What this Plan Covers & What You Pay for Covered Services ... · Important Questions Answers Why...

Important Questions Answers Why This Matters:

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would sharethe cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is onlya summary. Formoreinformationaboutyourcoverage,ortogetacopyofthecompletetermsofcoverage,https://www.aetna.com/sbcsearch/getpolicydocs?u=070500-080020-141771orbycalling1-888-982-3862.Forgeneraldefinitionsofcommonterms,suchasallowedamount,balancebilling,coinsurance,copayment,deductible,provider,orotherunderlinedtermsseetheGlossary.YoucanviewtheGlossaryathttps://www.healthcare.gov/sbc-glossary/orcall1-888-982-3862torequestacopy.

Coverage for: Individual+Family| Plan Type: HMO

Coverage Period: 01/01/2018 - 12/31/2018Summary of Benefits and Coverage: WhatthisPlanCovers&WhatYouPayforCoveredServices

Participating:Individual$0/Family$0.What is the overalldeductible?SeetheCommonMedicalEventschartbelowforyourcostsforservicesthisplancovers.

No.Are there services coveredbefore you meet yourdeductible?

Youwillhavetomeetthedeductiblebeforetheplanpaysforanyservices.

No.Are there other deductiblesfor specific services? Youdon'thavetomeetdeductiblesforspecificservices.

Participating:Individual$1,500/Family$3,000.What is the out-of-pocketlimit for this plan?Theout-of-pocketlimitisthemostyoucouldpayinayearforcoveredservices.Ifyouhaveotherfamilymembersinthisplan,theyhavetomeettheirownout-of-pocketlimitsuntiltheoverallfamilyout-of-pocketlimithasbeenmet.

Premiums,balance-billingcharges&healthcarethisplandoesn'tcover.

What is not included in theout-of-pocket limit? Eventhoughyoupaytheseexpenses,theydon'tcounttowardtheout-of-pocketlimit.

Yes.Seewww.aetna.com/docfindorcall1-888-982-3862foralistofparticipatingproviders.

Thisplanusesaprovidernetwork.Youwillpaylessifyouuseaproviderintheplan'snetwork.Youwillpaythemostifyouuseanout-of-networkprovider,andyoumightreceiveabillfromaproviderforthedifferencebetweentheprovider'schargeandwhatyourplanpays(balancebilling).Beaware,yournetworkprovidermightuseanout-of-networkproviderforsomeservices(suchaslabwork).Checkwithyourproviderbeforeyougetservices.

Will you pay less if you use anetwork provider?

Do you need a referral to seea specialist? Youcanseethespecialistyouchoosewithoutareferral.

No.

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UNIVERSITYOFPENNSYLVANIAPOSTDOCTORALINSURANCEPLAN:HealthNetworkOnlySM-PA:

https://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#premiumhttps://www.healthcare.gov/sbc-glossary/https://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#out-of-pocket-limithttps://www.healthcare.gov/sbc-glossary/#out-of-pocket-limithttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#out-of-pocket-limithttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#out-of-pocket-limithttps://www.healthcare.gov/sbc-glossary/#out-of-pocket-limithttps://www.healthcare.gov/sbc-glossary/#premiumhttps://www.healthcare.gov/sbc-glossary/#balance-billinghttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#out-of-pocket-limithttps://www.healthcare.gov/sbc-glossary/#out-of-pocket-limitwww.aetna.com/docfindhttps://www.healthcare.gov/sbc-glossary/#providerhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#providerhttps://www.healthcare.gov/sbc-glossary/#networkhttps://www.healthcare.gov/sbc-glossary/#providerhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#networkhttps://www.healthcare.gov/sbc-glossary/#out-of-network-providerhttps://www.healthcare.gov/sbc-glossary/#providerhttps://www.healthcare.gov/sbc-glossary/#providerhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#balance-billinghttps://www.healthcare.gov/sbc-glossary/#network-providerhttps://www.healthcare.gov/sbc-glossary/#out-of-network-providerhttps://www.healthcare.gov/sbc-glossary/#providerhttps://www.healthcare.gov/sbc-glossary/#network-providerhttps://www.healthcare.gov/sbc-glossary/#referralhttps://www.healthcare.gov/sbc-glossary/#specialisthttps://www.healthcare.gov/sbc-glossary/#specialisthttps://www.healthcare.gov/sbc-glossary/#referral

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Non-ParticipatingProvider

(You will pay the most)Services You May Need

Participating Provider (You will pay the least)

Limitations, Exceptions & Other ImportantInformation

What You Will PayCommon

Medical Event

Notcovered$20copay/visitPrimarycarevisittotreataninjuryorillnessNone

Notcovered$30copay/visitSpecialistvisit None

NotcoveredNochargePreventivecare/screening/immunization

If you visit a healthcare provider's officeor clinic

Youmayhavetopayforservicesthataren'tpreventive.Askyourprovideriftheservicesneededarepreventive.Thencheckwhatyourplanwillpayfor.

NotcoveredNochargeDiagnostictest(x-ray,bloodwork) NoneNotcovered$30copay/visitImaging(CT/PETscans,MRIs)

If you have a testNone

NotcoveredCopay/prescription:$10(retail),$20(mailorder)GenericdrugsCovers30daysupply(retail),31-90daysupply(mailorder).Includescontraceptivedrugs&devicesobtainablefromapharmacy,oralfertilitydrugs.NochargeforpreferredgenericFDA-approvedwomen'scontraceptivesin-network.

NotcoveredCopay/prescription:$15(retail),$30(mailorder)Preferredbranddrugs

NotcoveredCopay/prescription:$30(retail),$60(mailorder)Non-preferredbranddrugs

NotcoveredApplicablecostasnotedaboveforgenericorbranddrugs

Specialtydrugs

If you need drugs totreat your illness orconditionMoreinformationaboutprescription drugcoverageisavailableatwww.aetnapharmacy.com/premierplus

PremierPlusFormulary

Firstprescriptionfillataretailpharmacyorspecialtypharmacy.SubsequentfillsmustbethroughtheAetnaSpecialtyPharmacyNetwork.Precertificationrequiredforcoverage.

Notcovered$100copay/visitFacilityfee(e.g.,ambulatorysurgerycenter)None

NotcoveredNochargePhysician/surgeonfees

If you have outpatientsurgery None

$75copay/visit$75copay/visitEmergencyroomcare Nocoveragefornon-emergencyuse.NochargeNochargeEmergencymedicaltransportation NoneNotcovered$30copay/visitUrgentcare

If you need immediatemedical attention

Nocoveragefornon-urgentuse.Notcovered$250copay/stayFacilityfee(e.g.,hospitalroom) NoneNotcoveredNochargePhysician/surgeonfees

If you have a hospitalstay None

Allcopaymentandcoinsurancecostsshowninthischartareafteryourdeductiblehasbeenmet,ifadeductibleapplies.

070500-080020-141771

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Non-ParticipatingProvider

(You will pay the most)Services You May Need

Participating Provider (You will pay the least)

Limitations, Exceptions & Other ImportantInformation

What You Will PayCommon

Medical Event

NotcoveredOffice:$30copay/visit;otheroutpatientservices:nocharge

OutpatientservicesNone

Notcovered$250copay/stayInpatientservices

If you need mentalhealth, behavioralhealth, or substanceabuse services None

NotcoveredNochargeOfficevisits Costsharingdoesnotapplyforpreventiveservices.MaternitycaremayincludetestsandservicesdescribedelsewhereintheSBC(i.e.ultrasound.)

Notcovered$30copay/pregnancyChildbirth/deliveryprofessionalservices

Notcovered$250copay/stayChildbirth/deliveryfacilityservicesIf you are pregnant

Notcovered$30copay/visitHomehealthcare None

Notcovered$30copay/visitRehabilitationservices 60visits/calendaryearforPhysical,Occupational&SpeechTherapycombined.Notcovered$30copay/visitHabilitationservices LimitedtotreatmentofAutism.Notcovered$250copay/staySkillednursingcare None

NotcoveredNochargeDurablemedicalequipmentLimitedto1durablemedicalequipmentforsame/similarpurpose.Excludesrepairsformisuse/abuse.

Notcovered$250copay/stayforinpatient;nochargeforoutpatient

Hospiceservices

If you need helprecovering or haveother special healthneeds

None

Notcovered$30copay/visitChildren'seyeexam 1routineeyeexam/24months.NotcoveredNotcoveredChildren'sglasses Notcovered.NotcoveredNotcoveredChildren'sdentalcheck-up

If your child needsdental or eye care

Notcovered.Excluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

AcupunctureBariatricsurgeryCosmeticsurgeryDentalcare(Adult&Child)

Glasses(Child)HearingaidsLong-termcareNon-emergencycarewhentravelingoutsidetheU.S.

Private-dutynursingRoutinefootcareWeightlossprograms-Exceptforrequiredpreventiveservices.

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Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.)

Chiropracticcare-20visits/calendaryear. Infertilitytreatment-Limitedtothediagnosis&treatmentofunderlyingmedicalcondition.

Routineeyecare(Adult)-1routineeyeexam/24months.

Your Rights to Continue Coverage:Thereareagenciesthatcanhelpifyouwanttocontinueyourcoverageafteritends.Thecontactinformationforthoseagenciesis:PennsylvaniaInsuranceDepartment,BureauofConsumerServices,(877)881-6388,http://www.insurance.pa.gov/Consumers

Othercoverageoptionsmaybeavailabletoyoutoo,includingbuyingindividualinsurancecoveragethroughtheHealthInsuranceMarketplace.FormoreinformationabouttheMarketplace,visitwww.HealthCare.govorcall1-800-318-2596.

Ifyourcoverageisachurchplan,churchplansarenotcoveredbytheFederalCOBRAcontinuationcoveragerules.Ifthecoverageisinsured,individualsshouldcontacttheirStateinsuranceregulatorregardingtheirpossiblerightstocontinuationcoverageunderStatelaw.

IfyourgrouphealthcoverageissubjecttoERISA,youmayalsocontacttheDepartmentofLabor'sEmployeeBenefitsSecurityAdministrationat1-866-444-EBSA(3272)orwww.dol.gov/ebsa/healthreform.Fornon-federalgovernmentalgrouphealthplans,youmayalsocontacttheDepartmentofHealthandHumanServices,CenterforConsumerInformationandInsuranceOversight,at1-877-267-2323x61565orwww.cciio.cms.gov.

Formoreinformationonyourrightstocontinuecoverage,contacttheplanat1-888-982-3862.

Your Grievance and Appeals Rights:Thereareagenciesthatcanhelpifyouhaveacomplaintagainstyourplanforadenialofaclaim.Thiscomplaintiscalledagrievanceorappeal.Formoreinformationaboutyourrights,lookattheexplanationofbenefitsyouwillreceiveforthatmedicalclaim.Yourplandocumentsalsoprovidecompleteinformationtosubmitaclaim,appeal,oragrievanceforanyreasontoyourplan.Formoreinformationaboutyourrights,thisnotice,orassistance,contact:

AetnadirectlybycallingthetollfreenumberonyourMedicalIDCard,orbycallingourgeneraltollfreenumberat1-888-982-3862.PennsylvaniaInsuranceDepartment,BureauofConsumerServices,(877)881-6388,http://www.insurance.pa.gov/Consumers.IfyourgrouphealthcoverageissubjecttoERISA,youmayalsocontacttheDepartmentofLabor'sEmployeeBenefitsSecurityAdministrationat1-866-444-EBSA(3272)orwww.dol.gov/ebsa/healthreform.Fornon-federalgovernmentalgrouphealthplans,youmayalsocontacttheDepartmentofHealthandHumanServices,CenterforConsumerInformationandInsuranceOversight,at1-877-267-2323x61565orwww.cciio.cms.gov.Additionally,aconsumerassistanceprogramcanhelpyoufileyourappeal.ContactPennsylvaniaInsuranceDepartment,BureauofConsumerServices,1209StrawberrySquare,Harrisburg,PA17111,(877)881-6388,http://www.insurance.pa.gov/Consumers.

Ifyoudon'thaveMinimum Essential Coverageforamonth,you'llhavetomakeapaymentwhenyoufileyourtaxreturnunlessyouqualifyforanexemptionfromtherequirementthatyouhavehealthcoverageforthatmonth.

Does this plan provide Minimum Essential Coverage? Yes.

070500-080020-141771

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Ifyourplandoesn'tmeettheMinimum Value Standards,youmaybeeligibleforapremium tax credittohelpyoupayforaplanthroughtheMarketplace.Does this plan Meet Minimum Value Standard? Yes.

-------------------To see examples of how this plan might cover costs for a sample medical situation, see the next section.-------------------

070500-080020-141771

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About these Coverage Examples:

DeductiblesCopaymentsCoinsurance

Limitsorexclusions$1,120


Limitsorexclusions

$0$1,100

$0

$20

This is not a cost estimator.Treatmentsshownarejustexamplesofhowthisplanmightcovermedicalcare.Youractualcostswillbedifferentdependingontheactualcareyoureceive,thepricesyourproviderscharge,andmanyotherfactors.Focusonthecost sharingamounts(deductibles,copaymentsandcoinsurance)andexcluded servicesundertheplan.Usethisinformationtocomparetheportionofcostsyoumightpayunderdifferenthealthplans.Pleasenotethesecoverageexamplesarebasedonself-onlycoverage.

The plan's overall deductibleSpecialist copaymentHospital (facility) copayment


Limitsorexclusions

$0$400

$0

$460$60

Peg is Having a baby(9monthsofin-networkpre-natalcareanda

hospitaldelivery)

Other copayment

This EXAMPLE event includes services like:Specialistofficevisits(prenatal care)Childbirth/DeliveryProfessionalServicesChildbirth/DeliveryFacilityServicesDiagnostictests(ultrasounds and blood work)Specialistvisit(anesthesia)

$0$30

$250$0 $0 $0

In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:Cost Sharing

What isn't covered What isn't covered What isn't covered

The total Joe would pay is The total Mia would pay isThe total Peg would pay is

Cost Sharing

Total Example Cost Total Example Cost Total Example Cost

Cost Sharing

$200

$0$200

$0

$0

Managing Joe's type 2 Diabetes(ayearofroutinein-networkcareofa

well-controlledcondition)

Mia's Simple Fracture(in-networkemergencyroomvisitandfollowup

care)

TheplanwouldberesponsiblefortheothercostsoftheseEXAMPLEcoveredservices.

The plan's overall deductibleSpecialist copaymentHospital (facility) copaymentOther copayment

This EXAMPLE event includes services like:Primarycarephysicianofficevisits(includingdisease education)Diagnostictests(blood work)PrescriptiondrugsDurablemedicalequipment(glucose meter)

$0 $0$30 $30

$250 $250

The plan's overall deductibleSpecialist copaymentHospital (facility) copaymentOther copayment

This EXAMPLE event includes services like:Emergencyroomcare(including medical supplies)Diagnostictest(x-ray)Durablemedicalequipment(crutches)Rehabilitationservices(physical therapy)

$12,800 $7,400 $1,900

Note:Ifyourplanhasawellnessprogramandyouchoosetoparticipate,youmaybeabletoreduceyourcosts.

070500-080020-141771

https://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#providerhttps://www.healthcare.gov/sbc-glossary/#cost-sharinghttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#copaymenthttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#excluded-serviceshttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#specialisthttps://www.healthcare.gov/sbc-glossary/#copaymenthttps://www.healthcare.gov/sbc-glossary/#copaymenthttps://www.healthcare.gov/sbc-glossary/#copaymenthttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#specialisthttps://www.healthcare.gov/sbc-glossary/#copaymenthttps://www.healthcare.gov/sbc-glossary/#copaymenthttps://www.healthcare.gov/sbc-glossary/#copaymenthttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#specialisthttps://www.healthcare.gov/sbc-glossary/#copaymenthttps://www.healthcare.gov/sbc-glossary/#copaymenthttps://www.healthcare.gov/sbc-glossary/#copaymenthttps://www.healthcare.gov/sbc-glossary/#plan

Personsusingassistivetechnologymaynotbeabletofullyaccessthefollowinginformation.Forassistance,pleasecall1-888-982-3862.

Toviewdocumentsfromyoursmartphoneortablet,thefreeWinZipappisrequired.ItmaybeavailablefromyourAppStore.

Assistive Technology

Smartphone or Tablet

Non-Discrimination

Aetnaprovidesfreeaids/servicestopeoplewithdisabilitiesandtopeoplewhoneedlanguageassistance.

Ifyoubelievewehavefailedtoprovidetheseservicesorotherwisediscriminatedbasedonaprotectedclassnotedabove,youcanalsofileagrievancewiththeCivilRightsCoordinatorbycontacting:

CivilRightsCoordinator

P.O.Box14462,Lexington,KY40512(CAHMOcustomers:POBox24030,Fresno,CA93779)

1-800-648-7817,TTY:711,Fax:859-425-3379(CAHMOcustomers:1-860-262-7705)

Email:[email protected]

YoucanalsofileacivilrightscomplaintwiththeU.S.DepartmentofHealthandHumanServices,OfficeforCivilRightsComplaintPortal,availableathttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf,orat:U.S.DepartmentofHealthandHumanServices,200IndependenceAvenueSW.,Room509F,HHHBuilding,Washington,DC20201,orat1-800-368-1019,800-537-7697(TDD).

AetnacomplieswithapplicableFederalcivilrightslawsanddoesnotdiscriminate,excludeortreatpeopledifferentlybasedontheirrace,color,nationalorigin,sex,age,ordisability.

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company, Coventry HealthCare plans and their affiliates (Aetna).

Ifyouneedaqualifiedinterpreter,writteninformationinotherformats,translationorotherservices,callthenumberonyourIDcard.

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Kurdish- 1-888-982-3862

Laotian- , 1-888-982-3862 .Marathi- () 1-888-982-3862 .Marshallese- an bk jipa ilo Kajin Majol, kallok 1-888-982-3862 ilo ejjelok wnn.

Ohng palien sawas en soun kawewe ni omw lokaia Ponape koahl 1-888-982-3862 ni sohte isais.Micronesian-Pohnpeyan- 1-888-982-3862 Mon-Khmer,Cambodian-

Navajo- T' shi shizaad k'ehj bee shk a'doowol nnzingo Din k'ehj koji' t' jk'e hlne' 1-888-982-3862

Nepali- () 1-888-982-3862Nilotic-Dinka- Tn kuny thok Thuj cl 1-888-982-3862 kecn ac.Norwegian- For sprkassistanse p norsk, ring 1-888-982-3862 kostnadsfritt.

Panjabi- , 1-888-982-3862 PennsylvaniaDutch- Fer Helfe in Deitsch, ruf: 1-888-982-3862 aa. Es Aaruf koschtet nix.

Persian- 1-888-982-3862Polish- Aby uzyska pomoc w jzyku polskim, zadzwo bezpatnie pod numer 1-888-982-3862.

Portuguese- Para obter assistncia lingustica em portugus ligue para o 1-888-982-3862 gratuitamente.

Romanian- Pentru asisten lingvistic n romnete telefonai la numrul gratuit 1-888-982-3862

Russian- , 1-888-982-3862.

Samoan- Mo fesoasoani tau gagana I le Gagana Samoa vala'au le 1-888-982-3862 e aunoa ma se totogi.Serbo-Croatian- Za jezinu pomo na hrvatskom jeziku pozovite besplatan broj 1-888-982-3862.

Spanish- Para obtener asistencia lingstica en espaol, llame sin cargo al 1-888-982-3862.

Sudanic-Fulfude- Fii yo on heu balal e ko yowitii e haala Pular noddee e oo numero oo 1-888-982-3862. Njodi woo fawaaki on.

Swahili- Ukihitaji usaidizi katika lugha ya Kiswahili piga simu kwa 1-888-982-3862 bila malipo.

Syriac- . 3862-982-888-1

Tagalog- Para sa tulong sa wika na nasa Tagalog, tawagan ang 1-888-982-3862 nang walang bayad.

Telugu- 1-888-982-3862 . ()Thai- 1-888-982-3862 Tongan- Kapau oku fiema'u h tokoni i he lea faka-Tonga telefoni 1-888-982-3862 o ikai h ttngi.

Trukese- Ren ninnisin chiak ren (Kapasen Chuuk) kopwe kkkri 1-888-982-3862 nge esapw kam ngonuk.

Turkish- (Dil) ars dil yardm iin. Hibir cret demeden 1-888-982-3862.

Ukrainian- , 1-888-982-3862.

Urdu- 1-888-982-3862

Vietnamese- c h tr ngn ng bng (ngn ng), hay goi min phi n s 1-888-982-3862.Yiddish- 1-888-982-3862Yoruba- Fn rnlw npa d (Yorb) pe 1-888-982-3862 li san ow kankan rr.

The family deductible and family out-of-pocket limit are cumulative for all familymembers. The family deductible and out-of-pocket limit can be met by a combinationof family members; however no single individual within the family will be subject tomore than the individual deductible or out-of-pocket limit amount.

How is the overall deductible orout-of-pocket limit met?

Individual deductible andout-of-pocket limit

payments apply to thefamily deductible andout-of-pocket limit.

How your out-of-network care is reimbursed:Your plan does not cover care you get outside of our network. Generally, we will not pay anything for that care. But your plan will pay for emergencyservices you receive from health care providers not in our network. Your cost sharing deductibles, coinsurance, copayments will be the same as ifyou got the care in-network. You are not responsible for paying anything else. If you get a bill for anything more, contact us.

Other important information about your plan:This plan does not cover all health care expenses and includes exclusions and limitations. Members should refer to their plan documents to determinewhich health care services are covered and to what extent.

Additional information regarding your plan is available in the Disclosure Document on www.aetna.com.

Information includes:Knowing what is covered which describes how we review a request for coverage for a service or supply

Prescription drug benefit which describes procedures we use to manage prescription drug benefits. These procedures include how to obtain a list ofcovered drugs and the exception policy for receiving coverage of a drug that is not on a closed formulary

Health benefits and health insurance plans are offered and/or underwritten by Aetna Health Inc., Aetna Health of California Inc., Aetna HealthInsurance Company of New York, Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). In Florida, by Aetna Health Inc.and/or Aetna Life Insurance Company. In Maryland, by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT 06156. Each insurer has sole financialresponsibility for its own products. While this material is believed to be accurate as of the production date, it is subject to change.Health benefits and health insurance plans contain exclusions and limitations. Not all health services are covered.

071100-100020-331744Page 1 of 3or visit us at www.HealthReformPlanSBC.com.

Questions: Call the toll free number on your ID card (1-888-982-3862 for prospective members), TDD 1-800-628-3323 (hearing impaired only),

UNIVERSITY OF PENNSYLVANIA POSTDOCTORAL INSURANCEPLAN

Supplemental Information Coverage for: Individual + Family | Plan Type: HMO

See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary bylocation and are subject to change. You may be responsible for the health care provider's full charges for any non-covered services, includingcircumstances where you have exceeded a benefit limit contained in the plan. Providers are independent contractors and are not agents of Aetna.Provider participation may change without notice. We do not provide care or guarantee access to health services.

The following is a partial list of services and supplies that are generally not covered. However, your plan documents may contain exceptions to this listbased on state mandates or the plan design or rider(s) purchased by you or your employer.

Donor egg retrieval

All medical and hospital services not specifically covered in, or which arelimited or excluded by your plan documents

Orthotics except diabetic orthotics

Non-medically necessary services or supplies

Radial keratotomy or related proceduresHome births

Experimental and investigational procedures, except for coverage formedically necessary routine patient care costs for members participating ina cancer clinical trial with respect to the treatment of cancer or otherlife-threatening disease or condition.

Outpatient prescription drugs (except for treatment of diabetes),unless covered by a prescription plan rider and over-the-countermedications (except as provided in a hospital) and supplies

Implantable drugs and certain injectable drugs including injectable infertilitydrugs

Immunizations for travel or work except where medically necessary orindicated

Services for the treatment of sexual dysfunction or inadequacies,including therapy, supplies, counseling or prescription drugs

Reversal of sterilization

Long-term rehabilitation therapy Therapy or rehabilitation other than those listed as covered

Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna's Preferred Drug List. Rebates do not reduce theamount a member pays the pharmacy for covered prescriptions. Aetna Rx Home Delivery refers to Aetna Rx Home Delivery, LLC, a licensed pharmacysubsidiary of Aetna Inc., that operates through mail order. The charges that Aetna negotiates with Aetna Rx Home Delivery may be higher than the costthey pay for the drugs and the cost of the mail order pharmacy services they provide. For these purposes, the pharmacy's cost of purchasing drugs takesinto account discounts, credits and other amounts that they may receive from wholesalers, manufacturers, suppliers and distributors.





2014 Aetna Inc.

We consider your personal information to be private. We have policies and procedures in place to protect your personal information from unlawful useand disclosure. For a summary of our policy, go to www.aetna.com. You'll find the Privacy Notices link at the bottom of the page.

In case of emergency, call 911 or your local emergency hotline, or go directly to an emergency care facility.

Plan features and availability may vary by location and group size.





Colorado Supplement to the Summary of Benefits and Coverage Form

071100-100020-331745 Page 1 of 3

2. Type of Plan Health maintenance organization (HMO)

3. Areas of Colorado WherePlan Is Available

Plan is available only in the following areas: Adams, Arapahoe, Boulder,Broomfield, Denver,Douglas, El Paso, Elbert, Fremont, Jefferson, Larimer, Mesa, Pueblo, Teller, Weld.

Aetna Health Inc.

Health Network OnlySM - PA

Large Employer Group Policy1. Type of Policy

Important Note: The contents of this form are subject to the provisions of the policy, which contains all terms, covenants and conditionsof coverage. It provides additional information meant to supplement the Summary of Benefits and Coverage you have received for thisplan. This plan may exclude coverage for certain treatments, diagnoses, or services not specifically noted. Consult the actual policy todetermine the exact terms and conditions of coverage.

SUPPLEMENTAL INFORMATION REGARDING BENEFITS

INSURANCE COMPANY NAME

NAME OF PLAN

Description

4. Annual Deductible Type

6. What is included in theIn-Network Out-of-PocketMaximum?

Deductible, copayments, coinsurance

071100-100020-331745 Page 2 of 3

5. Out-of-Pocket Type

7. Is pediatric dental coverageincluded in this plan?

8. What cancer screenings arecovered?

Prostate Cancer Screening, Cervical Cancer Screening, Breast Cancer Screening, ColorectalCancer Screening age and frequency schedules may apply.

INDIVIDUAL: The amount that each member of the family must meet prior to claims being paid.Claims will not be paid for any other individual until their individual deductible or the family deductiblehas been met.

FAMILY: The maximum amount that the family will pay for the year. The family deductible can bemet by 2 or more individuals.

EMBEDDED DEDUCTIBLE

INDIVIDUAL: The amount that each member of the family must meet prior to claims being paid at100%. Claims will not be paid at 100% for any other individual until their individual out-of-pocket orthe family out-of-pocket has been met.

FAMILY: The maximum amount that the family will pay for the year. The family out-of-pocket can bemet by 2 or more individuals.

EMBEDDED OUT-OF-POCKET

No, the plan does not include pediatric dental.

USING THE PLAN

9. If the provider charges more for acovered service than the plan normallypays, does the enrollee have to pay thedifference?

10. Does the plan have a bindingarbitration clause?

No

071100-100020-331745 Page 3 of 3

No

IN-NETWORK OUT-OF-NETWORK

Yes, refer to your certificate of coverage fordetails.

Questions: Call

Colorado Division of InsuranceConsumer Services, Life and Health Section1560 Broadway, Suite 850, Denver, CO 80202Call 303-894-7490 (in state, toll free: 800-930-3745)Email: [email protected]

If you are not satisfied with the resolution of your complaint or grievance, contact:

1-888-982-3862, TDD 1-800-628-3323 (hearing impaired only) or visit www.Aetna.com.

Aetna maintains and makes available to interested parties upon request a managed care network access plan on its business premises. Themanaged care network access plan demonstrates the managed care network contains an adequate number of accessible acute care hospitals,primary care providers, and specialists available to provide covered health care services. Among other things, the access plan describesAetna's process for monitoring and assuring on an ongoing basis the sufficiency of the network to meet the health care needs of planenrollees.

This document is available in other languages. Do you need this in another language? Call us.No Cost Language Services. You can get an interpreter. You can get documents read to you and some sent to you in your language. Forhelp, call us at the number listed on your ID card or 1-888-982-3862.

Si necesita asistencia lingistica en espaol, llmenos al nmero que figura en su tarjeta de identificacin (ID) mdica.Servicios de idiomas sin costo. Puede obtener un intrprete. Le pueden leer documentos y que le enven algunos en espaol. Para obtenerayuda, llmenos al nmero que figura en su tarjeta de identificacin o al 1-888-982-3862.

Colorado Network Access Plan Disclosure:

UNIVERSITYOFPENNSYLVANIAPOSTDOCTORALINSU_80075626_0861472_INS_070500-080020-141771_01012018_SBCUNIVERSITYOFPENNSYLVANIAPOSTDOCTORALINSU_80075626_0861472_INS_071100-100020-331744_01012018_SuppSTDUNIVERSITYOFPENNSYLVANIAPOSTDOCTORALINSU_80075626_0861472_INS_071100-100020-331745_01012018_SuppCO

What this Plan Covers & What You Pay for Covered Services ... · Important Questions Answers Why...

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