EMPLOYEE BENEFITS
ENROLLMENT GUIDE
Plan Year effective 8/1/2020
For the Benefit of:
IQor Global Services, Inc.
Page 1 of 66
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Why How can I called my Do I have
won’t my claim still be insurance mail-order
they pay carrier, but now prescription
my claim? “in process”? I’m just more benefits?
confused.
Services It’s been two
denied?! months!
Call the Benefit Resource Center (“BRC”),
We’re Here To Help!
We speak insurance.
Our Benefits Specialists can help you choose the right plan for you and your family,
translate confusing jargon, answer questions about which benefits are on your plan
and which aren’t, work directly with insurance carriers to resolve tricky issues
regarding claims and denials of service—and more!
Benefit Resource Center
BRCSouthwest@usi.com | Toll Free: 855-874-0110
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Contact Information
Have Questions? Need Help?
AOS, Inc is excited to offer access to the USI Benefit Resource Center (BRC), which is designed to
provide you with a responsive, consistent, hands-on approach to benefit inquiries. Benefit Specialists
are available to research and solve elevated claims, unresolved eligibility problems, and any other
benefit issues with which you might need assistance. The Benefit
Specialists are experienced professionals and their primary responsibility is to assist you.
The Specialists in the Benefit Resource Center are available Monday through Friday 8:00am to
5:00pm Mountain Time. If you need assistance outside of regular business hours, please leave a
message and one of the Benefit Specialists will promptly return your call or e-mail message by the
end of the following business day.
Carrier Contact Information
888-416-2277
Aetna Medical / 3 Plans 888-416-2277
Dental / Dual Plan 888-416-2277
Aetna
Vision
Aetna
= Voluntary Life & AD&D 800-523-2233
Short Term / Long Term Disability
The Hartford 800-523-2233
Accident / Critical Illness
The Hartford 800-607-3366
BRC
Aetna Benefit Questions 855-874-0110
Benefit Questions brcsouthwest@usi.com
Benefit Resource Center Benefit Questions Marlene Cisneros
USI Southwest, Inc.
USI Southwest, Inc. 915 534-9455
American One Source Micah Harrison
915 534-9495
Mandy Jones
254-751-0156
Page 4 of 66
Employee Benefits Open Enrollment
Eligibility Family Status Change Events Generally,
Employees that meet the following criteria; Full-Time you can only change your benefit elections during
Regular 30 Hours per Week and their eligible the annual benefits enrollment period. However,
dependents may participate in the AOS, Inc. benefits you may be able to change some of your benefit
program. elections upon the occurrence of certain change in
Generally, for the purpose of the AOS, Inc. status events, provided you properly notify your
benefits program,dependents are defined as: Employer and the change is permitted under the
plan terms. Examples of these changes in status
▪ Your spouse events may include:
▪ Dependent “child” up to age 26. (Child means ▪ Your marriage
▪ Your divorce or legal separation
the employee’s natural child or adopted child and ▪ Birth or adoption of an eligible child.
any other child as defined in the certificate of ▪ Death of your spouse or covered child
coverage) ▪ Change in your spouse’s work status that affects
For questions regarding your benefits or his or her benefits
enrollment options, please contact USI ▪ Change in your work status that affects your
Marlene Cisneros at 915 534-9455.
benefits
The Deadline to Enroll will be July 24th. ▪ Change in residence or work site that affects
You will not be able to make any plan
changes until next open enrollment unless you your eligibility for coverage
experience a change in family status. ▪ Change in your child’s eligibility for benefits
▪ Receiving Qualified Medical Child Support Order
(QMCSO)
If you have a family status change, you must notify
your HR Manager with in 30 days.and complete the
necessary forms.
Disclaimer
This brochure provides only a brief summary of the
benefits available under the AOS, Inc. benefit
plans. In the event of a discrepancy between this
summary and the plan document, the plan
document will prevail. AOS, Inc. retains the right to
modify or eliminate these or any other benefits at
any time and for any reason.
Page 5 of 66
Employee Benefits Open Enrollment
AOS, Inc.offers an excellent selectionof benefits What’s new this year?
for regular, full-time employees. This Employee
Benefits Enrollment Guide is designed to $5000 H.S.A. Plan
familiarize you with benfits that that are available. $1500 PPO Plan
Dental and Vision Plans with Aetna
Benefits are a significant part of your total
compensation package. It is important to be aware
of the benefits and the value they represent to you.
What is Open Enrollment?
Open Enrollment is a once-a-year opportunity to
make changes to your current benefits and to review
which dependents you will be covering during the
new plan year. All changes you request will take
effect 8/1/2020.
If you are currently enrolled you will be automatically
enrolled/transferred into a similar plan and If you
wish you will have the opportunity to make a change
during open enrollment effective 8/1/2020.
Page 6 of 66
AOS IQ OR Global Services (American One Source, Inc.)
Proposed Effective Date: 08-01-2019
Elect Choice® EPO - Texas
TX19 OAEPO 5000 70 Value IRX EC RX7 VP
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
PLAN FEATURES IN-NETWORK
Benefit Limitations - For any service or supply that is subject to a maximum visit, day, or dollar limitation on a per
year basis, the benefit year begins on January 1st unless otherwise mandated. Refer to your plan documents for more
information.
Deductible $5,000 Individual
(per calendar year) $10,000 Family
Unless otherwise indicated, the deductible must be met prior to benefits being payable.
Member cost sharing for certain services, as indicated in the plan, are excluded from charges to meet the Deductible.
Pharmacy expenses apply towards the Deductible.
The family Deductible is a cumulative Deductible for all family members. The family Deductible can be met by a
combination of family members; however, no single individual within the family will be subject to more than the
individual Deductible amount.
Member Coinsurance 30%
Applies to all expenses unless otherwise stated.
Payment Limit $7,150 Individual
(per calendar year) $14,300 Family
Certain member cost sharing elements may not apply toward the Payment Limit.
Pharmacy expenses apply towards the Payment Limit.
Only those out-of-pocket expenses resulting from the application of coinsurance percentage, copays, and deductibles
(except any penalty amounts) may be used to satisfy the Payment Limit.
The family Payment Limit is a cumulative Payment Limit for all family members. The family Payment Limit can be met
by a combination of family members; however, no single individual within the family will be subject to more than the
individual Payment Limit amount.
Lifetime Maximum
Unlimited except where otherwise indicated.
Primary Care Physician Selection Optional
Referral Requirement None
PREVENTIVE CARE IN-NETWORK
Routine Adult Physical Exams/ Covered 100%; deductible waived
Immunizations
1 exam every 12 months up to age 65, 1 exam every 12 months age 65 and older
Routine Well Child Exams Covered 100%; deductible waived
7 exams first 12 months, 3 exams 13th - 24th months, 3 exams 25th - 36th months, 1 exam per 12 months thereafter
to age 22.
Childhood Immunizations Covered 100%; deductible waived
The following immunizations will be covered at 100%: diphtheria; haemophilus influenza type b, hepatitis B; measles;
mumps; pertussis; polio; rubella; tetanus and varicella and any other immunization that is required by law for the child.
Routine Gynecological Care Covered 100%; deductible waived
Exams
1 obgyn exam and pap smear per year
Routine Mammograms Covered 100%; deductible waived
Women's Health Covered 100%; deductible waived
Includes: Screening for gestational diabetes, HPV (Human- Papillomavirus) DNA testing, counseling for sexually
transmitted infections, counseling and screening for human immunodeficiency virus, screening and counseling for
interpersonal and domestic violence, breastfeeding support, supplies and counseling.
Contraceptive methods, sterilization procedures, patient education and counseling. Limitations may apply.
Routine Digital Rectal Exam Covered 100%; deductible waived
No age or frequency applies.
Prepared: 06/18/2019 10:44 AM
Page 7 of 66
AOS IQ OR Global Services (American One Source, Inc.)
Proposed Effective Date: 08-01-2019
Elect Choice® EPO - Texas
TX19 OAEPO 5000 70 Value IRX EC RX7 VP
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
Prostate-specific Antigen Test Covered 100%; deductible waived
Recommended: For covered males age 40 and over.
Colorectal Cancer Screening Covered 100%; deductible waived
Recommended: For all members age 45 and over.
Routine Eye Exams $70 office visit copay; after deductible
1 routine exam per 24 months.
Newborn Hearing Screening $70 copay; deductible waived
1 in the first 30 days of life and follow-up diagnostic care until the age of 24 months
Routine Hearing Screening Covered 100%; deductible waived
PHYSICIAN SERVICES IN-NETWORK
Office Visits to Non-Specialist $40 office visit copay; deductible waived
Includes services of an internist, general physician, family practitioner or pediatrician.
Specialist Office Visits $70 copay; after deductible
Office Based Surgery 30%; after deductible
Hearing Exams $70 copay; after deductible
1 routine exam per24 months.
Pre-Natal Maternity Covered 100%; deductible waived
Walk-in Clinics $40 office visit copay; deductible waived
Walk-in Clinics are network, free-standing health care facilities. They are an alternative to a physician's office visit for
treatment of unscheduled, non-emergency illnesses and injuries and the administration of certain immunizations. It is
not an alternative for emergency room services or the ongoing care provided by a physician. Neither an emergency
room, nor the outpatient department of a hospital, shall be considered a Walk-in Clinic.
Allergy Testing Your cost sharing is based on the type of service and where it is performed
Allergy Injections Your cost sharing is based on the type of service and where it is performed
DIAGNOSTIC PROCEDURES IN-NETWORK
Diagnostic X-ray 30% after $65 copay; after deductible
(other than Complex Imaging Services)
If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the
applicable physician's office visit member cost sharing.
Diagnostic Laboratory 30% after $40 copay; after deductible
If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the
applicable physician's office visit member cost sharing.
Diagnostic Outpatient Complex 30% after $200 copay; after deductible
Imaging
If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the
applicable physician's office visit member cost sharing.
EMERGENCY MEDICAL CARE IN-NETWORK
Urgent Care Provider $100 copay; deductible waived
Non-Urgent Use of Urgent Care Not Covered
Provider
Emergency Room 30% after $200 copay; after deductible
Copay waived if admitted
Non-Emergency Care in an Not Covered
Emergency Room
Emergency Use of Ambulance 30%; after deductible
Non-Emergency Use of Ambulance Not Covered
Prepared: 06/18/2019 10:44 AM
Page 8 of 66
AOS IQ OR Global Services (American One Source, Inc.)
Proposed Effective Date: 08-01-2019
Elect Choice® EPO - Texas
TX19 OAEPO 5000 70 Value IRX EC RX7 VP
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
HOSPITAL CARE IN-NETWORK
Inpatient Coverage 30%; after deductible
Your cost sharing applies to all covered benefits incurred during your inpatient stay.
Inpatient Maternity Coverage 30%; after deductible
(includes delivery and postpartum
care)
Your cost sharing applies to all covered benefits incurred during your inpatient stay.
Outpatient Hospital Expenses 30%; after deductible
Your cost sharing applies to all covered benefits incurred during your outpatient visit.
Outpatient Surgery - Hospital 30% after $200 copay; after deductible
Your cost sharing applies to all covered benefits incurred during your outpatient visit.
Outpatient Surgery - Freestanding 30% after $200 copay; after deductible
Facility
Your cost sharing applies to all covered benefits incurred during your outpatient visit.
MENTAL HEALTH SERVICES IN-NETWORK
Inpatient 30%; after deductible
Your cost sharing applies to all covered benefits incurred during your inpatient stay.
Crisis Stabilization Units/ 30%; after deductible
Residential Treatment Centers (for
children and adolescents)
Mental Health Office Visits $70 copay; after deductible
Your cost sharing applies to all covered benefits incurred during your outpatient visit.
Other Mental Health Services 30% after $40 copay; after deductible
SUBSTANCE ABUSE IN-NETWORK
Inpatient 30%; after deductible
Your cost sharing applies to all covered benefits incurred during your inpatient stay.
Residential Treatment Facility 30%; after deductible
Substance Abuse Office Visits $70 copay; after deductible
Your cost sharing applies to all covered benefits incurred during your outpatient visit.
Other Substance Abuse Services 30% after $40 copay; after deductible
OTHER SERVICES IN-NETWORK
Skilled Nursing Facility 30%; after deductible
Limited to 60 days per year
Your cost sharing applies to all covered benefits incurred during your inpatient stay.
Home Health Care 30% after $70 copay; after deductible
Limited to 60 visits per year
Limited to 3 intermittent visits per day by a participating home health care agency; 1 visit equals a period of 4 hrs or
less.
Hospice Care - Inpatient 30%; after deductible
Your cost sharing applies to all covered benefits incurred during your inpatient stay.
Hospice Care - Outpatient 30% after $70 copay; after deductible
Your cost sharing applies to all covered benefits incurred during your outpatient visit.
Private Duty Nursing - Outpatient 30%; after deductible
Limited to 70 eight hour shifts per year.
Each period of private duty nursing of up to 8 hours will be deemed to be one private duty nursing shift.
Prepared: 06/18/2019 10:44 AM
Page 9 of 66
AOS IQ OR Global Services (American One Source, Inc.)
Proposed Effective Date: 08-01-2019
Elect Choice® EPO - Texas
TX19 OAEPO 5000 70 Value IRX EC RX7 VP
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
Outpatient Short-Term $70 copay; after deductible
Rehabilitation
Limited to 30 visits per year.
Includes speech, physical, occupational therapy
Spinal Manipulation Therapy $70 copay; after deductible
Limited to 20 visits per year
Habilitative Services Cost sharing same as any other physical, occupational, speech therapy
(Physical/Occupational/Speech expense.
Therapy)
Autism Behavioral Therapy $70 copay; after deductible
Covered same as any other Outpatient Mental Health benefit
Autism Applied Behavior Analysis 30% after $40 copay; after deductible
Covered same as any other Outpatient Mental Health Other Services benefit
Autism Physical Therapy $70 copay; after deductible
Autism Occupational Therapy $70 copay; after deductible
Autism Speech Therapy $70 copay; after deductible
Durable Medical Equipment 30%; after deductible
Prosthetics 30%; after deductible
Orthotics 30%; after deductible
Diabetic Supplies -- (if not covered Covered same as any other medical expense.
under Pharmacy benefit)
Affordable Care Act mandated Covered 100%; deductible waived
Women's Contraceptives
Women's Contraceptive drugs and Covered 100%; deductible waived
devices not obtainable at a
pharmacy
Hearing Aids 30%; after deductible
1 benefit maximum per ear for hearing aids every 3 years.
Infusion Therapy 30% after $70 copay; after deductible
Administered in the home or
physician's office
Infusion Therapy 30% after $70 copay; after deductible
Administered in an outpatient hospital
department or freestanding facility
Vision Eyewear Not Covered
Transplants 30%; after deductible
Preferred coverage is provided at an IOE contracted facility only.
Bariatric Surgery Not Covered
Your cost sharing applies to all covered benefits incurred during your inpatient stay.
Out of Area Dependents No coverage for non-emergency care received outside the service area.
FAMILY PLANNING IN-NETWORK
Infertility Treatment Your cost sharing is based on the type of service and where it is performed
Diagnosis and treatment of the underlying medical condition only.
Comprehensive Infertility Services Not Covered
Prepared: 06/18/2019 10:44 AM
Page 10 of 66
AOS IQ OR Global Services (American One Source, Inc.)
Proposed Effective Date: 08-01-2019
Elect Choice® EPO - Texas
TX19 OAEPO 5000 70 Value IRX EC RX7 VP
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
Advanced Reproductive Not Covered
Technology (ART)
In-vitro fertilization (IVF), zygote intrafallopian transfer (ZIFT), gamete intrafallopian transfer (GIFT), cryopreserved
embryo transfers, intracytoplasmic sperm injection (ICSI), or ovum microsurgery
Vasectomy Your cost sharing is based on the type of service and where it is performed
Tubal Ligation Covered 100%; deductible waived
PHARMACY IN-NETWORK
The full cost of the drug is applied to the deductible before any benefits are considered for payment under the
pharmacy plan.
Pharmacy Plan Type Aetna Value Plus Open Formulary
Value Drugs Tier 1A
Retail $3 copay
Mail Order $7.50 copay
Preferred Generic Drugs
Retail $15 copay
Mail Order $37.50 copay
Preferred Brand-Name Drugs
Retail $50 copay
Mail Order $125 copay
Non-Preferred Generic and Brand-Name Drugs
Retail $90 copay
Mail Order $225 copay
Retail Out-of-Network Coverage Not Covered
Specialty Drugs
Preferred Specialty $150 copay
Non-Preferred Specialty $300 copay
Pharmacy Day Supply and Requirements
Retail Up to a 30 day supply from Aetna National Network
For a 31-90 day supply you will be responsible for the Mail Order Drug copay.
Mail Order A 31-90 day supply from CVS Caremark® Mail Service Pharmacy
Specialty Up to a 30 day supply
Value Plus Specialty Drug List
Deductible waived for generics
Deductible waived for value drugs/tier 1A
Choose Generics - If the member or the physician requests brand-name when generic is available, the member pays
the applicable copay plus the difference between the generic price and the brand-name price.
Plan Includes: Diabetic supplies and Contraceptive drugs and devices obtainable from a pharmacy.
A limited list of over-the-counter medications are covered when filled with a prescription.
Oral chemotherapy drugs covered 100%
Value Plus Pre-certification included
Value Plus Step Therapy included
Seasonal Vaccinations covered 100% in-network
Preventive Vaccinations covered 100% in-network
One transition fill allowed within 90 days of member's effective date
Affordable Care Act mandated female contraceptives and preventive medications covered 100% in-network.
GENERAL PROVISIONS
Dependents Eligibility Spouse, children from birth to age 26 regardless of student status.
Prepared: 06/18/2019 10:44 AM
Page 11 of 66
AOS IQ OR Global Services (American One Source, Inc.)
Proposed Effective Date: 08-01-2019
Elect Choice® EPO - Texas
TX19 OAEPO 5000 70 Value IRX EC RX7 VP
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
Plans are provided by: Aetna Health Inc. 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.
See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan
features and availability may vary by location and are subject to change. You may be responsible for the health care
provider's full charges for any non-covered services, including circumstances where you have exceeded a benefit limit
contained in the plan. Providers are independent contractors and are not our agents. Provider participation may
change without notice. We do not provide care or guarantee access to health services.
This plan does not cover all health care expenses and includes 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, your plan documents may contain exceptions to
this list based on state mandates or the plan design or rider(s) purchased by your employer.
•All medical or hospital services not specifically covered in, or which are limited or excluded by your plan documents;
• Cosmetic surgery, including breast reduction;
• Custodial care;
• Dental care and dental X-rays;
• Donor egg retrieval;
• Experimental and investigational procedures, except for coverage for medically necessary routine patient care costs
for members participating in a cancer clinical trial;
• Hearing aids;
• Home births;
• Immunizations for travel or work except where medically necessary or indicated;
• Implantable drugs and certain injectable infertility drugs;
• Infertility services, including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT,
ICSI and other related services, unless specifically listed as covered in your plan documents;
• Long-term rehabilitation therapy;
• Non-medically necessary services or supplies;
• Outpatient prescription drugs (except for treatment of diabetes), unless covered by a prescription plan rider and over-
the-counter medications (except as provided in a hospital) and supplies;
• Radial keratotomy or related procedures;
• Reversal of sterilization;
• Services for the treatment of sexual dysfunction/enhancement, including therapy, supplies, or counseling or
prescription drugs;
• Special duty nursing;
• Therapy or rehabilitation other than those listed as covered;
• Weight control services including surgical procedure, medical treatments, weight control/loss programs, dietary
regimens and supplements, appetite suppressants and other medications; food or food supplements, exercise
programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or
treat obesity, including Morbid Obesity, or for the purpose of weight reduction, regardless of the existence of comorbid
conditions.
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. Aetna Rx Home
Delivery refers to Aetna Rx Home Delivery, LLC, a licensed pharmacy subsidiary of Aetna Inc., that operates through
mail order. The charges that Aetna negotiates with Aetna Rx Home Delivery may be higher than the cost they 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 takes into account discounts, credits and other amounts that they may receive from wholesalers,
manufacturers, suppliers and distributors.
In case of emergency, call 911 or your local emergency hotline, or go directly to an emergency care facility.
Translation of the material into another language may be available. Please call Member Services at 1-888-982-3862.
Prepared: 06/18/2019 10:44 AM
Page 12 of 66
AOS IQ OR Global Services (American One Source, Inc.)
Proposed Effective Date: 08-01-2019
Elect Choice® EPO - Texas
TX19 OAEPO 5000 70 Value IRX EC RX7 VP
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
Puede estar disponible la traduccion de este material en otro idioma. Por favor llame a Servicios al Miembro al 1-888-
982-3862.
Plan features and availability may vary by location and group size.
For more information about Aetna plans, refer to www.aetna.com.
Aetna and MinuteClinic, LLC (which either operates or provides certain management support services to MinuteClinic-
branded walk-in clinics) are both within the CVS Health family.
© 2014 Aetna Inc.
Prepared: 06/18/2019 10:44 AM
Page 13 of 66
PLAN DESIGN
Customer Name: AOS
Proposed Effective Date: 08-01-2020
Policy Period: 0
Data Source ID: D431686 - 1 - TX
Option: 1
Product Combination Name: TX20 OAMC 5000 100/70 HSA / RX3
Plan: Open POS Plus Plan
Location(s): Texas
Specialty Networks Included: DISCNTP : DISCOUNT NETWORK CVS MINCLINIC NATIONAL (11341)
Organization Name: Aetna
Prepared: 06/18/2020 03:25 PM
Page 14 of 66
AOS
Proposed Effective Date: 08-01-2020
Open Access® Managed Choice® POS - Texas
Qualified High Deductible Health Plan
TX20 OAMC 5000 100/70 HSA RX3
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK
Benefit Limitations - For any service or supply that is subject to a maximum visit, day, or dollar limitation on a per
year basis, the benefit year begins on January 1st unless otherwise mandated. Refer to your plan documents for more
information.
Deductible (per calendar year) $5,000 Individual $10,000 Individual
$10,000 Family $30,000 Family
All covered expenses accumulate separately toward the in-network and out-of-network Deductible.
Unless otherwise indicated, the deductible must be met prior to benefits being payable.
Member cost sharing for certain services, as indicated in the plan, are excluded from charges to meet the Deductible.
Pharmacy expenses apply towards the Deductible.
The family Deductible is a cumulative Deductible for all family members. The family Deductible can be met by a
combination of family members; however, no single individual within the family will be subject to more than the
individual Deductible amount.
Member Coinsurance Covered 100% 30%
Applies to all expenses unless otherwise stated.
Payment Limit (per calendar year) $6,000 Individual $15,000 Individual
$12,000 Family $45,000 Family
All covered expenses accumulate separately toward the in-network and out-of-network Payment Limit.
Certain member cost sharing elements may not apply toward the Payment Limit.
Pharmacy expenses apply towards the Payment Limit.
Only those out-of-pocket expenses resulting from the application of coinsurance percentage, copays, and deductibles
(except any penalty amounts) may be used to satisfy the Payment Limit.
The family Payment Limit is a cumulative Payment Limit for all family members. The family Payment Limit can be met
by a combination of family members; however, no single individual within the family will be subject to more than the
individual Payment Limit amount.
Lifetime Maximum
Unlimited except where otherwise indicated.
Payment for Out-of-Network Care** Not Applicable Professional: 90% of Medicare
Facility: 90% of Medicare
Primary Care Physician Selection Optional Not Applicable
Certification Requirements -
Certification for certain types of Out-of-Network care must be obtained to avoid a reduction in benefits paid for that
care. Certification for Hospital Admissions, Treatment Facility Admissions, Convalescent Facility Admissions, Home
Health Care, Hospice Care and Private Duty Nursing is required - excluded amount applied separately to each type of
expense is $400 per occurrence.
Referral Requirement None None
PREVENTIVE CARE IN-NETWORK OUT-OF-NETWORK
Routine Adult Physical Exams/ Covered 100%; deductible waived 30%; after deductible
Immunizations
1 exam every 12 months up to age 65, 1 exam every 12 months age 65 and older
Routine Well Child Exams Covered 100%; deductible waived 30%; after deductible
7 exams first 12 months, 3 exams 13th - 24th months, 3 exams 25th - 36th months, 1 exam per 12 months thereafter
to age 22.
Childhood Immunizations Covered 100%; deductible waived Covered 100%; deductible waived
The following immunizations will be covered 100% out-of-network for children to age 6: diphtheria; haemophilus
influenza type b, hepatitis B; measles; mumps; pertussis; polio; rubella; tetanus and varicella and any other
immunization that is required by law for the child.
Routine Gynecological Care Covered 100%; deductible waived 30%; after deductible
Exams
1 obgyn exam and pap smear per year
Prepared: 06/18/2020 03:25 PM
Page 15 of 66
AOS
Proposed Effective Date: 08-01-2020
Open Access® Managed Choice® POS - Texas
Qualified High Deductible Health Plan
TX20 OAMC 5000 100/70 HSA RX3
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
Routine Mammograms Covered 100%; deductible waived 30%; after deductible
Women's Health Covered 100%; deductible waived 30%; after deductible
Includes: Screening for gestational diabetes, HPV (Human- Papillomavirus) DNA testing, counseling for sexually
transmitted infections, counseling and screening for human immunodeficiency virus, screening and counseling for
interpersonal and domestic violence, breastfeeding support, supplies and counseling.
Contraceptive methods, sterilization procedures, patient education and counseling. Limitations may apply.
Routine Digital Rectal Exam Covered 100%; deductible waived 30%; after deductible
Recommended: For covered males age 40 and over.
Prostate-specific Antigen Test Covered 100%; deductible waived 30%; after deductible
Recommended: For covered males age 40 and over.
Colorectal Cancer Screening Covered 100%; deductible waived Covered under Routine Adult Exams
Recommended: For all members age 45 and over.
Coverage includes the following: Annual fecal occult blood test, Digital rectal exam and a flexible sigmoidoscopy every
5 years, Digital rectal exam and a double contrast barium enema every 5 years, and Digital rectal exam and a
colonoscopy every 10 years.
Routine Eye Exams Covered 100%; deductible waived 30%; after deductible
1 routine exam per 24 months.
Newborn Hearing Screening Covered 100%; deductible waived 30%; deductible waived
1 in the first 30 days of life and follow-up diagnostic care until the age of 24 months
Routine Hearing Screening Covered 100%; deductible waived 30%; after deductible
PHYSICIAN SERVICES IN-NETWORK OUT-OF-NETWORK
Office Visits to PCP Covered 100%; after deductible 30%; after deductible
Includes services of an internist, general physician, family practitioner or pediatrician.
Specialist Office Visits Covered 100%; after deductible 30%; after deductible
Hearing Exams Covered 100%; after deductible 30%; after deductible
1 routine exam per 24 months.
Office Based Surgery Covered 100%; after deductible 30%; after deductible
Pre-Natal Maternity Covered 100%; deductible waived 30%; after deductible
Walk-in Clinics Covered 100%; after deductible 30%; after deductible
Designated Walk-in Clinics
Covered 100%; after deductible
Walk-in Clinics are free-standing health care facilities that (a) may be located in or with a pharmacy, drug store,
supermarket or other retail store; and (b) provide limited medical care and services on a scheduled or unscheduled
basis. Urgent care centers, emergency rooms, the outpatient department of a hospital, ambulatory surgical centers,
and physician offices are not considered to be Walk-in Clinics.
Allergy Testing Your cost sharing is based on the Your cost sharing is based on the
type of service and where it is type of service and where it is
performed performed
Allergy Injections Your cost sharing is based on the Your cost sharing is based on the
type of service and where it is type of service and where it is
performed; Covered 100% when an performed
office visit charge is not applicable.
DIAGNOSTIC PROCEDURES IN-NETWORK OUT-OF-NETWORK
Diagnostic X-ray Covered 100%; after deductible 30%; after deductible
If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the
applicable physician's office visit member cost sharing.
Diagnostic Laboratory Covered 100%; after deductible 30%; after deductible
If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the
applicable physician's office visit member cost sharing.
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Page 16 of 66
AOS
Proposed Effective Date: 08-01-2020
Open Access® Managed Choice® POS - Texas
Qualified High Deductible Health Plan
TX20 OAMC 5000 100/70 HSA RX3
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
Diagnostic Outpatient Complex Covered 100%; after deductible 30%; after deductible
Imaging
If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the
applicable physician's office visit member cost sharing.
EMERGENCY MEDICAL CARE IN-NETWORK OUT-OF-NETWORK
Urgent Care Provider Covered 100%; after deductible 30%; after deductible
Non-Urgent Use of Urgent Care Not Covered Not Covered
Provider
Emergency Room Covered 100%; after deductible Same as in-network care
Non-Emergency Care in an Not Covered Not Covered
Emergency Room Covered 100%; after deductible Same as in-network care
Emergency Use of Ambulance
Non-Emergency Use of Ambulance Not Covered Not Covered
HOSPITAL CARE IN-NETWORK OUT-OF-NETWORK
Inpatient Coverage Covered 100%; after deductible 30%; after deductible
Your cost sharing applies to all covered benefits incurred during your inpatient stay.
Inpatient Maternity Coverage Covered 100%; after deductible 30%; after deductible
(includes delivery and postpartum
care)
Your cost sharing applies to all covered benefits incurred during your inpatient stay.
Outpatient Hospital Expenses Covered 100%; after deductible 30%; after deductible
Your cost sharing applies to all covered benefits incurred during your outpatient visit.
Outpatient Surgery - Hospital Covered 100%; after deductible 30%; after deductible
Your cost sharing applies to all covered benefits incurred during your outpatient visit.
Outpatient Surgery - Freestanding Covered 100%; after deductible 30%; after deductible
Facility
Your cost sharing applies to all covered benefits incurred during your outpatient visit.
MENTAL HEALTH SERVICES IN-NETWORK OUT-OF-NETWORK
Inpatient Covered 100%; after deductible 30%; after deductible
Your cost sharing applies to all covered benefits incurred during your inpatient stay.
Crisis Stabilization Units/ Covered 100%; after deductible 30%; after deductible
Residential Treatment Centers (for
children and adolescents)
Mental Health Office Visits Covered 100%; after deductible 30%; after deductible
Your cost sharing applies to all covered benefits incurred during your outpatient visit.
Other Mental Health Services Covered 100%; after deductible 30%; after deductible
SUBSTANCE ABUSE IN-NETWORK OUT-OF-NETWORK
Inpatient Covered 100%; after deductible 30%; after deductible
Your cost sharing applies to all covered benefits incurred during your inpatient stay.
Residential Treatment Facility Covered 100%; after deductible 30%; after deductible
Substance Abuse Office Visits Covered 100%; after deductible 30%; after deductible
Your cost sharing applies to all covered benefits incurred during your outpatient visit.
Other Substance Abuse Services Covered 100%; after deductible 30%; after deductible
OTHER SERVICES IN-NETWORK OUT-OF-NETWORK
Skilled Nursing Facility Covered 100%; after deductible 30%; after deductible
Limited to 60 days per year
Your cost sharing applies to all covered benefits incurred during your inpatient stay.
Home Health Care Covered 100%; after deductible 30%; after deductible
Limited to 60 visits per year
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Page 17 of 66
AOS
Proposed Effective Date: 08-01-2020
Open Access® Managed Choice® POS - Texas
Qualified High Deductible Health Plan
TX20 OAMC 5000 100/70 HSA RX3
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
Private Duty Nursing not included.
Limited to 3 intermittent visits per day by a participating home health care agency; 1 visit equals a period of 4 hrs or
less.
Hospice Care - Inpatient Covered 100%; after deductible 30%; after deductible
Your cost sharing applies to all covered benefits incurred during your inpatient stay.
Hospice Care - Outpatient Covered 100%; after deductible 30%; after deductible
Your cost sharing applies to all covered benefits incurred during your outpatient visit.
Private Duty Nursing - Outpatient Covered 100%; after deductible 30%; after deductible
Limited to 70 eight hour shifts per year.
Each period of private duty nursing of up to 8 hours will be deemed to be one private duty nursing shift.
Spinal Manipulation Therapy Covered 100%; after deductible 30%; after deductible
Limited to 20 visits per year
Outpatient Short-Term Covered 100%; after deductible 30%; after deductible
Rehabilitation
Limited to 30 visits per year.
Includes speech, physical, occupational therapy
Habilitative Services Cost sharing same as any other Cost sharing same as any other
(Physical/Occupational/Speech physical, occupational, speech physical, occupational, speech
Therapy) therapy expense. therapy expense.
Autism Behavioral Therapy Covered 100%; after deductible 30%; after deductible
Covered same as any other Outpatient Mental Health benefit
Autism Applied Behavior Analysis Covered 100%; after deductible 30%; after deductible
Covered same as any other Outpatient Mental Health Other Services benefit
Autism Physical Therapy Covered 100%; after deductible 30%; after deductible
Autism Occupational Therapy Covered 100%; after deductible 30%; after deductible
Autism Speech Therapy Covered 100%; after deductible 30%; after deductible
Hearing Aids Covered 100%; after deductible 30%; after deductible
Limited to:1 benefit maximum per ear for hearing aids every 3 years.
Durable Medical Equipment Covered 100%; after deductible 30%; after deductible
Diabetic Supplies -- (if not covered Covered same as any other medical Covered same as any other medical
under Pharmacy benefit) expense. expense.
Prosthetics Covered 100%; after deductible 30%; after deductible
Orthotics Covered 100%; after deductible 30%; after deductible
Women's Contraceptive drugs and Covered 100%; deductible waived Covered same as any other expense.
devices not obtainable at a
pharmacy
Affordable Care Act mandated Covered 100%; deductible waived Covered same as any other expense.
Women's Contraceptives
Infusion Therapy Covered 100%; after deductible 30%; after deductible
Administered in the home or
physician's office
Infusion Therapy Covered 100%; after deductible 30%; after deductible
Administered in an outpatient hospital
department or freestanding facility
Vision Eyewear Not Covered Not Covered
Transplants Covered 100%; after deductible 30%; after deductible
Preferred coverage is provided at an Non-Preferred coverage is provided
IOE contracted facility only. at a Non-IOE facility.
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Page 18 of 66
AOS
Proposed Effective Date: 08-01-2020
Open Access® Managed Choice® POS - Texas
Qualified High Deductible Health Plan
TX20 OAMC 5000 100/70 HSA RX3
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
Bariatric Surgery Not Covered Not Covered
Out of Area Dependents Coverage provided at the non-preferred benefit level of the plan if in-network
provider is not available.
FAMILY PLANNING IN-NETWORK OUT-OF-NETWORK
Infertility Treatment Your cost sharing is based on the Your cost sharing is based on the
type of service and where it is type of service and where it is
performed performed
Diagnosis and treatment of the underlying medical condition only.
Comprehensive Infertility Services Not Covered Not Covered
Artificial insemination and ovulation induction
Advanced Reproductive Not Covered Not Covered
Technology (ART)
Vasectomy Covered 100%; after deductible 30%; after deductible
Tubal Ligation Covered 100%; deductible waived 30%; after deductible
PHARMACY IN-NETWORK OUT-OF-NETWORK
The full cost of the drug is applied to the deductible before any benefits are considered for payment under the
pharmacy plan.
Pharmacy Plan Type Advanced Control Plan - Aetna
Preferred Generic Drugs
Retail $15 copay 30% of submitted cost; after
applicable copay
Mail Order $37.50 copay 30% of submitted cost; after
applicable copay
Preferred Brand-Name Drugs
Retail $50 copay 30% of submitted cost; after
applicable copay
Mail Order $125 copay 30% of submitted cost; after
applicable copay
Non-Preferred Generic and Brand-Name Drugs
Retail $90 copay 30% of submitted cost; after
applicable copay
Mail Order $225 copay 30% of submitted cost; after
applicable copay
Specialty Drugs
Preferred Specialty $200 copay 30% of submitted cost; after
applicable copay
Non-Preferred Specialty $200 copay 30% of submitted cost; after
applicable copay
Pharmacy Day Supply and Requirements
Retail Up to a 30 day supply from Aetna National Network
For a 31-90 day supply you will be responsible for the Mail Order Drug copay.
Mail Order A 31-90 day supply from CVS Caremark® Mail Service Pharmacy
Specialty Up to a 30 day supply
Advanced Control Formulary Aetna Insured List
Preventive Medications - Deductible is waived for certain preventive medications. A full list of these drugs is available
on your secure member site or from your employer.
Choose Generics - If the member or the physician requests brand when generic is available, the member pays the
applicable copay plus the difference between the generic price and the brand price.
Plan Includes: Diabetic supplies and Contraceptive drugs and devices obtainable from a pharmacy.
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AOS
Proposed Effective Date: 08-01-2020
Open Access® Managed Choice® POS - Texas
Qualified High Deductible Health Plan
TX20 OAMC 5000 100/70 HSA RX3
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
A limited list of over-the-counter medications are covered when filled with a prescription.
Oral chemotherapy drugs covered 100%
Precertification and quantity limits included
Step Therapy included
Seasonal Vaccinations covered 100% in-network
Preventive Vaccinations covered 100% in-network
Affordable Care Act mandated female contraceptives and preventive medications covered 100% in-network.
GENERAL PROVISIONS
Dependents Eligibility Spouse, children from birth to age 26 regardless of student status.
**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 we pay for your out-of-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.
• For doctors and other professionals the amount is based on what Medicare pays for these services. The government
sets the Medicare rate. Exactly how much we "recognize" depends on the plan you or your employer picks.
• For hospitals and other facilities, the amount is based on what Medicare pays for these services. The government
sets the Medicare rate. Exactly how much we "recognize" depends on the plan you or your employer picks.
Your doctor sets his or her own rate to charge you. It may be higher -- sometimes much higher -- than what your plan
"recognizes." Your doctor may bill you for the dollar amount that we don'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 our
website.
Plans are provided by: Aetna Life Insurance Company. 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.
See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan
features and availability may vary by location and are subject to change. You may be responsible for the health care
provider's full charges for any non-covered services, including circumstances where you have exceeded a benefit limit
contained in the plan. Providers are independent contractors and are not our agents. Provider participation may
change without notice. We do not provide care or guarantee access to health services.
If you are in a plan that requires the selection of a primary care physician and your primary care physician is part of an
integrated delivery system or physician group, your primary care physician will generally refer you to specialists and
hospitals that are affiliated with the delivery system or physician group.
The following is a list of services and supplies that are generally not covered. However, your plan documents may
contain exceptions to this list based on state mandates or the plan design or rider(s) purchased by your employer.
Prepared: 06/18/2020 03:25 PM
Page 20 of 66
AOS
Proposed Effective Date: 08-01-2020
Open Access® Managed Choice® POS - Texas
Qualified High Deductible Health Plan
TX20 OAMC 5000 100/70 HSA RX3
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
• All medical and hospital services not specifically covered in, or which are limited or excluded by your plan documents.
• Cosmetic surgery, including breast reduction.
• Custodial care.
• Dental care and dental X-rays.
• Donor egg retrieval
• Experimental and investigational procedures, except for coverage for medically necessary routine patient care costs
for members participating in a cancer clinical trial.
• Hearing aids
• Home births
• Immunizations for travel or work, except where medically necessary or indicated.
• Implantable drugs and certain injectable drugs including injectable infertility drugs.
• Infertility services, including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT,
ICSI and other related services, unless specifically listed as covered in your plan documents.
• Long-term rehabilitation therapy.
• Non-medically necessary services or supplies.
• Outpatient prescription drugs (except for treatment of diabetes), unless covered by a prescription plan rider and over-
the-counter medications (except as provided in a hospital) and supplies.
• Radial keratotomy or related procedures.
• Reversal of sterilization.
• Services for the treatment of sexual dysfunction/enhancement, including therapy, supplies or counseling or
prescription drugs.
• Special duty nursing.
• Therapy or rehabilitation other than those listed as covered.
• Weight control services including surgical procedures, medical treatments, weight control/loss programs, dietary
regimens and supplements, appetite suppressants and other medications; food or food supplements, exercise
programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or
treat obesity, including Morbid Obesity, or for the purpose of weight reduction, regardless of the existence of comorbid
conditions.
Aetna, or its affiliate(s), receives rebates from drug manufacturers that may be taken into account in determining
Aetna's Preferred Drug List. Rebates may reduce the amount a member pays the pharmacy for covered prescriptions.
CVS Caremark ® Mail Service Pharmacy refers to CVS Caremark ® Mail Service Pharmacy, a licensed pharmacy
subsidiary of Aetna Inc., that operates through mail order. The charges that Aetna negotiates with CVS Caremark ®
Mail Service Pharmacy may be higher than the cost they 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 takes into account discounts,
credits and other amounts that they may receive from wholesalers, manufacturers, suppliers and distributors.
In case of emergency, call 911 or your local emergency hotline, or go directly to an emergency care facility.
Translation of the material into another language may be available. Please call Member Services at 1-888-982-3862.
Puede estar disponible la traduccion de este material en otro idioma. Por favor llame a Servicios al Miembro al 1-888-
982-3862.
Plan features and availability may vary by location and group size.
For more information about Aetna plans, refer to www.aetna.com.
Aetna and MinuteClinic, LLC (which either operates or provides certain management support services to MinuteClinic-
branded walk-in clinics) are both within the CVS Health family.
© 2014 Aetna Inc.
Prepared: 06/18/2020 03:25 PM
Page 21 of 66
PLAN DESIGN
Customer Name: AOS
Proposed Effective Date: 08-01-2020
Policy Period: 0
Data Source ID: D431686 - 1 - TX
Option: 1
Product Combination Name: TX20 OAMC 1500 80/50 / RX1
Plan: Open POS Plus Plan
Location(s): Texas
Specialty Networks Included: DISCNTP : DISCOUNT NETWORK CVS MINCLINIC NATIONAL (11341)
Organization Name: Aetna
Prepared: 06/18/2020 03:25 PM
Page 22 of 66
AOS
Proposed Effective Date: 08-01-2020
Open Access® Managed Choice® POS - Texas
TX20 OAMC 1500 80/50 RX1
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK
Benefit Limitations - For any service or supply that is subject to a maximum visit, day, or dollar limitation on a per
year basis, the benefit year begins on January 1st unless otherwise mandated. Refer to your plan documents for more
information.
Deductible (per calendar year) $1,500 Individual $3,000 Individual
$3,000 Family $9,000 Family
All covered expenses accumulate separately toward the in-network and out-of-network Deductible.
Unless otherwise indicated, the deductible must be met prior to benefits being payable.
Member cost sharing for certain services, as indicated in the plan, are excluded from charges to meet the Deductible.
Pharmacy expenses do not apply towards the Deductible.
The family Deductible is a cumulative Deductible for all family members. The family Deductible can be met by a
combination of family members; however, no single individual within the family will be subject to more than the
individual Deductible amount.
Member Coinsurance 20% 50%
Applies to all expenses unless otherwise stated.
Payment Limit (per calendar year) $5,000 Individual $10,000 Individual
$10,000 Family $30,000 Family
All covered expenses accumulate separately toward the in-network and out-of-network Payment Limit.
Certain member cost sharing elements may not apply toward the Payment Limit.
Pharmacy expenses apply towards the Payment Limit.
Only those out-of-pocket expenses resulting from the application of coinsurance percentage, copays, and deductibles
(except any penalty amounts) may be used to satisfy the Payment Limit.
The family Payment Limit is a cumulative Payment Limit for all family members. The family Payment Limit can be met
by a combination of family members; however, no single individual within the family will be subject to more than the
individual Payment Limit amount.
Lifetime Maximum
Unlimited except where otherwise indicated.
Payment for Out-of-Network Care** Not Applicable Professional: 90% of Medicare
Facility: 90% of Medicare
Primary Care Physician Selection Optional Not Applicable
Certification Requirements -
Certification for certain types of Out-of-Network care must be obtained to avoid a reduction in benefits paid for that
care. Certification for Hospital Admissions, Treatment Facility Admissions, Convalescent Facility Admissions, Home
Health Care, Hospice Care and Private Duty Nursing is required - excluded amount applied separately to each type of
expense is $400 per occurrence.
Referral Requirement None None
PREVENTIVE CARE IN-NETWORK OUT-OF-NETWORK
Routine Adult Physical Exams/ Covered 100%; deductible waived 50%; after deductible
Immunizations
1 exam every 12 months up to age 65, 1 exam every 12 months age 65 and older
Routine Well Child Exams Covered 100%; deductible waived 50%; after deductible
7 exams first 12 months, 3 exams 13th - 24th months, 3 exams 25th - 36th months, 1 exam per 12 months thereafter
to age 22.
Childhood Immunizations Covered 100%; deductible waived Covered 100%; deductible waived
The following immunizations will be covered 100% out-of-network for children to age 6: diphtheria; haemophilus
influenza type b, hepatitis B; measles; mumps; pertussis; polio; rubella; tetanus and varicella and any other
immunization that is required by law for the child.
Routine Gynecological Care Covered 100%; deductible waived 50%; after deductible
Exams
1 obgyn exam and pap smear per year
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Page 23 of 66
AOS
Proposed Effective Date: 08-01-2020
Open Access® Managed Choice® POS - Texas
TX20 OAMC 1500 80/50 RX1
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
Routine Mammograms Covered 100%; deductible waived 50%; after deductible
Women's Health Covered 100%; deductible waived 50%; after deductible
Includes: Screening for gestational diabetes, HPV (Human- Papillomavirus) DNA testing, counseling for sexually
transmitted infections, counseling and screening for human immunodeficiency virus, screening and counseling for
interpersonal and domestic violence, breastfeeding support, supplies and counseling.
Contraceptive methods, sterilization procedures, patient education and counseling. Limitations may apply.
Routine Digital Rectal Exam Covered 100%; deductible waived 50%; after deductible
Recommended: For covered males age 40 and over.
Prostate-specific Antigen Test Covered 100%; deductible waived 50%; after deductible
Recommended: For covered males age 40 and over.
Colorectal Cancer Screening Covered 100%; deductible waived Covered under Routine Adult Exams
Recommended: For all members age 45 and over.
Coverage includes the following: Annual fecal occult blood test, Digital rectal exam and a flexible sigmoidoscopy every
5 years, Digital rectal exam and a double contrast barium enema every 5 years, and Digital rectal exam and a
colonoscopy every 10 years.
Routine Eye Exams $50 copay; deductible waived 50%; after deductible
1 routine exam per 24 months.
Newborn Hearing Screening $50 copay; deductible waived 50%; deductible waived
1 in the first 30 days of life and follow-up diagnostic care until the age of 24 months
Routine Hearing Screening Covered 100%; deductible waived 50%; after deductible
PHYSICIAN SERVICES IN-NETWORK OUT-OF-NETWORK
Office Visits to PCP $30 copay; deductible waived 50%; after deductible
Includes services of an internist, general physician, family practitioner or pediatrician.
Specialist Office Visits $50 copay; deductible waived 50%; after deductible
Hearing Exams $50 copay; deductible waived 50%; after deductible
1 routine exam per 24 months.
Office Based Surgery 20%; after deductible 50%; after deductible
Pre-Natal Maternity Covered 100%; deductible waived 50%; after deductible
Walk-in Clinics $30 copay; deductible waived 50%; after deductible
Designated Walk-in Clinics
Covered 100%; deductible waived
Walk-in Clinics are free-standing health care facilities that (a) may be located in or with a pharmacy, drug store,
supermarket or other retail store; and (b) provide limited medical care and services on a scheduled or unscheduled
basis. Urgent care centers, emergency rooms, the outpatient department of a hospital, ambulatory surgical centers,
and physician offices are not considered to be Walk-in Clinics.
Allergy Testing Your cost sharing is based on the Your cost sharing is based on the
type of service and where it is type of service and where it is
performed performed
Allergy Injections Your cost sharing is based on the Your cost sharing is based on the
type of service and where it is type of service and where it is
performed performed
DIAGNOSTIC PROCEDURES IN-NETWORK OUT-OF-NETWORK
Diagnostic X-ray 20%; after deductible 50%; after deductible
If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the
applicable physician's office visit member cost sharing.
Diagnostic Laboratory 20%; after deductible 50%; after deductible
If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the
applicable physician's office visit member cost sharing.
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Page 24 of 66
AOS
Proposed Effective Date: 08-01-2020
Open Access® Managed Choice® POS - Texas
TX20 OAMC 1500 80/50 RX1
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
Diagnostic Outpatient Complex 20%; after deductible 50%; after deductible
Imaging
If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the
applicable physician's office visit member cost sharing.
EMERGENCY MEDICAL CARE IN-NETWORK OUT-OF-NETWORK
Urgent Care Provider $75 copay; deductible waived 50%; after deductible
Non-Urgent Use of Urgent Care Not Covered Not Covered
Provider
Emergency Room 20% after $300 copay; deductible Same as in-network care
waived
Copay waived if admitted
Non-Emergency Care in an Not Covered Not Covered
Emergency Room
Emergency Use of Ambulance 20%; after deductible Same as in-network care
Non-Emergency Use of Ambulance Not Covered Not Covered
HOSPITAL CARE IN-NETWORK OUT-OF-NETWORK
Inpatient Coverage 20%; after deductible 50%; after deductible
Your cost sharing applies to all covered benefits incurred during your inpatient stay.
Inpatient Maternity Coverage 20%; after deductible 50%; after deductible
(includes delivery and postpartum
care)
Your cost sharing applies to all covered benefits incurred during your inpatient stay.
Outpatient Hospital Expenses 20%; after deductible 50%; after deductible
Your cost sharing applies to all covered benefits incurred during your outpatient visit.
Outpatient Surgery - Hospital 20%; after deductible 50%; after deductible
Your cost sharing applies to all covered benefits incurred during your outpatient visit.
Outpatient Surgery - Freestanding 20%; after deductible 50%; after deductible
Facility
Your cost sharing applies to all covered benefits incurred during your outpatient visit.
MENTAL HEALTH SERVICES IN-NETWORK OUT-OF-NETWORK
Inpatient 20%; after deductible 50%; after deductible
Your cost sharing applies to all covered benefits incurred during your inpatient stay.
Crisis Stabilization Units/ 20%; after deductible 50%; after deductible
Residential Treatment Centers (for
children and adolescents)
Mental Health Office Visits $50 copay; deductible waived 50%; after deductible
Your cost sharing applies to all covered benefits incurred during your outpatient visit.
Other Mental Health Services 20%; after deductible 50%; after deductible
SUBSTANCE ABUSE IN-NETWORK OUT-OF-NETWORK
Inpatient 20%; after deductible 50%; after deductible
Your cost sharing applies to all covered benefits incurred during your inpatient stay.
Residential Treatment Facility 20%; after deductible 50%; after deductible
Substance Abuse Office Visits $50 copay; deductible waived 50%; after deductible
Your cost sharing applies to all covered benefits incurred during your outpatient visit.
Other Substance Abuse Services 20%; after deductible 50%; after deductible
OTHER SERVICES IN-NETWORK OUT-OF-NETWORK
Skilled Nursing Facility 20%; after deductible 50%; after deductible
Limited to 60 days per year
Your cost sharing applies to all covered benefits incurred during your inpatient stay.
Prepared: 06/18/2020 03:25 PM
Page 25 of 66
AOS
Proposed Effective Date: 08-01-2020
Open Access® Managed Choice® POS - Texas
TX20 OAMC 1500 80/50 RX1
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
Home Health Care 20%; after deductible 50%; after deductible
Limited to 60 visits per year
Private Duty Nursing not included.
Limited to 3 intermittent visits per day by a participating home health care agency; 1 visit equals a period of 4 hrs or
less.
Hospice Care - Inpatient 20%; after deductible 50%; after deductible
Your cost sharing applies to all covered benefits incurred during your inpatient stay.
Hospice Care - Outpatient 20%; after deductible 50%; after deductible
Your cost sharing applies to all covered benefits incurred during your outpatient visit.
Private Duty Nursing - Outpatient 20%; after deductible 50%; after deductible
Limited to 70 eight hour shifts per year.
Each period of private duty nursing of up to 8 hours will be deemed to be one private duty nursing shift.
Spinal Manipulation Therapy $50 copay; deductible waived 50%; after deductible
Limited to 20 visits per year
Outpatient Short-Term $50 copay; deductible waived 50%; after deductible
Rehabilitation
Limited to 30 visits per year.
Includes speech, physical, occupational therapy
Habilitative Services Cost sharing same as any other Cost sharing same as any other
(Physical/Occupational/Speech physical, occupational, speech physical, occupational, speech
Therapy) therapy expense. therapy expense.
Autism Behavioral Therapy $50 copay; deductible waived 50%; after deductible
Covered same as any other Outpatient Mental Health benefit
Autism Applied Behavior Analysis 20%; after deductible 50%; after deductible
Covered same as any other Outpatient Mental Health Other Services benefit
Autism Physical Therapy $50 copay; deductible waived 50%; after deductible
Autism Occupational Therapy $50 copay; deductible waived 50%; after deductible
Autism Speech Therapy $50 copay; deductible waived 50%; after deductible
Hearing Aids 20%; after deductible 50%; after deductible
Limited to:1 benefit maximum per ear for hearing aids every 3 years.
Durable Medical Equipment 20%; after deductible 50%; after deductible
Diabetic Supplies -- (if not covered Covered same as any other medical Covered same as any other medical
under Pharmacy benefit) expense. expense.
Prosthetics 20%; after deductible 50%; after deductible
Orthotics 20%; after deductible 50%; after deductible
Women's Contraceptive drugs and Covered 100%; deductible waived Covered same as any other expense.
devices not obtainable at a
pharmacy
Affordable Care Act mandated Covered 100%; deductible waived Covered same as any other expense.
Women's Contraceptives
Infusion Therapy 20%; after deductible 50%; after deductible
Administered in the home or
physician's office
Infusion Therapy 20%; after deductible 50%; after deductible
Administered in an outpatient hospital
department or freestanding facility
Vision Eyewear Not Covered Not Covered
Transplants 20%; after deductible 50%; after deductible
Preferred coverage is provided at an Non-Preferred coverage is provided
IOE contracted facility only. at a Non-IOE facility.
Prepared: 06/18/2020 03:25 PM
Page 26 of 66
AOS
Proposed Effective Date: 08-01-2020
Open Access® Managed Choice® POS - Texas
TX20 OAMC 1500 80/50 RX1
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
Bariatric Surgery Not Covered Not Covered
Out of Area Dependents Coverage provided at the non-preferred benefit level of the plan if in-network
provider is not available.
FAMILY PLANNING IN-NETWORK OUT-OF-NETWORK
Infertility Treatment Your cost sharing is based on the Your cost sharing is based on the
type of service and where it is type of service and where it is
performed performed
Diagnosis and treatment of the underlying medical condition only.
Comprehensive Infertility Services Not Covered Not Covered
Artificial insemination and ovulation induction
Advanced Reproductive Not Covered Not Covered
Technology (ART)
Vasectomy Your cost sharing is based on the 50%; after deductible
type of service and where it is
performed
Tubal Ligation Covered 100%; deductible waived 50%; after deductible
PHARMACY IN-NETWORK OUT-OF-NETWORK
Pharmacy Plan Type Advanced Control Plan - Aetna
Preferred Generic Drugs
Retail $15 copay 30% of submitted cost; after
applicable copay
Mail Order $37.50 copay 30% of submitted cost; after
applicable copay
Preferred Brand-Name Drugs
Retail $50 copay 30% of submitted cost; after
applicable copay
Mail Order $125 copay 30% of submitted cost; after
applicable copay
Non-Preferred Generic and Brand-Name Drugs
Retail $90 copay 30% of submitted cost; after
applicable copay
Mail Order $225 copay 30% of submitted cost; after
applicable copay
Specialty Drugs
Preferred Specialty $200 copay 30% of submitted cost; after
applicable copay
Non-Preferred Specialty $200 copay 30% of submitted cost; after
applicable copay
Pharmacy Day Supply and Requirements
Retail Up to a 30 day supply from Aetna National Network
For a 31-90 day supply you will be responsible for the Mail Order Drug copay.
Mail Order A 31-90 day supply from CVS Caremark® Mail Service Pharmacy
Specialty Up to a 30 day supply
Advanced Control Formulary Aetna Insured List
Choose Generics - If the member or the physician requests brand when generic is available, the member pays the
applicable copay plus the difference between the generic price and the brand price.
Plan Includes: Diabetic supplies and Contraceptive drugs and devices obtainable from a pharmacy.
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Page 27 of 66
AOS
Proposed Effective Date: 08-01-2020
Open Access® Managed Choice® POS - Texas
TX20 OAMC 1500 80/50 RX1
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
A limited list of over-the-counter medications are covered when filled with a prescription.
Oral chemotherapy drugs covered 100%
Precertification and quantity limits included
Step Therapy included
Seasonal Vaccinations covered 100% in-network
Preventive Vaccinations covered 100% in-network
Affordable Care Act mandated female contraceptives and preventive medications covered 100% in-network.
GENERAL PROVISIONS
Dependents Eligibility Spouse, children from birth to age 26 regardless of student status.
**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 we pay for your out-of-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.
• For doctors and other professionals the amount is based on what Medicare pays for these services. The government
sets the Medicare rate. Exactly how much we "recognize" depends on the plan you or your employer picks.
• For hospitals and other facilities, the amount is based on what Medicare pays for these services. The government
sets the Medicare rate. Exactly how much we "recognize" depends on the plan you or your employer picks.
Your doctor sets his or her own rate to charge you. It may be higher -- sometimes much higher -- than what your plan
"recognizes." Your doctor may bill you for the dollar amount that we don'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 our
website.
Plans are provided by: Aetna Life Insurance Company. 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.
See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan
features and availability may vary by location and are subject to change. You may be responsible for the health care
provider's full charges for any non-covered services, including circumstances where you have exceeded a benefit limit
contained in the plan. Providers are independent contractors and are not our agents. Provider participation may
change without notice. We do not provide care or guarantee access to health services.
If you are in a plan that requires the selection of a primary care physician and your primary care physician is part of an
integrated delivery system or physician group, your primary care physician will generally refer you to specialists and
hospitals that are affiliated with the delivery system or physician group.
The following is a list of services and supplies that are generally not covered. However, your plan documents may
contain exceptions to this list based on state mandates or the plan design or rider(s) purchased by your employer.
Prepared: 06/18/2020 03:25 PM
Page 28 of 66
AOS
Proposed Effective Date: 08-01-2020
Open Access® Managed Choice® POS - Texas
TX20 OAMC 1500 80/50 RX1
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
• All medical and hospital services not specifically covered in, or which are limited or excluded by your plan documents.
• Cosmetic surgery, including breast reduction.
• Custodial care.
• Dental care and dental X-rays.
• Donor egg retrieval
• Experimental and investigational procedures, except for coverage for medically necessary routine patient care costs
for members participating in a cancer clinical trial.
• Hearing aids
• Home births
• Immunizations for travel or work, except where medically necessary or indicated.
• Implantable drugs and certain injectable drugs including injectable infertility drugs.
• Infertility services, including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT,
ICSI and other related services, unless specifically listed as covered in your plan documents.
• Long-term rehabilitation therapy.
• Non-medically necessary services or supplies.
• Outpatient prescription drugs (except for treatment of diabetes), unless covered by a prescription plan rider and over-
the-counter medications (except as provided in a hospital) and supplies.
• Radial keratotomy or related procedures.
• Reversal of sterilization.
• Services for the treatment of sexual dysfunction/enhancement, including therapy, supplies or counseling or
prescription drugs.
• Special duty nursing.
• Therapy or rehabilitation other than those listed as covered.
• Weight control services including surgical procedures, medical treatments, weight control/loss programs, dietary
regimens and supplements, appetite suppressants and other medications; food or food supplements, exercise
programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or
treat obesity, including Morbid Obesity, or for the purpose of weight reduction, regardless of the existence of comorbid
conditions.
Aetna, or its affiliate(s), receives rebates from drug manufacturers that may be taken into account in determining
Aetna's Preferred Drug List. Rebates may reduce the amount a member pays the pharmacy for covered prescriptions.
CVS Caremark ® Mail Service Pharmacy refers to CVS Caremark ® Mail Service Pharmacy, a licensed pharmacy
subsidiary of Aetna Inc., that operates through mail order. The charges that Aetna negotiates with CVS Caremark ®
Mail Service Pharmacy may be higher than the cost they 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 takes into account discounts,
credits and other amounts that they may receive from wholesalers, manufacturers, suppliers and distributors.
In case of emergency, call 911 or your local emergency hotline, or go directly to an emergency care facility.
Translation of the material into another language may be available. Please call Member Services at 1-888-982-3862.
Puede estar disponible la traduccion de este material en otro idioma. Por favor llame a Servicios al Miembro al 1-888-
982-3862.
Plan features and availability may vary by location and group size.
For more information about Aetna plans, refer to www.aetna.com.
Aetna and MinuteClinic, LLC (which either operates or provides certain management support services to MinuteClinic-
branded walk-in clinics) are both within the CVS Health family.
© 2014 Aetna Inc.
Prepared: 06/18/2020 03:25 PM
Page 29 of 66
7/3/19 5v 8 Dev Dental Benefits Summary AOS, Inc.
Effective Date: 08-01-2020
PPO Core Plan
Passive PDN
With PDNII Network
Annual Deductible* $50
Individual $150
Family 100%
80%
Preventive Services 50%
Basic Services $1,250
Major Services N/A
Annual Benefit Maximum Not Covered
Office Visit Copay Not Covered
Orthodontic Services Not Covered
Orthodontic Deductible
Orthodontic Lifetime Maximum
*The deductible applies to: Basic & Major services only
Partial List of Services Passive PDN
With PDNII Network
Preventive
Oral examinations (a) 100%
Cleanings (a) Adult/Child 100%
Fluoride (a) 100%
Sealants (permanent molars only) (a) 100%
Bitewing Images (a) 100%
Full mouth series Images (a) 100%
Space Maintainers 100%
Basic 80%
Root canal therapy 80%
Anterior teeth / Bicuspid teeth 80%
Root canal therapy, molar teeth 80%
Scaling and root planing (a) 80%
Gingivectomy (a)* 80%
Amalgam (silver) fillings 80%
Composite fillings (anterior teeth only) 80%
Stainless steel crowns 80%
Incision and drainage of abscess* 80%
Uncomplicated extractions 80%
Surgical removal of erupted tooth* 80%
Surgical removal of impacted tooth (soft tissue)* 80%
Osseous surgery (a)* 80%
Surgical removal of impacted tooth (partial bony/ full bony)* 80%
General anesthesia/intravenous sedation*
Crown Lengthening 50%
50%
Major 50%
Inlays 50%
Onlays 50%
Crowns 50%
Full & partial dentures 50%
Pontics 50%
Denture repairs
Crown Build-Ups
Implants
*Certain services may be covered under the Medical Plan. Contact Member Services for more details.
(a) Frequency and/or age limitations may apply to these services. These limits are described in the booklet/certificate.
#Proprietary PagePa3ge0: 1of 66 Prepared: 03/03/2020 12:56 PM
7/3/19 5v 8 Dev Dental Benefits Summary AOS, Inc.
Effective Date: 08-01-2020
PPO Enhanced Plan
Passive PDN
With PDNII Network
Annual Deductible* $50
Individual $150
Family 100%
80%
Preventive Services 50%
Basic Services $2,000
Major Services N/A
Annual Benefit Maximum 50%
Office Visit Copay None
Orthodontic Services (Adult and Child) $1,000
Orthodontic Deductible
Orthodontic Lifetime Maximum
*The deductible applies to: Basic & Major services only
Partial List of Services Passive PDN
With PDNII Network
Preventive
Oral examinations (a) 100%
Cleanings (a) Adult/Child 100%
Fluoride (a) 100%
Sealants (permanent molars only) (a) 100%
Bitewing Images (a) 100%
Full mouth series Images (a) 100%
Space Maintainers 100%
Basic 80%
Root canal therapy 80%
Anterior teeth / Bicuspid teeth 80%
Root canal therapy, molar teeth 80%
Scaling and root planing (a) 80%
Gingivectomy (a)* 80%
Amalgam (silver) fillings 80%
Composite fillings (anterior teeth only) 80%
Stainless steel crowns 80%
Incision and drainage of abscess* 80%
Uncomplicated extractions 80%
Surgical removal of erupted tooth* 80%
Surgical removal of impacted tooth (soft tissue)* 80%
Osseous surgery (a)* 80%
Surgical removal of impacted tooth (partial bony/ full bony)* 80%
General anesthesia/intravenous sedation*
Crown Lengthening 50%
50%
Major 50%
Inlays 50%
Onlays 50%
Crowns 50%
Full & partial dentures 50%
Pontics 50%
Denture repairs
Crown Build-Ups
Implants
*Certain services may be covered under the Medical Plan. Contact Member Services for more details.
(a) Frequency and/or age limitations may apply to these services. These limits are described in the booklet/certificate.
#Proprietary PagePa3ge1: 1of 66 Prepared: 03/03/2020 12:56 PM
BASE PLAN
Aetna VisionSM Preferred
Effective Date: 08-01-2020 www.aetnavision.com Out of Network*
Plan 56(a) External Plan ID 1005417108
Line Value 794 Summary of Benefits for AOS, Inc. $25 Reimbursement
12 12 24 Not Covered
In Network Not Covered
Exam with Dilation as Necessary Aetna Vision Network $10 Reimbursement
Use your Exam coverage once every rolling 12 months $25 Reimbursement
$55 Reimbursement
Routine/Comprehensive Eye Exam $10 Copay $55 Reimbursement
$25 Reimbursement
Standard Contact Lens Fit/Follow-Up Member pays discounted fee of $40
$25 Reimbursement
Premium Contact Lens Fit/Follow-Up Member pays 90% of retail
Eyeglass Lenses / Lens options
Use your Lens coverage once every rolling 12 months to purchase either 1 pair of eyeglass lenses OR 1 order of contact lenses
Standard Plastic Single Vision Lenses $25 Copay
Standard Plastic Bifocal Vision Lenses $25 Copay
Standard Plastic Trifocal Vision Lenses $25 Copay
Standard Plastic Lenticular Vision Lenses $25 Copay
Standard Progressive Vision Lenses $90 Copay
Premium Progressive Vision Lenses¹ 20% Discount off retail minus $120 plan allowance plus $90 copay =
member out-of-pocket
UV Treatment Member pays discounted fee of $15 Not Covered
Tint (Solid And Gradient) Member pays discounted fee of $15 Not Covered
Standard Plastic Scratch Coating $15 Reimbursement
Standard Polycarbonate Lenses - Adult $0 Copay Not Covered
Member pays discounted fee of $40
Standard Polycarbonate Lenses - Children To Age 19 $0 Copay $35 Reimbursement
Standard Anti-Reflective Coating Member pays discounted fee of $45 Not Covered
Polarized And Other Lens Add Ons Member pays 80% of retail Not Covered
$90 Reimbursement
Contact Lenses
Use your Lens coverage once every rolling 12 months to purchase either 1 pair of eyeglass lenses OR 1 order of contact lenses
Conventional Contact Lenses $120 Allowance**
Additional 20% off balance over allowance
Disposable Contact Lenses $120 Allowance $96 Reimbursement
Medically Necessary Contact Lenses $0 Copay $210 Reimbursement
Frames
Use your frame coverage once every rolling 24 months
Any Frame available, including frames for prescription $120 Allowance** $65 Reimbursement
sunglasses Additional 20% off balance over allowance
Rates - See detailed rate information on page 2
Employee Only $5.60
Employee + Spouse $10.65
Employee + Child(ren) $11.21
Employee + Family $16.46
In Network Discounts Up to a 40% Discount
20% Discount
Additional pairs of eyeglasses or prescription
sunglasses2 15% discount off retail or 5% discount off the promotional price
Non-covered items3 Member pays a discounted fee up to $39
Lasik Laser vision correction or PRK from U.S. Laser
Network4 only. Call 1-800-422-6600
Retinal Imaging5
version 04-15-20 Date Printed: 06-15-2020
P# roprietary
Page 32 of 66
Enhanced Plan
Aetna VisionSM Preferred
Effective Date: 08-01-2020 www.aetnavision.com Out of Network*
Plan 34(a) E External Plan ID 1005418109
Line Value 810 Summary of Benefits for AOS, Inc.
12 12 24
In Network
Exam with Dilation as Necessary Aetna Vision Network $32 Reimbursement
Use your Exam coverage once every rolling 12 months Not Covered
Routine/Comprehensive Eye Exam $10 Copay Not Covered
Member pays discounted fee of $40
Standard Contact Lens Fit/Follow-Up $10 Reimbursement
$25 Reimbursement
Premium Contact Lens Fit/Follow-Up Member pays 90% of retail $55 Reimbursement
$55 Reimbursement
Eyeglass Lenses / Lens options $25 Reimbursement
Use your Lens coverage once every rolling 12 months to purchase either 1 pair of eyeglass lenses OR 1 order of contact lenses $25 Reimbursement
Standard Plastic Single Vision Lenses $25 Copay $25 Reimbursement
Standard Plastic Bifocal Vision Lenses $25 Copay Not Covered
Not Covered
Standard Plastic Trifocal Vision Lenses $25 Copay $15 Reimbursement
Not Covered
Standard Plastic Lenticular Vision Lenses $25 Copay $35 Reimbursement
Standard Progressive Vision Lenses $90 Copay
Premium Progressive Vision Lenses¹ Tier 1 = $85 Copay
(Member pays bifocal copay plus tier amount based on Tier 2 = $95 Copay
brand) Tier 3 = $110 Copay
Other Premium Progressive Lenses1 20% Discount off retail minus $120 plan allowance plus $90 Copay =
member out-of-pocket
UV Treatment Member pays discounted fee of $15
Tint (Solid And Gradient) Member pays discounted fee of $15
Standard Plastic Scratch Coating
Standard Polycarbonate Lenses - Adult $0 Copay
Member pays discounted fee of $40
Standard Polycarbonate Lenses - Children To Age 19 $0 Copay
Standard Anti-Reflective Coating Member pays discounted fee of $45 Not Covered
Not Covered
Premium Anti-Reflective Coating1 Tier 1 = $57 Copay
(Tier amount based on brand) Tier 2 = $68 Copay
Tier 3 = 20% discount off retail
Photochromic/Transitions Plastic Member pays discounted fee of $75 Not Covered
Polarized And Other Lens Add Ons Member pays 80% of retail Not Covered
$90 Reimbursement
Contact Lenses
Use your Lens coverage once every rolling 12 months to purchase either 1 pair of eyeglass lenses OR 1 order of contact lenses
Conventional Contact Lenses $130 Allowance**
Additional 15% off balance over allowance
Disposable Contact Lenses $130 Allowance $104 Reimbursement
Medically Necessary Contact Lenses $0 Copay $200 Reimbursement
Frames
Use your frame coverage once every rolling 24 months
Any Frame available, including frames for prescription $130 Allowance** $90 Reimbursement
sunglasses Additional 20% off balance over allowance
Rates - See detailed rate information on page 2
Employee Only $6.30
Employee + Spouse $11.97
Employee + Child(ren) $12.60
Employee + Family $18.53
In Network Discounts Up to a 40% Discount
20% Discount
Additional pairs of eyeglasses or prescription
sunglasses2 15% discount off retail or 5% discount off the promotional price
Non-covered items3 Member pays a discounted fee up to $39
Lasik Laser vision correction or PRK from U.S. Laser
Network4 only. Call 1-800-422-6600
Retinal Imaging5
version 04-15-20 Date Printed: 06-15-2020
P# roprietary
Page 33 of 66
Highlights of the Aetna Accident Plan
The Aetna Accident Plan pays benefits for injuries related to an accident that happens when you aren’t at work.
The plan pays benefits for a long list of minor to serious injuries, including loss of life, resulting from an accident.
You can choose from two available plans. Below are just a few of the available benefits. Limits apply to the
number of benefits payable per member during a plan year as outlined in the benefit summary included in your
enrollment materials. For more details, including exclusions and limitations, review your benefit summary.
Aetna Accident Plan Benefits High Plan
Ground ambulance $300
Air ambulance
$1,500
Initial treatment — emergency room, hospital, physician’s
office or urgent care $150
X-ray/Lab $50
Accident follow-up— physician’s office or urgent care $50
Physical Therapy services $25
Aetna Accident Plan Hospital benefits* High Plan
Hospital admission $1,000
Intensive Care Unit (ICU) admission $2,000
Hospital daily** $200
ICU daily** $400
Step down ICU daily** $300
Rehabilitation Unit daily (30 day maximum per plan year) $100
Observation Unit $100
*Hospital benefits must be related to a covered accident.
**Important Note: All daily inpatient stay benefits begin on day two and count toward the plan year maximum of 365
combined days for all inpatient hospital stays.
Aetna Accident Surgical benefits* High Plan
Surgery (with repair) — $1,500
cranial, open abdominal and thoracic $250
hernia $750
ruptured disk / torn knee cartilage $750 - $1,500
tendon, ligament, rotator cuff
$150
Surgery (with no repair) — exploratory or arthroscopic
*Surgical benefits must be related to a covered accident.
©2019 Aetna Inc. Page 34 of 66
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More Highlights of the Aetna Accident Plan
Aetna Accident Plan benefits High Plan
Dislocations (range for closed – open) $150 - $3,000 closed /
$300 - $6,000 open
Fractures (range for closed – open) $225- $4,125 closed /
$500 - $8,250 open
Accidental death*/ Accidental death common carrier* $50,000 / $100,000
Accidental dismemberment (range)
Paralysis (range) $500 - $10,000
Brain Injury $2,500 - $10,000
Concussion/mild to moderate brain injury $150
Moderate/severe brain injury $450
Animal bite treatment (range) $100 - $300
Burn (2nd & 3rd degree - range) $1,000 - $18,000
Service Dog $1,500
*Covered dependent benefit is 50% of the employee benefit amount for an accidental death.
Premium Waiver- Inpatient sickness rider
Your premium will be waived if you miss 30 continuous days of work as the result of a covered accident. The premium waiver
does not apply to your covered dependents.
Accident Rates Employee Employee & Spouse Employee & Family
Children
Plan Option
High Plan $8.99 $15.46 $20.07 $25.87
©2019 Aetna Inc. Page 35 of 66
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Highlights of the Aetna Critical Illness Plan
The Aetna Critical Illness plan pays benefits when you are diagnosed with a critical illness, including cancer and
other conditions/illnesses. You have two options to choose from. Rates are based on your current age but will
increase as you move into a higher age-band. Rates are also based on your tobacco usage. Below are some of
the available benefits. If you enroll your eligible dependents, their available benefits will be based on 50% of your
available benefits. For more details, including exclusions and limitations that apply, review your benefit summary.
Insured Low Plan High Plan
Face Amount Face Amount
Employee
Spouse and Child(ren) (50% of employee face amount) $10,000 $20,000
$5,000 $10,000
Aetna Critical Illness Plan Low Plan High Plan Benefits related to a critical
illness
Heart attack (myocardial infarction) $10,000 $20,000 Covered at 100% of face amount
$20,000 Covered at 100% of face amount
Stroke $10,000
$2,500 $5,000 Covered at 25% of face amount
Coronary artery condition requiring bypass $10,000
surgery $20,000 Covered at 100% of face amount
Major organ failure $20,000 Covered at 100% of face amount
$20,000 Covered at 100% of face amount
Third degree burns $10,000 $20,000 Covered at 100% of face amount
$20,000 Covered at 100% of face amount
Coma $10,000
$5,000 Covered at 25% of face amount
Loss of hearing, sight, speech $10,000
Paralysis $10,000
Alzheimer’s disease, lupus, muscular dystrophy, $2,500
multiple sclerosis, Parkinson’s disease
Subsequent critical illness diagnosis benefit* $10,000 $20,000 Covered at 100% of face amount
(Diagnosis of a different Critical Illness) $5,000 $10,000 Covered at 50% of face amount
Recurrence critical illness diagnosis benefit*
(Diagnosis of the same Critical Illness)
*Subsequent or recurrence diagnosis must occur at least 180 days after initial diagnosis.
Cancer benefits* Low Plan High Plan Benefits related to cancer
Cancer (invasive) $10,000 $20,000 Covered at 100% of face amount
Carcinoma in situ (non-invasive) $2,500 $5,000 Covered at 25% of face amount
$1,000 Lump sum benefit paid once per
Skin cancer $1,000 lifetime
$10,000
Recurrence (invasive) cancer or carcinoma in situ $5,000 Covered at 50% of face amount
(non-invasive) diagnosis) benefit*
*Recurrence diagnosis must occur at least 180 days after initial diagnosis.
©2019 Aetna Inc. Page 36 of 66
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Critical Illness Non-Tobacco Rates
Critical Illness Tobacco Rates
Get rewarded for taking better care of your health
Health screening benefit – Pays a benefit of $50 annually per member for all covered members of the Critical
Illness plan for specific preventive health screening tests. See complete listing in your benefit summary.
©2019 Aetna Inc. Page 37 of 66
57.02.417.1 (7/18)
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We make it simple
If you’re eligible to enroll and apply for coverage, your acceptance is guaranteed. We don’t ask you any
questions about your health. Cash benefits are paid directly to you and are not reduced by other insurance
benefits you may have. And there’s more:
• You get access to negotiated group rates.
• You’ll enjoy the convenience of payroll deduction to pay premiums.
• If you leave your company, you can take your plan with you.
Filing a claim couldn’t be easier
After you become a member, you can review your benefits and file claims on our member portal at
myaetnasupplemental.com. Aetna medical members can also access the site from aetna.com. If you’re an
Aetna medical plan member, you don’t typically need to provide medical paperwork to process a claim. Not
an Aetna medical plan member? No problem. Just fill out the online form and upload your medical
paperwork.
THIS PLAN DOES NOT COUNT AS MINIMUM ESSENTIAL COVERAGE UNDER THE
AFFORDABLE CARE ACT.THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS
NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE.
This plan provides limited benefits. It pays fixed dollar benefits for covered services without regard to the health care
provider’s actual charges. The benefits payments are not intended to cover the full cost of medical care. You are
responsible for making sure the provider’s bills get paid. These benefits are paid in addition to any other health coverage
you may have.
This material is for information only. Insurance plans contain exclusions and limitations. Not all health services are covered,
and coverage is subject to applicable laws and regulations, including economic and trade sanctions. See plan documents
for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features, rates, eligibility and
availability may vary by location and are subject to change. Providers are independent contractors and are not agents of
Aetna. Aetna does not provide care or guarantee access to health services. Health information programs provide general
health information and are not a substitute for diagnosis or treatment by a physician or other health care professional.
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 aetna.com.
Accident Plan Policy form numbers issued in Oklahoma include: GR-96841, GR-96842.
Accident Plan Policy form numbers issued in Idaho include: GR-96841.
Accident Policy form numbers issued in Missouri include: GR-96841 01, GR-96842 01.
Critical Illness Policy form numbers issued in Oklahoma include: GR-96843, GR-96844.
Critical Illness Policy form numbers issued in Idaho include: GR-96843.
Critical Illness Policy form numbers issued in Missouri include: GR-96844 01.
©2019 Aetna Inc. Page 38 of 66
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Accident Plan Exclusions and Limitations
This plan has exclusions and limitations. Refer to the actual policy and certificate to determine which benefits are not
payable. The following is a partial list of services and supplies that are generally not covered. However, the plan may
contain exceptions to this list based on state mandates or the plan design purchased.
Benefits under the policy will not be payable for any care, service or supply for an accidental injury related to the
following:
1. Certain competitive or recreational activities, including but not limited to: ballooning, bungee jumping, parachuting,
skydiving;
2. Any semi-professional or professional competitive athletic contest, including officiating or coaching, for which you
receive any payment;
3. Act of war, riot, war;
4. Operating, learning to operate or serving as a pilot or crew member of any aircraft, whether motorized or not;
5. Assault, felony, illegal occupation, or other criminal act;
6. Bacterial infections that are not caused by a cut or wound from an accidental injury;
7. Care provided by immediate family members or any household member;
8. Elective or cosmetic surgery;
9. Nutritional supplements;
10. Suicide or attempt at suicide, intentionally self-inflicted injury, or any attempt at self-inflicted injury, or any form of
intentional asphyxiation, except when resulting from a diagnosed disorder;
11. Violating any cellular device use laws of the state in which the accident occurred, while operating a motor vehicle;
12. Accidental injury sustained while intoxicated or under the influence of any drug intoxicant, including those
prescribed by a physician that are misused;
13. Occupational injuries
We will not pay any benefits for a service or supply rendered or received that are not specifically covered or not related
to an accidental injury.
The stay, visit or service must be on or after the effective date of coverage, while coverage is in force and take place in
the United States or its territories.
Critical Illness Plan Exclusions and Limitations
This plan has exclusions and limitations. Refer to the actual booklet certificate and schedule of benefits to determine
which 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 may contain exceptions to this list based on state mandates or the plan design
purchased.
Benefits under the Policy will not be payable for any critical illness, cancer (invasive), carcinoma in situ or skin cancer that
is diagnosed or for which care was received outside the United States and its territories, or for any loss caused in whole
or in part by or resulting in whole or part from the following:
1. Suicide or attempt at suicide, intentional self-inflicted injury or sickness, any attempt at intentional self-inflicted injury,
injury caused by a self-inflicted act or sickness, while sane or insane; except when resulting from a diagnosed disorder in
the most current version of the Diagnostic and Statistical Manual (DSM);
2. Being under the influence of a stimulant (such as amphetamines or pitrates), depressant, hallucinogen, narcotic or
any other drug intoxicant, including those prescribed by a physician that are misused by the insured person; except
when resulting from a diagnosed disorder in the most current version of the DSM;
3. Engaging in an assault, felony, illegal occupation or other criminal act;
4. Any act of war, whether declared or not, or voluntary participation in a riot, rebellion or civil insurrection.
not covered.
©2019 Aetna Inc. Page 39 of 66
57.02.417.1 (7/18)
Proprietary
GROUP SHORT-TERM DISABILITY INSURANCE
HIGHLIGHTS– Class 1 (Earnings are less than $40,000)
In the U.S., a disabling AOS, Inc.
injury occurs every
second.1 A disability can happen to anyone. A back injury, pregnancy, or serious illness can lead to months
without a regular paycheck. If you’re unable to work for a short period of time due to a non-work-
related condition, illness or injury, short-term disability insurance offers financial protection by
paying you a portion of your earnings.
To learn more about Short-Term Disability insurance, visit
thehartford.com/employeebenefits
COVERAGE INFORMATION
COVERAGE BENEFIT MAXIMUM SICKNESS INJURY BENEFIT BENEFIT
LEVEL PERCENTAGE $300 BENEFIT STARTS DURATION
STARTS
Core (PERCENT OF YOUR EARNINGS) On the 15th day 11 weeks
On the 15th day
40%
On the 15th day
Buy-Up 50% $385 On the 15th day 11 weeks
PREMIUMS
See the Premium Worksheet.2
ASKED & ANSWERED
WHO IS ELIGIBLE?
You are eligible if you are an active full time employee whose annual earnings are less than $40,000 and work at least 30 hours per week on a
regularly scheduled basis.
AM I GUARANTEED COVERAGE?
This insurance is guaranteed issue coverage – it is available without having to provide information about your health. If you are a late entrant,
evidence of insurability is required for the full coverage amount.
HOW MUCH DOES IT COST AND HOW DO I PAY FOR THIS INSURANCE?
Premium is provided on the Premium Worksheet.
Premium will be automatically paid through payroll deduction, as authorized by you during the enrollment process. This ensures you don’t have
to worry about writing a check or missing a payment.
WHEN CAN I ENROLL?
Your employer will automatically enroll you for core coverage.
You may enroll in buy-up coverage during any scheduled enrollment period, within 31 days of the date you have a change in family status, or
within 31 days of the completion of any eligibility waiting period established by your employer.
WHEN DOES THIS INSURANCE BEGIN?
Subject to any eligibility waiting period established by your employer, insurance will become effective in accordance with the terms of the
certificate (usually the first day of the month following the date you elect coverage).
You must be actively at work with your employer on the day your coverage takes effect.
WHEN DOES THIS INSURANCE END?
This insurance will end when you no longer satisfy the applicable eligibility conditions, premium is unpaid, you leave your employer, or the
coverage is no longer offered.
Page 40 of 66
WHAT DOES IT MEAN TO BE DISABLED?
Disability is defined in The Hartford’s certificate with your employer. Due to accidental bodily injury, sickness, mental illness, substance abuse
or pregnancy you are unable to perform the essential duties of your occupation, and as a result, you are earning 20% or less of your pre-
disability weekly earnings or you are able to perform some, but not all, of the essential duties of your occupation and as a result, you are
earning more than 20% but less than 80% (standard) of your pre-disability weekly earnings.
Pre-disability earnings are defined in your policy.
1Injury Facts. National Safety Council. 2015 Edition. P. 37. Web. 30 June 2017.
2Rates and/or benefits may be changed.
Prepare. Protect. Prevail. With The Hartford. ®
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Home Office is Hartford,
CT. 5962e NS 08/16 © 2016 The Hartford Financial Services Group, Inc. All rights reserved.
This Benefit Highlights document explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this document and the
policy, the terms of the policy apply. Benefits are subject to state availability. Policy terms and conditions vary by state. Complete details are in the Certificate of Insurance issued to each insured individual
and the Master Policy as issued to the policyholder. The Hartford compensates both internal and external producers, as well as others, for the sale and service of our products. For additional information regarding
Hartford’s compensation practices, please review our website http://thehartford.com/group-benefits-producer-compensation. Disability Form Series includes GBD-1000, GBD-1200, or state equivalent.
Page 41 of 66
GROUP LONG-TERM DISABILITY INSURANCE
HIGHLIGHTS – Class 1 (Earnings are less than $40,000)
AOS, Inc.
A disability can happen to anyone. Long-term disability insurance helps protect your
paycheck if you’re unable to work for a long period of time after a serious condition, injury
or sickness.
To learn more about Long-Term Disability insurance,
visit thehartford.com/employeebenefits
Just over 1 in 4 of
today’s 20 year-olds will
become disabled before
they retire (age 67).1
COVERAGE INFORMATION
COVERAGE BENEFIT MAXIMUM MINIMUM BENEFIT BENEFIT DURATION
LEVEL PERCENTAGE STARTS
(BASED ON MONTHLY Disabled before: Age 63
(PERCENT OF YOUR INCOME LOSS BEFORE (ELIMINATION Benefit duration: As long as you are disabled
EARNINGS) THE DEDUCTION OF PERIOD) Benefit duration maximum: The greater of
OTHER INCOME BENEFITS) your Social Security Normal Retirement Age
or 4 years
Core 40% $6,000 Disabled before: Age 63
$7,300 Benefit duration: As long as you are disabled
The greater of $100 or 10% of After 90 days Benefit duration maximum: The greater of
the benefit disabled your Social Security Normal Retirement Age
or 4 years
Buy-Up 50%
PREMIUMS
See the Premium Worksheet.2
ASKED & ANSWERED
WHO IS ELIGIBLE?
You are eligible if you are an active full time employee whose annual earnings are less than $40,000 and work at least 30 hours per week on
a regularly scheduled basis.
AM I GUARANTEED COVERAGE?
If this is the first time you are eligible to elect coverage, evidence of insurability is not required.
If you did not elect coverage the first time it was offered to you, evidence of insurability is required to elect coverage. 2
This coverage is subject to a pre-existing condition exclusion, which is detailed on the Limitations & Exclusions sheet.
HOW MUCH DOES IT COST AND HOW DO I PAY FOR THIS INSURANCE?
Premium is provided on the Premium Worksheet.
Premiums will be automatically paid through payroll deduction, as authorized by you during the enrollment process. This ensures you don’t
have to worry about writing a check or missing a payment.
WHEN CAN I ENROLL?
Your employer will automatically enroll you for core coverage.
You may enroll in buy-up coverage during any scheduled enrollment period, or within 31 days of the date you have a change in family status.
Page 42 of 66
WHEN DOES THIS INSURANCE BEGIN?
Insurance will become effective in accordance with the terms of the certificate (usually the first day of the month following the date you elect
coverage).
You must be actively at work with your employer on the day your coverage takes effect.
WHEN DOES THIS INSURANCE END?
This insurance will end when you no longer satisfy the applicable eligibility conditions, premium is unpaid, you leave your employer, or the
coverage is no longer offered.
WHAT DOES IT MEAN TO BE DISABLED?
Disability is defined in The Hartford’s certificate with your employer.
Typically, disability means that you cannot perform one or more of the essential duties of your occupation due to injury, sickness, pregnancy
or other medical condition covered by the insurance, and as a result, your current monthly earnings are less than 80% of your pre-disability
earnings. Once you have been disabled for 2 years following the elimination period, you must be prevented from performing one or more of
the essential duties of any occupation and as a result, your current monthly earnings are less than or equal to 60% of your pre-disability
earnings.
Pre-disability earnings are defined in your policy.
1U.S. Social Security Administration Fact Sheet. Web. 30 June 2017 https://www.ssa.gov/news/press/factsheets/basicfact-alt.pdf
2Rates and/or benefits may be changed.
3The Long Term Disability policy contains a Pre-Existing Condition Exclusion. Please refer to the certificate for more information on exclusions and limitations, such as Pre-Existing Conditions.
Prepare. Protect. Prevail. With The Hartford. ®
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Home Office is
Hartford, CT. 5962e NS 08/16 © 2016 The Hartford Financial Services Group, Inc. All rights reserved.
This Benefit Highlights document explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this document and the
policy, the terms of the policy apply. Benefits are subject to state availability. Policy terms and conditions vary by state. Complete details are in the Certificate of Insurance issued to each insured individual
and the Master Policy as issued to the policyholder. The Hartford compensates both internal and external producers, as well as others, for the sale and service of our products. For additional information regarding
Hartford’s compensation practices, please review our website http://thehartford.com/group-benefits-producer-compensation. Disability Form Series includes GBD-1000, GBD-1200, or state equivalent.
Page 43 of 66
Premium Worksheet Class 1 (Earnings less than $40,000)
Rates and/or benefits can change.
VOLUNTARY SHORT TERM DISABILITY INSURANCE
Bi-weekly Premium Amount (Cost per Pay Period – 26/Year)QQ2
To calculate your bi-weekly premium amount, use the following formula.
÷ 52 = x 50% = ÷ 10 = x $0.3231 =
Rate Premium Amount
Your Annual Your Weekly Weekly Benefit Max
Earnings Earnings = $385
5962e NS 08/16 © 2016.The Hartford Financial Services Group, Inc. All rights reserved. Disability Form Series includes GBD-1000, GBD-1200, or state equivalent.
VOLUNTARY LONG TERM DISABILITY INSURANCE
Bi-weekly Premium Amount (Cost per Pay Period – 26/Year)QQ5.2
To calculate your bi-weekly premium amount, use the following formula.
÷ 12 = ÷ 100 = x $0.0508 =
Rate Premium Amount
Your Annual Earnings Your Monthly Earnings
Maximum = $175,200
5962e NS 08/16 © 2016.The Hartford Financial Services Group, Inc. All rights reserved. Disability Form Series includes GBD-1000, GBD-1200, or state equivalent.
Prepare. Protect. Prevail. With The Hartford. ®
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Home Office is Hartford, CT.
This document explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this document and the policy, the terms of the policy
apply. Benefits are subject to state availability. Policy terms and conditions vary by state. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy as issued to the
policyholder.
PAGE 1 OF 1 CREATION DATE: 8/7/2019
AOS IQOR GLOBAL SERVICES, INC./00097926
Page 44 of 66
BASIC TERM LIFE and ACCIDENTAL DEATH & DISMEMBERMENT
INSURANCE HIGHLIGHTS – Class 1 (Earnings are less than $40,000)
Approximately 50 million AOS, Inc.
households recognize
they need more life The group term Life and Accidental Death and Dismemberment (AD&D) insurance
available through your employer gives extra protection that you and your family may
insurance (40 percent of need. Life and AD&D insurance offers financial protection by providing you coverage in
households).1 case of an untimely death or an accident that destroys your income-earning ability. Life
benefits are disbursed to your beneficiaries in a lump sum in the event of your death.
To learn more about Life and AD&D insurance,
visit thehartford.com/employeebenefits
COVERAGE INFORMATION
APPLICANT LIFE COVERAGE AD&D COVERAGE
AD&D: Included
Employee Benefit2: 1 times earnings
Maximum: $40,000
AD&D BENEFITS – PERCENT OF COVERAGE AMOUNT PER ACCIDENT
Covered accidents or death can occur up to 365 days after the accident. The total benefit for all losses due to the same accident will not
exceed 100% of your coverage amount.
LOSS FROM ACCIDENT COVERAGE
Life 100%
Both Hands or Both Feet or Sight of Both Eyes 100%
One Hand and One Foot 100%
Speech and Hearing in Both Ears 100%
Either Hand or Foot and Sight of One Eye 100%
Movement of Both Upper and Lower Limbs (Quadriplegia) 100%
Movement of Both Lower Limbs (Paraplegia) 75%
Movement of Three Limbs (Triplegia) 75%
Movement of the Upper and Lower Limbs of One Side of the Body (Hemiplegia) 50%
Either Hand or Foot 50%
Sight of One Eye 50%
Speech or Hearing in Both Ears 50%
Movement of One Limb (Uniplegia) 25%
Thumb and Index Finger of Either Hand 25%
PREMIUMS
Your employer pays 100% of the premium for your coverage.3
ASKED & ANSWERED
WHO IS ELIGIBLE?
You are eligible if you are an active full time employee whose annual earnings are less than $40,000 and work at least 30 hours per
week on a regularly scheduled basis.
2
Page 45 of 66
AM I GUARANTEED COVERAGE?
This insurance is guaranteed issue coverage - it is available without having to provide information about your health.
AD&D is available without having to provide information about your health.
HOW MUCH DOES IT COST AND HOW DO I PAY FOR THIS INSURANCE?
Your employer pays 100% of the premium for your (employee) coverage.2
WHEN CAN I ENROLL?
Your employer will automatically enroll you for this coverage. If you have not already done so, you must designate a beneficiary.
WHEN DOES THIS INSURANCE BEGIN?
This insurance will become effective for you on the date you become eligible.
You must be actively at work with your employer on the day your coverage takes effect.
WHEN DOES THIS INSURANCE END?
This insurance will end when you no longer satisfy the applicable eligibility conditions, premium is unpaid, you are no longer are
actively working, you leave your employer, or the coverage is no longer offered.
CAN I KEEP THIS INSURANCE IF I LEAVE MY EMPLOYER OR AM NO LONGER A MEMBER OF THIS GROUP?
Yes, you can take this life coverage with you. Coverage may be continued for you under a group portability certificate or an
individual conversion life certificate. The specific terms and qualifying events for conversion and portability are described in the
certificate. Conversion and portability are not available for AD&D coverage.
1LIMRA, Facts About Life 2016. Web. 30 June 2017. <https://www.limra.com/uploadedFiles/limra.com/LIMRA_Root/Posts/PR/_Media/PDFs/Facts-of-Life-
2016.pdf> 3Rates and/or benefits may be changed.
Prepare. Protect. Prevail. With The Hartford. ®
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Home Office is Hartford,
CT. 5962a and 5962b NS 08/16 © 2016 The Hartford Financial Services Group, Inc. All rights reserved.
This Benefit Highlights document explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this document and the policy,
the terms of the policy apply. Benefits are subject to state availability. Policy terms and conditions vary by state. Complete details are in the Certificate of Insurance issued to each insured individual and the
Master Policy as issued to the policyholder. The Hartford compensates both internal and external producers, as well as others, for the sale and service of our products. For additional information regarding Hartford’s
compensation practices, please review our website http://thehartford.com/group-benefits-producer-compensation. Life Form Series includes GBD-1000, GBD-1100, or state equivalent.
Page 46 of 66
LIMITATIONS & EXCLUSIONS
This insurance coverage includes certain limitations and exclusions. The certificate details all provisions, limitations, and exclusions for this insurance coverage. A copy of
the certificate can be obtained from your employer.
GROUP LIFE INSURANCE
GENERAL LIMITATIONS AND EXCLUSIONS
35% @ 65, 55% of Orig @ 70, and 75% of Orig @ 75*
You must be a citizen or legal resident of the United States, its territories and protectorates.
5962a NS 08/16 © 2016.The Hartford Financial Services Group, Inc. All rights reserved. Life Form Series includes GBD-1000, GBD-1100, or state equivalent.
GROUP ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE
GENERAL LIMITATIONS AND EXCLUSIONS
35% @ 65, 55% of Orig @ 70, and 75% of Orig @ 75*
This insurance does not cover losses caused by:
Sickness; disease; or any treatment for either
Any infection, except certain ones caused by an accidental cut or wound
Intentionally self-inflicted injury, suicide or suicide attempt
War or act of war, whether declared or not
Injury sustained while in the armed forces of any country or international authority
Injury sustained on aircraft in certain circumstances
Taking prescription or illegal drugs unless prescribed by or administered by a licensed physician
Injury sustained while riding, driving, or testing any motor vehicle for racing
Injury sustained while committing or attempting to commit a felony
Injury sustained while driving while intoxicated
You must be a citizen or legal resident of the United States, its territories and protectorates.
DEFINITIONS
Loss means, with regard to hands and feet, actual severance through or above wrist or ankle joints; with regard to sight, speech or hearing, entire and irrecoverable loss thereof;
with regard to thumb and index finger, actual severance through or above the metacarpophalangeal joints; with regard to movement, complete and irreversible paralysis of such
limbs.
Injury means bodily injury resulting directly from an accident, independent of all other causes, which occurs while you have coverage. 5962c
NS 08/16 © 2016.The Hartford Financial Services Group, Inc. All rights reserved. Accident Form Series includes GBD-1000, GBD-1300, or state equivalent.
GROUP SHORT TERM DISABILITY INSURANCE
LIMITATIONS AND EXCLUSIONS
GENERAL EXCLUSIONS
You must be under the regular care of a physician to receive benefits.
You cannot receive disability insurance benefit payments for disabilities that are caused or contributed to by:
War or act of war (declared or not)
The commission of, or attempt to commit a felony
An intentionally self-inflicted injury
Your being engaged in an illegal occupation
Sickness or injury for which workers' compensation benefits are paid, or may be paid, if duly claimed
Sickness or injury sustained as a result of doing any work for pay or profit for another employer, including self-employment
OFFSETS
Your benefit payments will be reduced by other income you receive or are eligible to receive due to your disability, such as:
Social Security disability insurance (please see next section for exceptions)
Other employer-based insurance coverage you may have
Unemployment benefits
Settlements or judgments for income loss
Retirement benefits that your employer fully or partially pays for (such as a pension plan)
Your benefit payments will not be reduced by certain kinds of other income, such as:
Retirement benefits if you were already receiving them before you became disabled
Retirement benefits that are funded by your after-tax contributions your personal savings, investments, IRAs or Keoghs profit-sharing
Most personal disability policies
Social Security cost-of-living increases
This example is for purposes of illustrating the effect of the benefit reductions and is not intended to reflect the situation of a particular claimant under the Policy:
Insured’s weekly [Pre-Disability Earnings/Basic weekly Pay] $1,000
Short term disability benefits percentage x 60%
Unreduced maximum benefit $600
Less Social Security disability benefit per week - $300
Less state disability income benefit per week - $100
Total amount of short term disability benefit per week $200
This policy provides disability income insurance only. It does NOT provide basic hospital, basic medical or major medical insurance as defined by the New York Department of Financial Services.
5962e NS 08/16 © 2016.The Hartford Financial Services Group, Inc. All rights reserved. Disability Form Series includes GBD-1000, GBD-1200, or state equivalent.
GROUP LONG TERM DISABILITY INSURANCE
LIMITATIONS AND EXCLUSIONS
GENERAL EXCLUSIONS
You must be under the regular care of a physician to receive benefits.
You cannot receive disability insurance benefit payments for disabilities that are caused or contributed to by:
War or act of war (declared or not)
The commission of, or attempt to commit a felony
An intentionally self-inflicted injury
Your being engaged in an illegal occupation
PRE-EXISTING CONDITIONS
Page 47 of 66
Your insurance excludes the benefits you can receive for pre-existing conditions. In general, if you were diagnosed or received care for a condition before the effective date of your
certificate, you will be covered for a disability due to that condition only if:
You have not received treatment for your condition for 6 months before the effective date of your insurance, or
You have been insured under this coverage for 12 months prior to your disability commencing, so you can receive benefits even if you're receiving treatment, or
You have already satisfied the pre-existing condition requirement of your previous insurer
LIMITATIONS
OFFSETS
Your benefit payments will be reduced by other income you receive or are eligible to receive due to your disability, such as:
Social Security disability insurance (please see next section for exceptions)
Workers’ compensation
Other employer-based insurance coverage you may have
Unemployment benefits
Settlements or judgments for income loss
Retirement benefits that your employer fully or partially pays for (such as a pension plan)
Your benefit payments will not be reduced by certain kinds of other income, such as:
Retirement benefits if you were already receiving them before you became disabled
Retirement benefits that are funded by your after-tax contributions your personal savings, investments, IRAs or Keoghs profit-sharing
Most personal disability policies
Social Security cost-of-living increases
This example is for purposes of illustrating the effect of the benefit reductions and is not intended to reflect the situation of a particular claimant under the Policy:
Insured’s monthly [Pre-Disability Earnings/Basic Monthly Pay] $3,000
Long term disability benefits percentage x 60%
Unreduced maximum benefit $1,800
Less Social Security disability benefit per month - $900
Less state disability income benefit per month - $300
Total amount of long term disability benefit per month $600
This policy provides disability income insurance only. It does NOT provide basic hospital, basic medical or major medical insurance as defined by the New York Department of Financial Services.
5962d NS 08/16 © 2016.The Hartford Financial Services Group, Inc. All rights reserved. Disability Form Series includes GBD-1000, GBD-1200, or state equivalent.
Prepare. Protect. Prevail. With The Hartford. ®
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Home Office is
Hartford, CT.
This Benefit Highlights document explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this document
and the policy, the terms of the policy apply. Benefits are subject to state availability. Policy terms and conditions vary by state. Complete details are in the Certificate of Insurance issued to each insured
individual and the Master Policy as issued to the policyholder.
Page 48 of 66
Page 49 of 66
GROUP SHORT-TERM DISABILITY INSURANCE
HIGHLIGHTS– Class 2 (Earnings are more than $40,000)
In the U.S., a disabling AOS, Inc.
injury occurs every
second.1 A disability can happen to anyone. A back injury, pregnancy, or serious illness can lead to months
without a regular paycheck. If you’re unable to work for a short period of time due to a non-work-
related condition, illness or injury, short-term disability insurance offers financial protection by
paying you a portion of your earnings.
To learn more about Short-Term Disability insurance, visit
thehartford.com/employeebenefits
COVERAGE INFORMATION
COVERAGE BENEFIT MAXIMUM SICKNESS INJURY BENEFIT BENEFIT
LEVEL PERCENTAGE $1,500 BENEFIT STARTS DURATION
STARTS
Core (PERCENT OF YOUR EARNINGS) On the 1st day 13 weeks
On the 8th day
50%
On the 8th day
Buy-Up 70% $2,000 On the 1st day 13 weeks
PREMIUMS
See the Premium Worksheet.2
ASKED & ANSWERED
WHO IS ELIGIBLE?
You are eligible if you are an active full time employee whose annual earnings are $40,000 or more and work at least 30 hours per week on a
regularly scheduled basis.
AM I GUARANTEED COVERAGE?
This insurance is guaranteed issue coverage – it is available without having to provide information about your health. If you are a late entrant,
evidence of insurability is required for the full coverage amount.
HOW MUCH DOES IT COST AND HOW DO I PAY FOR THIS INSURANCE?
Premium is provided on the Premium Worksheet.
Premium will be automatically paid through payroll deduction, as authorized by you during the enrollment process. This ensures you don’t have
to worry about writing a check or missing a payment.
WHEN CAN I ENROLL?
Your employer will automatically enroll you for core coverage.
You may enroll in buy-up coverage during any scheduled enrollment period, or within 31 days of the date you have a change in family status.
WHEN DOES THIS INSURANCE BEGIN?
Insurance will become effective in accordance with the terms of the certificate (usually the first day of the month following the date you elect
coverage).
You must be actively at work with your employer on the day your coverage takes effect.
WHEN DOES THIS INSURANCE END?
This insurance will end when you no longer satisfy the applicable eligibility conditions, premium is unpaid, you leave your employer, or the
coverage is no longer offered.
Page 50 of 66
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