Cornell Program for Healthy Living Addendum – Effective January 1, 2016 Addendum to the Cornell Program for Healthy Living Plan (CPHL) Summary Plan Description (SPD) The information below is intended to serve as an update to the 2014 Cornell Program for Healthy Living Plan (CPHL) Summary Plan Description (SPD) Effective January 1, 2016 The medical and prescription drug copays apply to the out of pocket maximum for in-network services. The plan includes all of the preventive care benefits mandated by the ACA. Below are the items revised or added for 2016: • Eye exam (routine)-is now covered every year after copay • Routine physical exam Age limit modified for CPHL: from age 19 changed to age 22 and up; • Well Child age limit changed from birth to age 3 to birth to age 22 Preventive Care Covered at 100% In-network Routine Physical Exams Family Planning – Tubal Ligation Obesity Preventive Counseling Lactation Consultation Tobacco Preventive Counseling Contraceptive drugs and devices (except those covered by RX plan) including associated office visit (i.e. IUDs). Alcohol/Drug Abuse Counseling Breast Pumps and supplies Preventive Lung Cancer Screening Contraceptive Consultation Colorectal Cancer Screening (ie colonoscopy) Routine PSA and DRE Routine GYN and Pap Routine eye exam (includes pediatric) is covered at 100% every (instead of every year). Routine mammography Prenatal care covered at 100% (delivery & nursery care remain covered at 90%). Breast Pumps and supplies OptumRx Prescription Drug Plan covers: Oral Contraceptives, barrier methods, OTC contraceptives, Plan B and ella (prescription required). Pre-natal maternity office visits OptumRx Prescription Drug Plan covers: Aspirin products, iron supplements, Vitamin D, Folic Acid & Prenatal Vitamins with prescription. This is only a brief summary of the Plan Features. Please refer to the Summary of Benefits and Plan Booklet for a complete description. The Prescription Drug Plan is changing from Express Scripts (ESI) to OptumRx • The copays are not changing and remain $5/$30/$50 for retail and $10/$60/$90 Home Delivery in-network • The drug formulary is changing • Some medications are excluded • Home Delivery of maintenance medications/specialty medications can be delivered to your home address or new for 2016, you can direct the delivery to Gannett Health Center Pharmacy on the Ithaca campus. • Briova is the specialty pharmacy replacing ESI’s Accredo • Aspirin products, iron supplements, Vitamin D, Folic Acid & Prenatal Vitamins with prescription covered at $0 copay (in-network) Effective April 1, 2015 Documentation Requirements Effective 4/1/15-copies only Employee: Social Security Card (or ITIN-Individual Taxpayer Identification Number for non- US Citizens). You must provide copies of documents to support your dependent’s eligibility for coverage. Spouse or Domestic Partner: Birth Certificate (or Visa/Passport accepted for non-US citizens), Social Security Card (or ITIN-Individual Taxpayer Identification Number for non-US citizens), Marriage Certificate, Domestic Partner Statement Children (biological), stepchild, adopted: Birth Certificate (or Visa/Passport accepted for non- US citizens), Social Security Card, ITIN (Individual Taxpayer Identification Number) for non- US citizens, Proof of Disability, if applicable, Documentation establishing Paternity by Court Order acknowledging Paternity. If your child is neither of the above, you must also complete the Special Dependent Enrollment Form. Effective January 1, 2015 Express Scripts Prescription Drug Plan Changes Preferred Retail Pharmacy Network You pay $5/$30/$50 copay at retail for up to a 30 day supply if you use pharmacies participating in the Preferred Retail Pharmacy Network. Pharmacies include: Kinney, Rite Aid, Target, Walmart, Wegmans, Quilans, Green Street Pharmacy, Gannett Student Health Center, You pay $15/$40/$60, if you use CVS/Walgreens (Duane Reed), pharmacies not participating. Aetna CPHL Addendum 1/1/16 Exclusionary Formulary: Certain medications that are available as generics or on the formulary are no longer covered as of 1/1/15. Members can appeal and ESI will review the clinical information provided by the physician. Social Security’s Definition of a “Spouse”. As of January 1, 2015, the Social Security’s definition of “spouse” has expanded to include a same-sex spouse for the purpose of determining Medicare primacy. Therefore, an active employee’s same-sex spouse, age 65 or older, will be Aetna primary not Medicare primary. Certificates of Creditable Coverage (HIPAA Certs) No Longer Required The Affordable Care Act prohibits the use of pre-existing condition clauses resulting in the need to provide certificates of creditable coverage no longer necessary. On February 24, 2014, the Treasury, the Department of Labor, and the Department of Health and Human Service jointly issued final regulations which eliminated the requirement for plan sponsors to issue the certificates after 12/31/14. Grandfathered Health Plan Notice for January 1, 2015 Cornell University believes your plan is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to your employer or Aetna member services using the phone number on your member id card. If your plan is governed by ERISA, you may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or HUwww.dol.gov/ebsa/healthreformUH. This website has a table summarizing which protections do and do not apply to grandfathered health plans. If your plan is a nonfederal governmental plan, you may also contact the U.S. Department of Health and Human Services at HUwww.healthreform.govUH. Aetna CPHL Addendum 1/1/16 Schedule of Benefits Employer: Cornell University ASC: 397366 Issue Date: July 1, 2014 Effective Date: January 1, 2014 Schedule: 8A Booklet Base: 8 For: Cornell Program for Healthy Living This is an ERISA plan, and you have certain rights under this plan. Please contact your Employer for additional information. Aetna Choice POS II Medical Plan CPHL ENHANCED PLAN FEATURES WELLNESS AND IN- **OUT-OF-NETWORK NETWORK Calendar Year Deductible* Individual Deductible* None $400 Family Deductible* None $800 Once family deductible is met, all family members will be considered as having met their deductible for the remainder of the Calendar Year * Unless otherwise indicated, any applicable deductible must be met before benefits are paid. ** Subject to Recognized Charge The Maximum Out of Pocket Limit includes plan deductible. The Maximum Out of Pocket Limit excludes precertification penalties, copayments, expenses paid at 50%, non-covered expenses and charges over the recognized charge. Individual Maximum Out of Pocket Limit:  For network expenses: $2,000.  For out-of-network expenses: $3,500. Family Maximum Out of Pocket Limit:  For network expenses: $4,000.  For out-of-network expenses: $7,000. Lifetime Maximum Benefit per Person Unlimited Unlimited 1 How the Cornell Program for Healthy Living Works The Cornell Program for Healthy Living (CPHL) is a new comprehensive health plan that encourages and facilitates your progress to healthier living. This is achieved by focusing on your total health through an Enhanced Wellness Program. There are two components: the underlying Medical Plan and the Enhanced Wellness Program. Highlights of the Medical Plan (Choice POSII) In-Network Out-of-Network Level of Health Plan Support Higher so you pay less out of pocket: Lower so you pay more out of pocket: No Deductible $400 deductible $20 office visit copay 80% thereafter 90% for other services Pharmacy is administered by Express Pharmacy is administered by Express Scripts/Medco. Scripts/Medco. PCP Requirement Applies to enhanced wellness benefit only N/A (see back page for details). Referral Requirement to a Specialist No referrals needed. No referrals needed. Preventive Care Covered at 100%, regardless of where you Covered at 80% after deductible. live and the network PCP you choose. Broad National Network of Fully available at discount prices. You may use out-of-network Physicians and Hospitals providers but it will cost you more. Balance Billing Providers have agreed not to bill you over Providers are free to bill you over the (the amount billed by your provider that is allowed amount. allowed amount. over the insurance company’s allowed amount) Certification for Inpatient Hospital Participating provider precertifies for you. You precertify by calling the toll-free and Other Medical Services number on your ID card. Failure to precertify may result in substantially reduced benefits. Claim Forms to File No. Yes. 2 The Enhanced Wellness Program The Enhanced Wellness Benefits are available only if you chose to utilize a PCP from a select list of Ithaca based In- Network Providers. Please note: there is NO PCP selection required if you and your family members elect not to take part in the Enhanced Wellness Exam and related services. Step 1 All covered family members, including children, must select a PCP from a select list of Ithaca To Receive an Enhanced based In-Network providers if you would like to take advantage of the Enhanced Wellness Wellness Exam Program. These PCPs have committed to support this plan and a play a pivotal role in helping Select a PCP you reach your wellness goals for the year. You can select your PCP at the time of enrollment through Benefit Services, or after enrollment through Aetna Navigator or by calling Aetna Member Services at 1-877-371-2007. You can find the names of the Ithaca based PCP’s at https://www.hr.cornell.edu/benefits/health/cphl_directory.pdf. Step 2 You and your enrolled adult family members (spouse, domestic partner and children ages 1and Schedule Physical Exam over) schedule annual comprehensive physical exam(s) and lab work with your Enhanced and Lab Work Wellness PCP unless otherwise directed by your PCP. Your comprehensive exam and routine lab work are covered at 100%. Step 3 You and your enrolled adult family members (spouse, domestic partner and children ages 18 Complete a Sustainable and over) will complete a Sustainable Health Questionnaire (SHQ)/Health Risk Assessment Health Questionnaire (HRA) once a year. This SHQ/HRA must be completed no more than one week prior to your SHQ/HRA annual comprehensive physical exam with your PCP. Children age 1 through 17 will complete a pediatric assessment in their PCP’s office. Step 4 Once you have completed your SHQ/HRA, you are ready for a comprehensive physical exam Comprehensive Exam and a review of your SHQ results with your Enhanced Wellness PCP. There is no cost to you. and Wellness Report Once the exam and review have been completed, your PCP will provide you with an Annual Wellness Report from which you and your PCP will develop a healthy living action plan. Step 5 Your Wellness Report and healthy living action plan may include referrals to local resources, or The Healthy Living to additional services within your PCP’s office, to assist you in achieving your goals. These Wellness Resources additional services for smoking cessation, nutritional counseling and diabetic education are covered at 100%. In addition, if you have medical complications or need special attention, your PCP may refer you to the Cayuga Center for Healthy Living (CCHL) for advanced wellness counseling and support for the following services. The costs for these services at CCHL are  Health Behavior Assessment $20 copay  Health Risk Assessment Interpretation $20 copay  Medically Supervised Exercise $20 copay  Team Conference $20 copay  Preventive Medical Counseling $20 copay  Stress Management $20 copay Faculty and Staff are also eligible to receive a $15 monthly discount from either the Ithaca YMCA, Island Fitness or the Cornell Wellness Program (the discount makes the Cornell Wellness free). Spouses and domestic partners who are Cornell employees are eligible if they are covered under CPHL. The CPHL Aetna ID Card and Cornell ID are required to be presented to the fitness centers to confirm eligibility for the discount. Step 6 Following your Enhanced Wellness exam, your PCP may decide to have you return for up to 3 Follow-up Visits monitoring or counseling check-ups during the year. These extra visits are also covered at 100% under the Enhanced Wellness benefit. You are strongly encouraged to see your Enhanced Wellness PCP at least once every year to complete steps 2-5 above unless otherwise directed by your PCP. 3 Payment Percentages listed in the Schedule below reflects the Plan Payment Percentage. This is the amount Aetna pays. You are responsible to pay any deductibles, copayments, and the remaining payment percentage. You are responsible for full payment of any non-covered expenses you incur. Covered Expenses That Are Subject To The Calendar Year Deductible Are Noted In The Schedule Below. * The In-Network benefit level includes medically necessary care provided out of the country. CPHL ENHANCED PLAN FEATURES IN-NETWORK* OUT-OF-NETWORK WELLNESS Wellness Benefit Routine Physical Exams 100% including lab and 100% including lab and 80% per exam after Adults only. x-ray x-ray Calendar Year deductible Includes coverage for immunizations. Maximum Exams per Calendar Year Adults age 18 and over 1 exam plus 3 follow up 1 exam 1 exam preventive visits Well Child Exams 100% including lab and 100% including lab and 80% per exam after Includes coverage for x-ray x-ray Calendar Year deductible immunizations Maximum Exams Under age 3 first 12 months of life 7 exams 7 exams 7 exams th th 13 – 24 months of life 4 exams 3 exams 3 exams th th 25 – 36 months of life 4 exams 3 exams 3 exams For age 3 to 18 4 exams 1 exam 1 exam Immunizations Same as In-Network 100% 80% per visit after when not part of the Calendar Year deductible physical exam Screening & Counseling 100% per visit 100% per visit 80% per visit after Services - Obesity, Misuse of Calendar Year deductible Alcohol and/or Drugs & Use of Tobacco Products Nutritional Counseling 100% per visit $20 per visit copay then 80% per visit after other than Screening & the plan pays 100% Calendar Year deductible Counseling Services for in an office setting; Obesity otherwise 90% 4 Obesity Maximum Visits per Unlimited 26 visits (however, of these 26 visits (however, of these Calendar Year only 10 visits will be only 10 visits will be (This maximum applies only to allowed under the Plan for allowed under the Plan for Covered Persons ages 18 and older.) healthy diet counseling healthy diet counseling provided in connection with provided in connection with Hyperlipidemia (high Hyperlipidemia (high cholesterol) and other cholesterol) and other known risk factors for known risk factors for cardiovascular and cardiovascular and diet-related chronic disease* diet-related chronic disease* *Note: In figuring the Maximum Visits, each session of up to 60 minutes is equal to one visit. Nutritional Counseling other than for Obesity Maximum Visits per Unlimited Based on Medical Based on Medical Calendar Year Necessity Necessity Use of Tobacco Products Maximum Visits per Calendar Unlimited 8 visits* 8 visits* Year *Note: In figuring the Maximum Visits, each session of up to 60 minutes is equal to one visit. Misuse of Alcohol and/or Drugs Maximum Visits per Calendar Unlimited 5 visits* 5 visits* Year *Note: In figuring the Maximum Visits, each session of up to 60 minutes is equal to one visit. CPHL ENHANCED PLAN FEATURES IN-NETWORK OUT-OF-NETWORK WELLNESS Routine Cancer Screenings Routine Mammography Same as In-Network 100% 80% per test after Calendar Year deductible Maximum 1 test 1 test 1 test tests per Calendar Year Prostate Specific Antigen 100% per test 100% 80% per test after Test Calendar Year deductible For covered males age 40 and over. Maximum tests per Calendar 1 test 1 test 1 test Year 5 Routine Digital Rectal 100% per test 100% 80% per test after Exam Calendar Year deductible For covered males age 40 and over. Maximum tests per Calendar 1 test 1 test 1 test Year Fecal Occult Blood Test Same as In-Network 100% 80% per test after Calendar Year deductible Maximum tests per Calendar 1 test 1 test 1 test Year Sigmoidoscopy Same as In-Network 100% 80% per test after Age 50 and over Calendar Year deductible Maximum Tests per 5 1 test 1 test 1 test consecutive year period Double Contrast Barium Same as In-Network 100% 80% per test after Enema (DCBE) Calendar Year deductible Age 50 and over Maximum Tests per 5 1 test 1 test 1 test consecutive year period Colonoscopy 1 test 100% 80% per test after age 50 and over Calendar Year deductible Maximum Tests per 10 1 test 1 test 1 test consecutive year period 6 All Other Routine Exams Same as In-Network 100% 80% per test after and Screenings Calendar Year deductible Maximum Subject to any age and Same Same per Calendar Year visit limits provide for in the current recommendations of the United States Preventive Services Task Force and comprehensive guidelines supported by the Health Resources and Services Administration For details, contact your physician, log onto the Aetna website www.aetna.com, or call the number on the back of your ID card. CPHL ENHANCED PLAN FEATURES IN-NETWORK OUT-OF-NETWORK WELLNESS Well Woman Preventive Visits Routine Gynecological Same as In-Network 100% 80% per exam / test after Exam (Including Routine Calendar Year deductible Pap Smears) Maximum 1 exam 1 exam 1 exam per Calendar Year Prenatal Visits Same as In-Network 100% 80% per exam after Calendar Year deductible CPHL ENHANCED PLAN FEATURES IN-NETWORK OUT-OF-NETWORK WELLNESS Comprehensive Lactation Support and Counseling Services Lactation Consultation Same as In-Network 100% for the first 6 visits 80% per visit after per year. $20 copay Calendar Year deductible thereafter Breast Pump and Supplies Same as In-Network 100% 80% after Calendar Year Electric Breast Pump 1 service deductible maximum in 36 months 7