pay a max. of $25 per visit* and Chiropractic Care after deductible after deductible
24 visits per calendar year* Aetna will pay a max. of $25 per visit*
Home Health Care — 30% 50%
in lieu of hospital after deductible after deductible Home Health Care — 30% 50%
30 visits per calendar year* in lieu of hospital after deductible after deductible
30 visits per calendar year*
Durable Medical Equipment 30% 50%
Durable Medical Equipment 30% 50%
Aetna will pay up to $2000 per after deductible after deductible
Aetna will pay up to $2000 per after deductible after deductible
calendar year*
calendar year*
phArmACy phArmACy
Pharmacy Deductible $500 $500 Pharmacy Deductible $500 $500
per individual Does not apply to generic per individual Does not apply to generic
Generic $20 copay $20 copay plus 30% Generic $20 copay $20 copay plus 30%
Oral Contraceptives Included deductible waived deductible waived Oral Contraceptives Included deductible waived deductible waived
Preferred Brand $40 copay $40 copay plus 30% Preferred Brand $40 copay $40 copay plus 30%
Oral Contraceptives Included after deductible after deductible Oral Contraceptives Included after deductible after deductible
Non-Preferred Brand Not covered Not covered Non-Preferred Brand Not covered Not covered
Oral Contraceptives Included Aetna Discount Oral Contraceptives Included Aetna Discount
Applies Applies
Self-Injectible Drugs Not covered Not covered Self-Injectible Drugs Not covered Not covered
Aetna Discount Aetna Discount
Applies Applies
Calendar Year Maximum $5,000 $5,000 Calendar Year Maximum $5,000 $5,000
per individual* per individual*
+ Payment for out-of-network facility covered expenses is determined based on
* Maximum applies to combined in and out-of-network benefits. Aetna’s Market Fee Schedule. Payment for out-of-network non-facility covered
** Copay is billed separately and not due at time of service. Copay does expenses is determined based on the negotiated charge that would apply if such
not count towards coinsurance or out-of-pocket maximum. services were received from a Network Provider.
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10. 5) preventive and hospital
Care 1250***
preventive and hospital Care
3000 (hsA Compatible)
member benefits in-network out-of-network+ member benefits in-network out-of-network+
Deductible Deductible
Individual $1,250 $2,500 Individual $3,000 $6,000
Family $2,500 $5,000 Family $6,000 $12,000
Coinsurance 20% after 50% after Coinsurance 20% after 50% after
(Member’s responsibility) deductible up to deductible up to (Member’s responsibility) deductible up to deductible up to
out-of-pocket max. out-of-pocket max. out-of-pocket max. out-of-pocket max.
$0 once out-of-pocket max. is satisfied $0 once out-of-pocket max. is satisfied
Coinsurance Maximum Coinsurance Maximum
Individual $3,000 $7,500 Individual $2,000 $4,000
Family $6,000 $15,000 Family $4,000 $8,000
Out-of-Pocket Maximum Out-of-Pocket Maximum
Individual $4,250 $10,000 Individual $5,000 $10,000
Family $8,500 $20,000 Family $10,000 $20,000
Includes deductible Includes deductible
Lifetime Maximum* per insured $1,000,000 Lifetime Maximum* per insured $1,000,000
Non-Specialist Office Visit Not covered Not covered Non-Specialist Office Visit Not covered Not covered
Unlimited visits Unlimited visits
General Physician, Family Practitioner, General Physician, Family
Pediatrician or Internist Practitioner, Pediatrician or Internist
Specialist Visit Not covered Not covered Specialist Visit Not covered Not covered
Unlimited visits Unlimited visits
Hospital Admission 20% 50% Hospital Admission 20% 50%
after deductible after deductible after deductible after deductible
Outpatient Surgery 20% 50% Outpatient Surgery 20% 50%
after deductible after deductible after deductible after deductible
Urgent Care Facility Not covered Not covered Urgent Care Facility Not covered Not covered
Emergency Room $100 copay** (waived if admitted); Emergency Room $100 copay** (waived if admitted);
20% coinsurance after deductible 20% coinsurance after deductible
Annual Routine Gyn Exam $0 copay 50% Annual Routine Gyn Exam $0 copay 50%
No waiting period, deductible waived after deductible No waiting period, deductible waived after deductible
no calendar year max. no calendar year max.
Annual Pap/Mammogram Annual Pap/Mammogram
Maternity Not covered Maternity Not covered
(except for pregnancy complications) (except for pregnancy complications)
Preventive Health — $25 copay 50% Preventive Health — $35 copay 50%
Routine Physical deductible waived after deductible Routine Physical deductible waived after deductible
Aetna will pay up to $200 per exam* Aetna will pay up to $200 per exam*
Includes lab work and X-rays Includes lab work and X-rays
No waiting period No waiting period
Lab/X-Ray Not covered Not covered Lab/X-Ray Not covered Not covered
Skilled Nursing — in lieu of hospital 20% 50% Skilled Nursing — in lieu of hospital 20% 50%
30 days per calendar year* after deductible after deductible 30 days per calendar year* after deductible after deductible
Physical/Occupational Therapy Not covered Not covered Physical/Occupational Therapy Not covered Not covered
and Chiropractic Care and Chiropractic Care
24 visits per calendar year* 24 visits per calendar year*
Home Health Care — 20% 50% Home Health Care — 20% 50%
in lieu of hospital after deductible after deductible in lieu of hospital after deductible after deductible
30 visits per calendar year* 30 visits per calendar year*
Durable Medical Equipment Not covered Durable Medical Equipment Not covered
Aetna will pay up to $2000 per (except coverage for Aetna will pay up to $2000 per (except coverage for
calendar year* Diabetic Equipment and Supplies) calendar year* Diabetic Equipment and Supplies)
phArmACy
phArmACy
Pharmacy Deductible Not Applicable Not Applicable
Pharmacy Deductible Not Applicable Not Applicable per individual
per individual
Generic Not covered Not covered
Generic $15 copay $15 copay plus 50% Oral Contraceptives Included Aetna Discount
Oral Contraceptives Included Applies
Preferred Brand Not covered Not covered Preferred Brand Not covered Not covered
Oral Contraceptives Included Aetna Discount Oral Contraceptives Included Aetna Discount
Applies Applies
Non-Preferred Brand Not covered Not covered Non-Preferred Brand Not covered Not covered
Oral Contraceptives Included Aetna Discount Oral Contraceptives Included Aetna Discount
Applies Applies
Self-Injectible Drugs Not covered Not covered Self-Injectible Drugs Not covered Not covered
Aetna Discount Aetna Discount
Applies Applies
Calendar Year Maximum $5,000 $5,000 Calendar Year Maximum Not Applicable Not Applicable
per individual* per individual*
* Maximum applies to combined in and out-of-network benefits. + Payment for out-of-network facility covered expenses is determined based on
** Copay is billed separately and not due at time of service. Copay does Aetna’s Market Fee Schedule. Payment for out-of-network non-facility covered
not count towards coinsurance or out-of-pocket maximum. expenses is determined based on the negotiated charge that would apply if such
*** Brokers: please see broker information about commissions for this plan. services were received from a Network Provider.
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