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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services STATE OF FLORIDA - DEPARTMENT OF MANAGEMENT SERVICES (DMS): Aetna Open Access Aetna SelectSM - Standard HMO Plan

Coverage Period: 01/01/2018-12/31/2018

Coverage for: Individual + Family | Plan Type: EPOThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, www.HealthReformPlanSBC.com or by calling 1-800-370-4526. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary/ or call 1-800-370-4526 to request a copy.

Important Questions Answers Why This Matters: What is the overall deductible? Individual $0 / Family $0.

See the Common Medical Events chart below for your costs for services this plan covers.

Are there services covered before you meet your deductible?

Yes. This plan has no deductible. This plan covers some items and services if you havent yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible.

Are there other deductibles for specific services? No.

You dont have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services your plan covers.

What is the out-of-pocket limit for this plan?

Medical: Individual $1,500 / Family $3,000. Global: Individual $7,350 / Family $14,700. (met by medical and prescription copays or prescription copays only).

The outofpocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own outofpocket limits until the overall family outofpocket limit has been met.

What is not included in the out-of-pocket limit? Premiums and services this plan doesnt cover.

Even though you pay these expenses, they dont count toward the outofpocket limit.

Will you pay less if you use a network provider?

Yes. See www.aetna.com/docfind or call 1-877-858-6507 for a list of in-network providers.

This plan uses a provider network. You will pay less if you use a provider in the plans network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider's charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral.

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All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event Services You May Need

What You Will Pay Limitations, Exceptions & Other Important

Information In-Network

Provider (You will pay the

least)

Out-of-Network Provider

(You will pay the most)

If you visit a health care providers office or clinic

Primary care visit to treat an injury or illness $20 copay/visit Not covered Additional charges may apply for non-preventive services performed in the Physicians office.

Specialist visit $40 copay/visit Not covered Additional charges may apply for non-preventive services performed in the Physicians office.

Preventive care /screening /immunization No charge Not covered You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.

If you have a test

Diagnostic test (x-ray, blood work) No charge Not covered Charges for office visits may apply if services are performed in a Physicians office.

Imaging (CT/PET scans, MRIs) No charge Not covered

Charge for office visits or Physician/professional services may also apply depending where services are received.

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Common Medical Event Services You May Need

What You Will Pay Limitations, Exceptions & Other Important

Information In-Network

Provider (You will pay the

least)

Out-of-Network Provider

(You will pay the most)

If you need drugs to treat your illness or condition Prescription drug coverage is administered by CVS/Caremark More information about prescription drug coverage is available at www.caremark.com

Generic drugs (Tier 1)

$7 copay/ prescription (retail); $14 copay/ prescription (participating retail pharmacy or mail order)

Not covered Prescription drug coverage is provided through CVS/Caremark. For a list of participating pharmacies, go to www.caremark.com/sofrxplan or call 1-888-766-5490. Generic & Brand drugs: covers up to a 90-day supply at retail pharmacies and a 60-90 day supply via mail order. Certain drugs in all tiers require prior authorization. Brand additional charge may apply. Specialty and cost-sharing drugs available in 30-day supply only; not available via mail order.

Preferred brand drugs (Tier 2)

$30 copay/ prescription (retail); $60 copay/ prescription (participating retail pharmacy or mail order)

Not covered

Non-preferred brand drugs (Tier 3)

$50 copay/ prescription (retail); $100 copay/ prescription (participating retail pharmacy or mail order)

Not covered

https://www.healthcare.gov/sbc-glossary/#prescription-drug-coveragehttps://www.healthcare.gov/sbc-glossary/#prescription-drug-coveragehttps://www.healthcare.gov/sbc-glossary/#prescription-drug-coveragehttps://www.healthcare.gov/sbc-glossary/#prescription-drug-coveragehttp://www.caremark.com/http://www.caremark.com/sofrxplan%20or%20call%201-888-766-5490http://www.caremark.com/sofrxplan%20or%20call%201-888-766-5490

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Common Medical Event Services You May Need

What You Will Pay Limitations, Exceptions & Other I