Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services

Coverage Period: 05/01/2019 - 04/30/2020

: COMPUNNEL INC. ®
Aetna Open Access Managed Choice® - Gold Coverage for: Individual + Family | Plan Type: POS
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would
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,
https://www.aetna.com/sbcsearch/getpolicydocs?u=083000-040020-011979 or by calling 1-888-982-3862. 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 1-888-982-3862 to request a copy.
Important Questions Answers Why This Matters:
What is the overall In-Network: Individual $1,000 / Family $2,000. See the Common Medical Events chart below for your costs for services this plan
deductible? Out-of-Network: Individual $3,000 / Family $6,000. covers.
This plan covers some items and services even if you haven’t yet met the deductible
Are there services Yes. Emergency care & prescription drugs; plus amount. But a copayment or coinsurance may apply. For example, this plan covers
covered before you meet in-network office visits & preventive care are covered certain preventive services without cost sharing and before you meet your deductible.
your deductible? before you meet your deductible. See a list of covered preventive services at
https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other
deductibles for specific No. You don’t have to meet deductibles for specific services.
services?
The out-of-pocket limit is the most you could pay in a year for covered services. If you
What is the out-of-pocket In-Network: Individual $2,000 / Family $4,000. have other family members in this plan, they have to meet their own out-of-pocket
limit for this plan? Out-of-Network: Individual $4,500 / Family $9,000.
limits until the overall family out-of-pocket limit has been met.
Premiums, balance-billing charges, health care this
What is not included in plan doesn't cover & penalties for failure to obtain Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
the out-of-pocket limit?
pre-authorization for services.
This plan uses a provider network. You will pay less if you use a provider in the plan’s
network. You will pay the most if you use an out-of-network provider, and you might
Will you pay less if you Yes. See http://www.aetna.com/docfind or call receive a bill from a provider for the difference between the provider's charge and what
use a network provider? 1-888-982-3862 for a list of in-network providers. 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 No. You can see the specialist you choose without a referral.
see a specialist?

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

What You Will Pay

Common Out–of–Network Limitations, Exceptions, & Other Important
Services You May Need In-Network Provider (You Provider
Medical Event (You will pay Information
will pay the least) the most)
Primary care visit to treat an injury or $25 copay/visit, deductible
30% coinsurance None
illness doesn't apply
$25 copay/visit, deductible
Specialist visit 30% coinsurance None
If you visit a health care doesn't apply
provider’s office or clinic 30% coinsurance, You may have to pay for services that aren't
Preventive care /screening except deductible preventive. Ask your provider if the services
No charge
/immunization doesn't apply to child needed are preventive. Then check what your
immunizations plan will pay for.
Diagnostic test (x-ray, blood work) 10% coinsurance 30% coinsurance None
If you have a test
Imaging (CT/PET scans, MRIs) 10% coinsurance 30% coinsurance None
Copay/prescription,
deductible doesn't apply:
50% coinsurance,
$15 for 30 day supply
Generic drugs deductible doesn't
(retail), $37.50 for 31-90
apply (retail)
day supply (retail & mail Covers 30 day supply (retail), 31-90 day supply
order) (retail & mail order). Includes contraceptive
If you need drugs to treat Copay/prescription, drugs & devices obtainable from a pharmacy,
your illness or condition deductible doesn't apply: oral & injectable fertility drugs. No charge for
50% coinsurance,
$35 for 30 day supply preferred generic FDA-approved women's
More information about Preferred brand drugs deductible doesn't
prescription drug (retail), $87.50 for 31-90 contraceptives in-network. Review your
apply (retail)
coverage is available at day supply (retail & mail formulary for prescriptions requiring
www.aetnapharmacy.com/v order) precertification for coverage. Your cost will be
alueplus Copay/prescription, higher for choosing Brand over Generics unless
deductible doesn't apply: prescribed Dispense as Written.
50% coinsurance,
$65 for 30 day supply
Non-preferred brand drugs deductible doesn't
(retail), $162.50 for 31-90
apply (retail)
day supply (retail & mail
order)
Applicable cost as noted Applicable cost as
Specialty drugs above for generic or brand noted above for generic None
drugs or brand drugs

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 What You Will Pay
Common Out–of–Network Limitations, Exceptions, & Other Important
Services You May Need In-Network Provider (You Provider
Medical Event (You will pay Information
will pay the least) the most)
Facility fee (e.g., ambulatory surgery
If you have outpatient 10% coinsurance 30% coinsurance None
center)
surgery
Physician/surgeon fees 10% coinsurance 30% coinsurance None
$100 copay/visit,
$100 copay/visit, deductible
Emergency room care deductible doesn't No coverage for non-emergency use.
doesn't apply
apply
If you need immediate
medical attention Non-emergency transport: not covered, except
Emergency medical transportation 10% coinsurance 10% coinsurance
if pre-authorized.
$75 copay/visit, deductible
Urgent care 30% coinsurance None
doesn't apply
Penalty of $400 (or 50% of allowed amount if
If you have a Facility fee (e.g., hospital room) 10% coinsurance 30% coinsurance less) for failure to obtain pre-authorization for
hospital stay out-of-network care.
Physician/surgeon fees 10% coinsurance 30% coinsurance None
Office: $25 copay/visit,
Office & other
deductible doesn't apply;
Outpatient services outpatient services: None
If you need mental health, other outpatient services:
30% coinsurance
behavioral health, or 10% coinsurance
substance abuse services
Penalty of $400 (or 50% of allowed amount if
Inpatient services 10% coinsurance 30% coinsurance less) for failure to obtain pre-authorization for
out-of-network care.
Office visits No charge 30% coinsurance Cost sharing does not apply for preventive
Childbirth/delivery professional services. Maternity care may include tests
10% coinsurance 30% coinsurance and services described elsewhere in the SBC
services
If you are pregnant (i.e. ultrasound.) Penalty of $400 (or 50% of
allowed amount if less) for failure to obtain
Childbirth/delivery facility services 10% coinsurance 30% coinsurance pre-authorization for out-of-network care may
apply.

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 What You Will Pay
Common Out–of–Network Limitations, Exceptions, & Other Important
Services You May Need In-Network Provider (You Provider
Medical Event (You will pay Information
will pay the least) the most)
3 visits/day & 100 visits/calendar year. Penalty
of $400 (or 50% of allowed amount if less) for
Home health care 10% coinsurance 30% coinsurance
failure to obtain pre-authorization for
out-of-network care.
$20 copay/visit, deductible 90 visits/calendar year for Physical,
Rehabilitation services 30% coinsurance
doesn't apply Occupational & Speech Therapy combined.
$20 copay/visit, deductible
Habilitation services 30% coinsurance None
If you need help doesn't apply
recovering or have other 90 days/calendar year. Penalty of $400 (or 50%
special health needs Skilled nursing care 10% coinsurance 30% coinsurance of allowed amount if less) for failure to obtain
pre-authorization for out-of-network care.
Limited to 1 durable medical equipment for
Durable medical equipment 10% coinsurance 50% coinsurance same/similar purpose. Excludes repairs for
misuse/abuse.
Penalty of $400 (or 50% of allowed amount if
Hospice services 10% coinsurance 30% coinsurance less) for failure to obtain pre-authorization for
out-of-network care.
Children's eye exam No charge 30% coinsurance 1 routine eye exam/24 months.
If your child needs dental
or eye care Children's glasses Not covered Not covered Not covered.
Children's dental check-up Not covered Not covered Not covered.
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
• Acupuncture • Long-term care • Routine foot care
• Cosmetic surgery • Non-emergency care when traveling outside the • Weight loss programs - Except for required
• Dental care (Adult & Child) U.S. preventive services.
• Glasses (Child) • Private-duty nursing

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Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Bariatric surgery • Infertility treatment - Limited to the diagnosis & • Routine eye care (Adult) - 1 routine eye exam/24
• Chiropractic care treatment of underlying medical condition, artificial months.
• Hearing aids - 1 hearing aid to $1,000 maximum per insemination, ovulation induction & oral & injectable
ear/24 months for children up to age 16. fertility drugs. Advanced reproductive technology: 4
complete egg retrievals/lifetime.
Your Rights to Continue Coverage:
There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Office of Managed Care, Consumer
Protection Services, NJ Department of Banking and Insurance, Phone: 1-888-393-1062 or Consumer Hotline: 1-800-446-7467, http://www.state.nj.us/dobi/consumer.htm.
● For more information on your rights to continue coverage, contact the plan at 1-888-982-3862.

● If your group health coverage is subject to ERISA, you may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA
(3272) or https://www.dol.gov/agencies/ebsa.
● For non-federal governmental group health plans, you may also contact the Department of Health and Human Services, Center for Consumer Information and
Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov.
● If your coverage is a church plan, church plans are not covered by the Federal COBRA continuation coverage rules. If the coverage is insured, individuals should
contact their State insurance regulator regarding their possible rights to continuation coverage under State law.
Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about
the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.
Your Grievance and Appeals Rights:
There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about
your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a
grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact:
● Aetna directly by calling the toll free number on your Medical ID Card, or by calling our general toll free number at 1-888-982-3862.
● Office of Managed Care, Consumer Protection Services, NJ Department of Banking and Insurance, Phone: 1-888-393-1062 or Consumer Hotline: 1-800-446-7467,
http://www.state.nj.us/dobi/consumer.htm.
● If your group health coverage is subject to ERISA, you may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA
(3272) or https://www.dol.gov/agencies/ebsa.
● For non-federal governmental group health plans, you may also contact the Department of Health and Human Services, Center for Consumer Information and
Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov.
● Additionally, a consumer assistance program can help you file your appeal. Contact The Office of the Insurance Ombudsman, NJ Department of Banking and
Insurance, 20 West State Street, PO Box 472, Trenton, NJ 08625-0472, 1-800-446-7467, Fax: 609-292-2431, http://www.state.nj.us/dobi/consumer.htm,
[email protected]

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Does this plan provide Minimum Essential Coverage? Yes.
If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the
requirement that you have health coverage for that month.
Does this plan meet Minimum Value Standards? Yes.
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
-------------------To see examples of how this plan might cover costs for a sample medical situation, see the next section.-------------------

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About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be
different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing
amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of
costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby Managing Joe’s type 2 Diabetes Mia’s Simple Fracture
(9 months of in-network pre-natal care and (a year of routine in-network care of a (in-network emergency room visit and
a hospital delivery) well-controlled condition) follow up care)

■ The plan’s overall deductible $1,000 ■ The plan’s overall deductible $1,000 ■ The plan’s overall deductible $1,000
■ Specialist copayment $25 ■ Specialist copayment $25 ■ Specialist copayment $25
■ Hospital (facility) coinsurance 10% ■ Hospital (facility) coinsurance 10% ■ Hospital (facility) coinsurance 10%
■ Other coinsurance 10% ■ Other coinsurance 10% ■ Other coinsurance 10%
This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical supplies)
Childbirth/Delivery Professional Services disease education) Diagnostic test (x-ray)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy)
Specialist visit (anesthesia) Durable medical equipment (glucose meter)

Total Example Cost $12,800 Total Example Cost $7,400 Total Example Cost $1,900
In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $1,000 Deductibles $100 Deductibles $600
Copayments $0 Copayments $1,500 Copayments $200
Coinsurance $1,000 Coinsurance $0 Coinsurance $0
What isn't covered What isn't covered What isn't covered
Limits or exclusions $60 Limits or exclusions $20 Limits or exclusions $0
The total Peg would pay is $2,060 The total Joe would pay is $1,620 The total Mia would pay is $800

The plan would be responsible for the other costs of these EXAMPLE covered services.
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Assistive Technology
Persons using assistive technology may not be able to fully access the following information. For assistance, please call 1-888-982-3862.
Smartphone or Tablet
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Non-Discrimination
Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color, national origin, sex, age,
or disability.
Aetna provides free aids/services to people with disabilities and to people who need language assistance.
If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card.
If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil
Rights Coordinator by contacting:
Civil Rights Coordinator
P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030, Fresno, CA 93779)

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

Email: [email protected]
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building,
Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company, Coventry Health
Care plans and their affiliates.
TTY: 711
Language Assistance:
For language assistance in your language call 1-888-982-3862 at no cost.

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Arabic - 1-888-982-3862
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Choctaw - (Chahta) anumpa ya apela a chi I paya hinla 1-888-982-3862.
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Greek - Για γλωσσική βοήθεια στα Ελληνικά καλέστε το 1-888-982-3862 χωρίς χρέωση.
Gujarati - ગુજરાતીમાં ભાષામાં સહાય માટે કોઈ પણ ખર્ચ વગર 1-888-982-3862 પર કૉલ કરો.
Hawaiian - No ke kōkua ma ka ʻōlelo Hawaiʻi, e kahea aku i ka helu kelepona 1-888-982-3862. Kāki ʻole ʻia kēia kōkua nei.

Hindi - हिन्दी में भाषा सहायता के लिए, 1-888-982-3862 पर मुफ्त कॉल करें।
Hmong - Yog xav tau kev pab txhais lus Hmoob hu dawb tau rau 1-888-982-3862.
Ibo - Maka enyemaka asụsụ na Igbo kpọọ 1-888-982-3862 na akwụghị ụgwọ ọ bụla
Ilocano - Para iti tulong ti pagsasao iti pagsasao tawagan ti 1-888-982-3862 nga awan ti bayadanyo.
Italian - Per ricevere assistenza linguistica in italiano, può chiamare gratuitamente 1-888-982-3862.
Japanese - 日本語で援助をご希望の方は、1-888-982-3862 まで無料でお電話ください。
Karen - v>w>frRp>Rw>fuwdRusd.ft*D>f usd.f ud; 1-888-982-3862 v>wtd.f'D;w>fv>mfbl.fv>mfphRb.

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Kru-Bassa - Ɓɛ́ m̀ ké gbo-kpá-kpá dyé pídyi ɖé Ɓǎsɔ́ɔ̀-wùɖùǔn wɛ̃ɛ, ɖá 1-888-982-3862

Kurdish - 1-888-982-3862

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Marshallese - Ñan bōk jipañ ilo Kajin Majol, kallok 1-888-982-3862 ilo ejjelok wōnān.
Micronesian - Ohng palien sawas en soun kawewe ni omw lokaia Ponape koahl 1-888-982-3862 ni sohte isais.
Pohnpeyan
Mon-Khmer, 1-888-982-3862
Cambodian -
Navajo - T'áá shi shizaad k'ehjí bee shíká a'doowol nínízingo Diné k'ehjí koji' t'áá jíík'e hólne' 1-888-982-3862

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Nilotic-Dinka - Tën kuɔɔny ë thok ë Thuɔŋjäŋ cɔl 1-888-982-3862 kecïn aɣöc.
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Pennsylvania Dutch - Fer Helfe in Deitsch, ruf: 1-888-982-3862 aa. Es Aaruf koschtet nix.
Persian - 1-888-982-3862
Polish - Aby uzyskać pomoc w języku polskim, zadzwoń bezpłatnie pod numer 1-888-982-3862.
Portuguese - Para obter assistência linguística em português ligue para o 1-888-982-3862 gratuitamente.
Romanian - Pentru asistenţă lingvistică în româneşte telefonaţi la numărul gratuit 1-888-982-3862
Russian - Чтобы получить помощь русскоязычного переводчика, позвоните по бесплатному номеру 1-888-982-3862.
Samoan - Mo fesoasoani tau gagana I le Gagana Samoa vala'au le 1-888-982-3862 e aunoa ma se totogi.
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Spanish - Para obtener asistencia lingüística en español, llame sin cargo al 1-888-982-3862.
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Swahili - Ukihitaji usaidizi katika lugha ya Kiswahili piga simu kwa 1-888-982-3862 bila malipo.
Syriac - ‫ܢܘܦܝܠܬܕ ܐܳܡܩܰܪ ܟܳܠ ܐܳܗ ܐܳܿܝܳܝܪܽܘܣ ܐܳܢܫܶܠܒ ܐܬܽܘܢܪܕܰܥܡ ܬ̱ܢܰܐ ܐܶܥܳܒ ܢܶܐ‬1-888-982-3862 ‫ܢܳܓܰܡܘ‬.
Tagalog - Para sa tulong sa wika na nasa Tagalog, tawagan ang 1-888-982-3862 nang walang bayad.
Telugu - భాషతో సాయం కొరకు ఎలాంటి ఖర్చు లేకుండ ా 1-888-982-3862 కు కాల్ చేయండి. (తెలుగు)
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Trukese - Ren áninnisin chiakú ren (Kapasen Chuuk) kopwe kékkééri 1-888-982-3862 nge esapw kamé ngonuk.
Turkish - (Dil) çağrısı dil yardım için. Hiçbir ücret ödemeden 1-888-982-3862.
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Urdu - 1-888-982-3862
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Yiddish - 1-888-982-3862
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