Open Enrollment Guide - CarMax Associate Benefits

VIEW YOUR 2016 OPEN ENROLLMENT GUIDE AT BENEFITS.CARMAX.COM
F U L L- T I M E A S S O C I AT E S
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2016 Updates
Medical
Health Spending Accounts
Dental & Vision
DCSA
Appendix
Table of Contents
•H
ow to Have a Successful Open Enrollment _____________ 3
• This Year’s Updates _________________________________ 4
• Medical Plan Overview ______________________________ 5
• Health Spending Accounts Overview ___________________ 9
• Dental & Vision Plan Overview _______________________ 11
• Day Care Savings Account (DCSA) Overview ____________ 12
•A
ppendix _ _ ________________________________________ 13
Core 60 Medical Plan Chart_ _ _____________________________ 14
Select 70 Medical Plan Chart______________________________ 15
Premium 80 Medical Plan Chart____________________________ 16
Glossary of Terms _ _ ____________________________________ 17
Examples of Claims ____________________________________ 18
Who to Contact _______________________________________20
page 2 of 20
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2016 Updates
Medical
Health Spending Accounts
Dental & Vision
OPEN ENROLLMENT
DCSA
Appendix
is here!
From January 7 to 25, you can enroll in or change your Medical, Dental, and Vision coverage for the
new Plan Year that begins March 1, 2016.
During this time, you can enroll in health spending accounts and the Day Care Savings Account for the
new Plan Year. (Remember, you must enroll every year if you want to participate!) And, you can also elect
or change your life insurance coverage.
Here’s how to have a successful Open Enrollment:
1. Complete the KMXU Open Enrollment training
2. Review the online Open Enrollment Guide
3. Check out ALEX, our new medical plan decision tool at benefits.carmax.com under Open Enrollment
4. Enroll at mykmxhr.com by January 25
If you don’t wish to change your current Medical, Dental, or Vision coverage for next year, you don’t need
to do anything. Your current elections will continue.
If you have any questions about Open Enrollment, call (888) 695-6947 or visit benefits.carmax.com.
page 3 of 20
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2016 Updates
Medical
Health Spending Accounts
THIS YE AR’S
Dental & Vision
DCSA
Appendix
updates
You have three Medical Plan options to choose from during this Open Enrollment. Be sure to review each Plan
option on the charts that follow, so you can choose the one that’s best for you and your family.
While typical (industry-wide) Medical Plan increases are averaging around 5-6% for next year,
we’re pleased to announce that your Medical and Dental premiums are increasing just 2% for 2016!
CarMax Associates have been choosing and using the Health Plans wisely, and many of you are living
healthier by participating in the CarMax Wellness programs.
Other changes:
• Increased Vision Plan coverage for frames and contact lenses
• NEW – Coverage for ABA therapy
• Enhanced coverage for speech, physical, and occupational therapy
• NEW – Coverage for gender dysphoria treatment
Check out ALEX, your new Medical Plan Decision Tool!
•This new interactive tool will help you select the best health plan for you and your family. Find the tool at
benefits.carmax.com under Open Enrollment, on mykmxhr.com, and in the KMXU Open Enrollment training.
page 4 of 20
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MEDICAL PLAN
Dental & Vision
Appendix
overview
Medical Plan Options
Select 70 (Preferred Provider Organization plan)
CarMax offers you a choice of three Medical Plan options:
Core 60, Select 70, and Premium 80. See page 6
for details.
As a Select 70 member, you are automatically enrolled in a Health
Reimbursement Account (HRA). CarMax contributes to this
account and the funds can be used toward meeting your deductible
or other out-of-pocket eligible expenses.
These three options offer variations on how you can expect to
share the costs of care with the Plan you choose. Each option
covers the same services, but the option that you choose will
affect your paycheck deductions and the amount you pay for
services, like hospital visits or prescriptions.
This year, based on feedback we’ve received from CarMax
Associates, we’ve added or enhanced the following coverage:
• Applied Behavioral Analysis (ABA) therapy for children
with autism
• Our speech, physical, and occupational therapy session limits
are now 60 per year each (speech was 30 visits last year; PT and
OT were 60 visits combined)
• Gender dysphoria treatment (this includes reassignment
surgery and related mental health benefits)
Here’s a brief overview of the Medical Plan options:
Core 60 (High Deductible Health Plan)
The Core 60 Plan option is a High Deductible Health Plan
(HDHP) with a Health Savings Account (HSA). Core 60 Plan
members may enroll in this HSA. CarMax contributes to this
account and you can too!
IRS imposes special eligibility requirements on HSAs. Please review the
“The Core 60 Medical Plan Overview” and “Health Savings Account
Frequently Asked Questions” documents on benefits.carmax.com.
page 5 of 20
DCSA
Premium 80 (Preferred Provider Organization plan)
As a Premium 80 member, you’ll pay more out of each paycheck,
but less when you receive medical services.
Prescription Drug Program
CVS/caremark™ administers the CarMax Prescription Drug
Program for all three Medical Plan options. Here’s how you can
save money when you fill your prescriptions with CVS/caremark.
• Generic Medications: Talk with your doctor to see if a generic
alternative is right for you. Generics are cost effective and offer
the same benefits as their brand-name alternatives.
• Maintenance Choice: Have your 90-day maintenance
prescriptions filled through your local CVS pharmacy or
have them mailed to your home. Either way, when you sign
on with Maintenance Choice you’ll get every third month of
medication for free!
Beginning March 1, 2016, we are updating our coverage
to include a Generics First program. This program promotes the
use of generic prescription drugs to address specific conditions
(when generic options have a track record of success). If you are
affected by this change, you and your doctor will be notified
by CVS/caremark.
Visit caremark.com to find out more about CVS/caremark and
your Prescription Drug Program.
Detailed plan information is available at benefits.carmax.com
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Medical
Health Spending Accounts
overview cont’d
Aetna® Medical Plan Options
MEDICAL PL AN
Dental & Vision
Core 60
DCSA
Appendix
Select 70
In-Network Only
➤ Medical Plan Decision Tool
Premium 80
In-Network Only
In-Network Only
Individual $2,000
Two Individuals $4,000
Family $6,000
Individual $1,700
Two Individuals $3,400
Family $5,100
Health Savings Account
Health Reimbursement Account
Individual $200
Two Individuals $400
Family $600
Individual $200
Two Individuals $400
Family $600
n/a
Your Out-of-Pocket Maximum
Individual $6,550
Family $13,100
Individual $6,550
Family $13,100
Individual $6,550
Family $13,100
Preventive Care Services
$0
$0
$0
Lab & X-rays (Basic Imaging)
$0 after deductible
$0
$0
Primary Care Physician Office Visit
40% after deductible
$30 copay
$20 copay
Deductible
CarMax’s Contribution to Your Account
YOU PAY
Individual $600
Two Individuals $1,200
Family $1,800
YOU PAY
YOU PAY
Teladoc Virtual Visit
$40
$30 copay
$20 copay
Retail Walk-in Clinics (e.g., CVS MinuteClinic®)
40% after deductible
$30 copay
$20 copay
Urgent Care Center Visit
40% after deductible
$60 copay
$40 copay
Specialist Office Visit
40% after deductible
30% after deductible
$50 copay
Emergency Room Visit
40% after deductible
$250 copay + 30% after deductible
$150 copay + 20% after deductible
Other Covered Services (See Glossary)
40% after deductible
30% after deductible
20% after deductible
CVS/caremark™ Prescription Coverage
Generic Prescriptions*
Retail (30-day supply)
$25 copay after deductible
$15 copay
$10 copay
Maintenance (90-day supply)
$50 copay after deductible
$30 copay
$20 copay
Preferred Brand - Retail (30-day supply)
40% after deductible
Minimum $50; Maximum $125
30%
Minimum $40; Maximum $100
$35 copay
Preferred Brand - Maintenance (90-day supply)
40% after deductible
Minimum $100; Maximum $250
30%
Minimum $80; Maximum $200
$70 copay
Non-Preferred Brand - Retail (30-day supply)
40% after deductible
Minimum $70; Maximum $175
30%
Minimum $60; Maximum $150
$55 copay
Non-Preferred Brand - Maintenance (90-day supply)
40% after deductible
Minimum $140; Maximum $350
30%
Minimum $120; Maximum $300
$110 copay
Brand Prescriptions* **
**Subject to the Generics First Program
*Prescriptions on the Preventive Drug
List are not subject to the deductible
See more details for Core 60
page 6 of 20
See more details for Select 70 See more details for Premium 80
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MEDICAL PL AN
Medical
2016 Updates
overview
cont’d
Dental & Vision
Health Spending Accounts
2016 Medical Plan Rates
Core 60
DCSA
Appendix
Associate Cost ANNUALLY
Associate Cost BI-WEEKLY
Before Incentive
Medical Plan Credit*
After Incentive
After Incentive
Associate
$43.00
($23.08)
$19.92
$518.04
Associate + Child
$115.89
($23.08)
$92.81
$2,413.08
Associate + Children
$155.66
($23.08)
$132.58
$3,447.24
Associate + Spouse/
Domestic Partner
$164.01
($46.16)
$117.85
$3,064.20
Family
$232.31
($46.16)
$186.15
$4,839.96
Associate Cost BI-WEEKLY
Select 70
Associate Cost ANNUALLY
Before Incentive
Medical Plan Credit*
After Incentive
After Incentive
Associate
$87.10
($23.08)
$64.02
$1,664.52
Associate + Child
$135.11
($23.08)
$112.03
$2,912.88
Associate + Children
$183.12
($23.08)
$160.04
$4,161.24
Associate + Spouse/
Domestic Partner
$189.55
($46.16)
$143.39
$3,728.40
Family
$272.78
($46.16)
$226.62
$5,892.24
Associate Cost BI-WEEKLY
Premium 80
K E E P I N M I N D...
When you opt to pay more from each
paycheck (Select 70, Premium 80), you’ll
pay less when you receive medical care.
page 7 of 20
Associate Cost ANNUALLY
Before Incentive
Medical Plan Credit*
After Incentive
After Incentive
Associate
$108.08
($23.08)
$85.00
$2,210.04
Associate + Child
$180.35
($23.08)
$157.27
$4,089.00
Associate + Children
$252.60
($23.08)
$229.52
$5,967.48
Associate + Spouse/
Domestic Partner
$235.71
($46.16)
$189.55
$4,928.52
Family
$333.04
($46.16)
$286.88
$7,459.08
* Medical Plan Credit applies to those Associates/Spouses/Domestic Partners who have completed the Commitment to Health program.
Rounding differences may apply.
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MEDICAL PL AN
2016 Updates
overview
Medical
Health Spending Accounts
Dental & Vision
DCSA
Appendix
cont’d
Make a Commitment to Health and Earn a Medical Plan Credit
CarMax is committed to helping you be as healthy as possible, and all Associates are encouraged to commit to
their health and take positive steps toward improving it. Again this year, a portion of your and (if covered) your
Spouse/Domestic Partner’s Medical Plan Credit will be linked to your Know Your Numbers results. This begins
with Knowing Your Numbers, which includes:
• A confidential biometric screening, which measures your risk for Metabolic Syndrome through your
blood pressure, cholesterol, triglycerides, glucose, and waist circumference.
and
• An online Health Assessment, which is a confidential questionnaire that reveals health risks based
on your answers to questions about lifestyle habits, such as how you eat and how active you are.
If your results indicate you are at risk for Metabolic Syndrome, or if you are a tobacco user, you can still earn the
Medical Plan Credit by participating in Aetna’s Healthy Lifestyle Coaching program. And, if needed, we will
accommodate the recommendations of your doctor.
If Commitment to Health is completed
Savings per paycheck
Savings for Plan Year
Associate
$23.08
$600
Associate + Spouse/
Domestic Partner
$46.16
$1,200
Please see the Commitment to Health Policy, available at benefits.carmax.com for all the details
regarding the Commitment to Health program and the Aetna Healthy Lifestyle Coaching program.
page 8 of 20
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2016 Updates
Medical
Health Spending Accounts
Dental & Vision
DCSA
Appendix
H E A LT H S P E N D I N G ACCO U N T S
overview
Health spending accounts are pretax savings accounts that can help you save money
on your health expenses. For more information, see the chart on page 10.
• Health Care Flexible Spending Account (Health Care FSA)
(for Premium 80 or Select 70 Plan members)
•H
ealth Reimbursement Account (HRA)
(for Select 70 Plan members)
•H
ealth Savings Account (HSA)
(for Core 60 Plan members)
• L imited Purpose Flexible Spending Account (Limited Purpose FSA)
(for Core 60 Plan members)
REMINDER:
You must re-enroll in the Health Care FSA, HSA,
and Limited Purpose FSA each year if you want
to continue your participation.
page 9 of 20
The IRS imposes special eligibility requirements on HSAs. Please review “The Core 60 Medical Plan Option” and
“Health Savings Account Frequently Asked Questions” documents on benefits.carmax.com.
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Medical
HEALTH SPENDING ACCOUNTS
overview cont’d
Dental & Vision
Health Spending Accounts
DCSA
Appendix
The Medical Plan you choose determines the account(s) you are eligible to participate in.
The chart below provides an overview of the accounts and the Plan each applies to.
Health Care
Flexible Spending
Account
Health
Reimbursement
Account (HRA)
Health Savings
Account (HSA)
Limited Purpose
FSA
Medical Plan Eligibility
Premium 80 or Select 70
Select 70
Core 60
Core 60
Description of Account
Pretax account used to pay for
qualified health expenses
A CarMax funded account for
participants in the CarMax Select
70 Plan option to pay for
qualified Medical expenses
A pretax account for Associates
enrolled in the CarMax Core 60
Plan option to pay for qualified
health expenses
A pretax account used to pay
for qualified Dental and Vision
expenses or Medical expenses
you incur after you reach your
full deductible
If I don’t participate in a CarMax Medical Plan,
can I join the plan?
Yes, provided you are not
contributing to a Health
Savings Account
No
No
No
Do I have to re-enroll every year if I wish to contribute?
Yes
No
Yes
Yes
Is the “Plan Year” the same as the calendar year?
No. The Plan Year is March 1 February 28/29
No. The Plan Year is March 1 February 28/29
No. The Plan Year is March 1 February 28/29
No. The Plan Year is March 1 February 28/29
Does CarMax contribute to my account?
No
Yes
$200 per member, up to $600
Yes
$200 per member, up to $600
No
Can I contribute to my account?
Yes
No
Yes*
Yes
How much can I contribute to my account during
the Plan Year?
$2,550
n/a
$3,150 (Associate Only)
$6,350 (2-Person)
$6,150 (Family)
$500
Can I make a “catch up” contribution?
No
No
An additional $1,000 is allowed
for Associates who are ages 55
and older
No
Do I pay taxes on my or CarMax’s contributions to my account??
No
No
No
No
Debit Card at purchase or
Reimbursement Request
How do I use the money in my account?
Debit Card at purchase or
Reimbursement Request
Automatically applied when claim
is processed
You decide if you want to use
your account or save for future
expenses
What expenses can I use the Account for?
Note: Qualified Expenses are described in IRS Publication 502.
Qualified Medical, Dental, and
Vision expenses
Qualified Medical expenses only
Qualified Medical, Dental, and
Vision expenses
Qualified Dental and Vision
expenses or Medical expenses
incurred after you reach your
full Medical deductible
What happens to the money in my account if I leave CarMax?
You forfeit any unused account
balance
You forfeit any unused account
balance
You keep the money!
You forfeit any unused account
balance
Can I carry money forward from year to year?
Yes, you can carry forward up to
$500
Yes, up to 3 years as long as you
remain enrolled in Select 70
Yes
Yes, you can carry forward up to
$500
Can I change my contribution or my participation at any time?
No, changes are limited to IRSapproved Change in Status Events
n/a
Yes, certain limits may apply
No, changes are limited to IRSapproved Change in Status Events
page 10 of 20
*Subject to proration
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2016 Updates
Medical
Health Spending Accounts
Dental & Vision
D E N TA L & V I S I O N P L A N
DCSA
Appendix
overview
Dental Plan Highlights
Our Dental Plan is a PPO plan administered by Aetna. It covers preventive care, including cleanings and X-rays,
at 100% with no deductible. Basic and major services are covered at 80% and 50%, respectively, after you meet
your deductible.
2016 Dental Plan Rates (bi-weekly):
Our existing Dental Plan coverage will not change for 2016.
Coverage Level
Associate
Pretax Rate
Associate
$10.45
Associate + Child
$20.91
Associate + Children
$28.22
Associate + Spouse/
Domestic Partner
$20.91
Family
$35.64
Vision Plan Highlights
The EyeMed Vision Care Plan includes provisions for eye exams, contacts or lenses, and frames each Plan Year.
2016 Vision Plan Rates (bi-weekly):
We have made some improvements to the Vision Plan! CarMax
is increasing coverage for frames and contacts to $150/year, a $30
increase over last year!
page 11 of 20
Coverage Level
Associate
Pretax Rate
Associate
$2.88
Associate + Child
$5.33
Associate + Children
$8.03
Associate + Spouse/
Domestic Partner
$5.76
Family
$8.63
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2016 Updates
Medical
Health Spending Accounts
Dental & Vision
DCSA
Appendix
D AY C A R E S AV I N G S A C C O U N T
overview
The Day Care Savings Account (DCSA) lets you set aside money through pretax payroll
deductions for day care expenses.
When you enroll in the DCSA program, you’ll be reimbursed for eligible expenses that occur during the
Plan Year. You must enroll in the DCSA each year if you want to participate.
Plan your spending
You can set aside up to $5,000 for eligible out-of-pocket day care expenses in your DCSA. Carefully estimate your
day care expenses for the Plan Year, and use the calculator worksheets on benefits.carmax.com to help you figure
out how much you’ll need for the year. Please note that the $5,000 maximum is an IRS limitation per household,
so if your spouse also has a DCSA, you will need to coordinate under this limitation.
Your day care provider must claim the income for tax purposes in order for these expenses to be reimbursable from
your DCSA.
If you currently have a DCSA, claims for expenses incurred between March 1, 2015 and February 29, 2016 must
be submitted for reimbursement no later than May 29, 2016.
Any amounts you don’t use will be forfeited at the end of the Plan Year’s Run-out Period.
IRS Limitations
The IRS regulates flexible spending accounts, including the DCSA, to ensure highly-compensated employees do not reap significantly greater benefits than
non-highly-compensated employees. Participants considered “highly compensated” may be subject to reduced or suspended contributions at any time to
comply with these regulations. We will notify you if this applies to you.
REMINDER:
You must re-enroll in this account each year if
you want to continue your participation.
page 12 of 20
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Appendix
Core 60 Medical Plan Chart________________ 14
Select 70 Medical Plan Chart_______________ 15
Dental & Vision
DCSA
Appendix
State Children’s Health Insurance Program (SCHIP)
Special Enrollment Provisions
Glossary of Terms _______________________ 17
If you or your children are eligible for Medicaid or CHIP and
you’re eligible for health coverage under your Plan, your state
may have a premium assistance program that can help pay for
coverage, using funds from its Medicaid or CHIP programs.
Examples of Claims ______________________ 18
For more information about these programs, please see your Open Enrollment
materials and the SCHIP Notice available at benefits.carmax.com.
Premium 80 Medical Plan Chart______________ 16
Who to Contact __ _______________________20
Women’s Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy, you may be
entitled to certain benefits under the Women’s Health and Cancer
Rights Act of 1998 (WHCRA). For individuals receiving mastectomyrelated benefits, coverage will be provided in a manner determined
in consultation with the attending physician and the patient for:
Additional Disclosures – Please Review
The following documents are available at benefits.carmax.com under Open Enrollment:
• Enrollment Terms and Conditions
•Dependent Eligibility Guidelines – Medical, Dental, & Vision Plans
• Change in Status Events
Please review these documents carefully. When you enroll in the CarMax benefit plans,
you agree that you understand and accept the Enrollment Terms and Conditions.
page 13 of 20
• All stages of reconstruction of the breast on
which the mastectomy was performed;
• Surgery and reconstruction of the other breast
to produce a symmetrical appearance;
• Prostheses; and
• Treatment of physical complications of the
mastectomy, including lymphedema.
Coverage for these services is subject to deductible and coinsurance
provisions just like other medical or surgical services covered by the Plan.
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➤ Medical Plan Decision Tool
AETNA
Core 60
In-Network*
Out-of-Network
Deductible
Individual $2,000
Two Individuals $4,000
Family $6,000
Individual $5,000
Two Individuals $10,000
Family $15,000
Out-of-Pocket Maximums
Individual $6,550
Family $13,100
Individual $12,000
Family $24,000
The full amount of the deductible must be satisfied
before the Plan pays any benefits
(Combined Medical and Prescription)
CarMax contributions:
Individual: $200
Two Individuals: $400
Family: $600
Health Savings Account (HSA)
(Account can be used for both In-Network and
Out-of-Network services)
YOU PAY
Physician Services
YOU PAY
IMPORTANT DETAILS:
This summary provides Plan Highlights only. It is not
intended to provide all information about the Plan. Refer to
the Summary Plan Description (SPD) for more information.
If the information provided here conflicts with the SPD, the
SPD will prevail.
* In-Network providers participate in the Aetna Choice® POS
II Network.
** When you’re looking for a specialist in the Aetna network,
look for the Aexcel® blue star designation. Providers with this
mark meet certain quality and efficiency standards and offer
you the best value.
$0 for preventive visits
50% after deductible
40% after deductible‡/all other visits
50% after deductible
Free
n/a
$40/visit
n/a
Retail Walk-In Clinics (e.g., CVS MinuteClinic®)
40% after deductible‡
50% after deductible
Specialist Office Visit**
40% after deductible‡
50% after deductible
Generic
$0 after deductible‡
50% after deductible
Preferred Brand
40% after deductible‡
50% after deductible
Non-Preferred Brand
Primary Care Physician (PCP) Office Visits
(Family or General Practitioner, Internist,
Pediatrician, OB/GYN)
24/7 Aetna Nurseline
Teladoc
Telephonic or Video Virtual Office Visit
Diagnostic Lab and Basic Imaging
(e.g., X-rays, ultrasounds)
Complex Imaging
(e.g., MRI/CT Scan/PET Scan)
Hospital Services
Inpatient Services, Outpatient Services/Ambulatory
Surgery, Skilled Nursing Facility Services, Mental
Health Services, Substance Abuse Services, and
hospital labs and imaging
40% after deductible‡
50% after deductible
$0
50% after deductible
Delivery and Newborn Care
40% after deductible‡
50% after deductible
40% after deductible‡
50% after deductible
Urgent Care Center
40% after deductible‡
50% after deductible
Emergency Room***
40% after deductible‡
40% after deductible
page 14 of 20
Retail (max 30-day supply)
Generic
Preferred Brand ††
Prenatal Exams
Covers maternity office visits; coinsurance
applies for delivery and post-delivery services
Up to 60 visits each/Plan Year
3-Tier Prescription Drug Program
$25 copay after deductible is met
40% coinsurance, Min $50, Max $125
after deductible is met
40% coinsurance, Min $70, Max $175
after deductible is met
Maintenance Choice (max 90-day supply)
Maternity and Newborn Services
Speech/Physical/Occupational Therapy
*** If participants receive medical care in an emergency room
and symptoms did not indicate an emergency, no benefits will
be paid.
Back to Aetna Medical Plan Options
Non-Preferred Brand ††
$50 copay after deductible is met
40% coinsurance, Min $100, Max $250
after deductible is met
40% coinsurance, Min $140, Max $350
after deductible is met
Prescriptions on the Preventive Drug List are not subject to the deductible.
Please note: All maintenance prescriptions must be purchased through
CVS/caremark™ Maintenance Choice program. With Maintenance
Choice, you can get your prescriptions by mail or at your local
CVS. And, you’ll get 3 months of medication for the price of 2.
†† Subject to Generics First Program
‡ You pay 100% of the cost until you reach your full deductible,
which is based on your level of coverage.
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➤ Medical Plan Decision Tool
AETNA
Select 70
Deductible
In-Network*
Individual $1,700
Two Individuals $3,400
Family $5,100
(Account applies to both In-Network and
Out-of-Network services)
(Combined Medical and Prescription)
Individual $4,250
Two Individuals $8,500
Family $12,750
CarMax contributions:
Individual: $200
Two Individuals: $400
Family: $600
Health Reimbursement Account (HRA)
Out-of-Pocket Maximums
Out-of-Network
Individual $6,550
Family $13,100
Physician Services
* In-Network providers participate in the Aetna Choice® POS
II Network.
Individual $12,000
Family $24,000
YOU PAY
YOU PAY
$0 for preventive visits
50% after deductible
$30 copay/all other visits
50% after deductible
Free
n/a
$30 copay/visit
n/a
Retail Walk-In Clinics (e.g., CVS MinuteClinic®)
$30 copay/visit
50% after deductible
Specialist Office Visit**
30% after deductible
50% after deductible
$0
30% after deductible
Primary Care Physician (PCP) Office Visits
(Family or General Practitioner, Internist,
Pediatrician, OB/GYN)
24/7 Aetna Nurseline
Teladoc
Telephonic or Video Virtual Office Visit
Diagnostic Lab and Basic Imaging
(e.g., X-rays, ultrasounds)
Complex Imaging
(e.g., MRI/CT Scan/PET Scan)
Retail (max 30-day supply)
Preferred Brand
30% coinsurance, Min $40, Max $100
50% after deductible
Non-Preferred Brand
30% coinsurance, Min $60, Max $150
Maintenance Choice (max 90-day supply)
30% after deductible
50% after deductible
$0
50% after deductible
Delivery and Newborn Care
30% after deductible
50% after deductible
30% after deductible
50% after deductible
Urgent Care Center
$60 copay/visit
50% after deductible
Emergency Room***
$250 copay plus 30% after deductible $250 copay plus 30% after deductible
page 15 of 20
3-Tier Prescription Drug Program
50% after deductible
Prenatal Exams
Covers maternity office visits; coinsurance
applies for delivery and post-delivery services
Up to 60 visits each/Plan Year
***If participants receive medical care in an emergency room
and symptoms did not indicate an emergency, no benefits will
be paid.
$15 copay
Maternity and Newborn Services
Speech/Physical/Occupational Therapy
** When you’re looking for a specialist in the Aetna network,
look for the Aexcel® blue star designation. Providers with this
mark meet certain quality and efficiency standards and offer
you the best value.
Generic
Hospital Services
Inpatient Services, Outpatient Services/Ambulatory
Surgery, Skilled Nursing Facility Services, Mental
Health Services, Substance Abuse Services, and
hospital labs and imaging
IMPORTANT DETAILS:
This summary provides Plan Highlights only. It is not
intended to provide all information about the Plan. Refer to
the Summary Plan Description (SPD) for more information.
If the information provided here conflicts with the SPD, the
SPD will prevail.
Back to Aetna Medical Plan Options
Generic
$30 copay
Preferred Brand††
30% coinsurance, Min $80, Max $200
Non-Preferred Brand†† 30% coinsurance, Min $120, Max $300
Please note: All maintenance prescriptions must be purchased
through CVS/caremark™ Maintenance Choice program. With
Maintenance Choice, you can get your prescriptions by mail
or at your local CVS. And, you’ll get 3 months of medication
for the price of 2 — use the Health Care FSA to help you
manage your prescription costs and save even more!
†† Subject to Generics First Program
Prescriptions are not subject to the deductible in the
Select 70 Plan option.
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➤ Medical Plan Decision Tool
AETNA
Premium 80
Deductible
Out-of-Pocket Maximums
(Combined Medical and Prescription)
In-Network*
Out-of-Network
Individual $600
Two Individuals $1,200
Family $1,800
Individual $1,800
Two Individuals $3,600
Family $5,400
Individual $6,550
Family $13,100
Individual $12,000
Family $24,000
YOU PAY
Physician Services
YOU PAY
$0 for preventive visits
50% after deductible
$20 copay/all other visits
50% after deductible
Free
n/a
$20 copay/visit
n/a
Retail Walk-In Clinics (e.g., CVS MinuteClinic®)
$20 copay/visit
50% after deductible
Specialist Office Visit**
$50 copay/visit
50% after deductible
$0
50% after deductible
20% after deductible
50% after deductible
20% after deductible
50% after deductible
Primary Care Physician (PCP) Office Visits
(Family or General Practitioner, Internist,
Pediatrician, OB/GYN)
24/7 Aetna Nurseline
Teladoc
Telephonic or Video Virtual Office Visit
Diagnostic Lab and Basic Imaging
(e.g., X-rays, ultrasounds)
Complex Imaging
(e.g., MRI/CT Scan/PET Scan)
Hospital Services
Inpatient Services, Outpatient Services/Ambulatory
Surgery, Skilled Nursing Facility Services, Mental
Health Services, Substance Abuse Services, and
hospital labs and imaging
Maternity and Newborn Services
$0
50% after deductible
Delivery and Newborn Care
20% after deductible
50% after deductible
20% after deductible
50% after deductible
Urgent Care Center
$40 copay/visit
50% after deductible
Emergency Room***
$150 copay plus 20% after deductible $150 copay plus 20% after deductible
Up to 60 visits each/Plan Year
Back to Aetna Medical Plan Options
page 16 of 20
* In-Network providers participate in the Aetna Choice® POS
II Network.
** When you’re looking for a specialist in the Aetna network,
look for the Aexcel® blue star designation. Providers with this
mark meet certain quality and efficiency standards and offer
you the best value.
*** If participants receive medical care in an emergency room and
symptoms did not indicate an emergency, no benefits will be paid.
3-Tier Prescription Drug Program
Retail (max 30-day supply)
Generic
$10 copay
Preferred Brand
$35 copay
Non-Preferred Brand
$55 copay
Maintenance Choice (max 90-day supply)
Prenatal Exams
Covers maternity office visits; coinsurance
applies for delivery and post-delivery services
Speech/Physical/Occupational Therapy
IMPORTANT DETAILS:
This summary provides Plan Highlights only. It is not
intended to provide all information about the Plan. Refer to
the Summary Plan Description (SPD) for more information.
If the information provided here conflicts with the SPD, the
SPD will prevail.
Generic
$20 copay
Preferred Brand††
$70 copay
Non-Preferred Brand††
$110 copay
Please note: All maintenance prescriptions must be purchased
through CVS/caremark™ Maintenance Choice program. With
Maintenance Choice, you can get your prescriptions by mail
or at your local CVS. And, you’ll get 3 months of medication
for the price of 2 — use the Health Care FSA to help you
manage your prescription costs and save even more!
†† Subject to Generics First Program
Prescriptions are not subject to the deductible in the
Premium 80 Plan option.
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How To
2016 Updates
Medical
Appendix
Glossary of Terms
Aexcel® Network – Aetna’s network of specialists in 12
common specialties who meet certain quality and efficiency
standards. These specialists offer you the best value. Aexcel
specialists can be found using aetna.com’s DocFind provider
search tool —they have blue stars next to their names.
Brand Prescription – A prescription medication that is
made under a trademark. A brand-name drug typically costs
more than a generic medication, despite having the same
chemical composition. CVS/caremark™ has established a list
of preferred brand prescriptions that have a lower out-of-pocket
cost to you and to the Plan. Please refer to the CVS/caremark™
Performance Drug List on the Benefits website. Non-preferred
brand prescriptions have a higher out-of-pocket cost to you and a
higher cost to the Plan.
Coinsurance – Your share of the costs of a covered health
service, calculated as a percentage of the charges for the services.
Coinsurance applies after you have met your deductible in full.
Copay/Copayment – A fixed dollar amount you pay for a
covered health care service, usually when you receive the service.
Deductible – The amount you pay out-of-pocket for covered
health care services before the plan begins to pay. The InNetwork and Out-of-Network deductibles are separate — if
you have a medical situation that involves both In-Network and
Out-of-Network services, you’ll be subject to both deductibles.
Your deductible amount for you and your family depends on your
chosen Plan coverage.
Emergency Medical Condition – An illness, injury,
symptom, or condition so serious that a reasonable person would
seek care right away to avoid severe harm. Visits to emergency
rooms should be limited to significant medical emergencies.
If you get care in an emergency room and your symptoms did
not indicate an emergency, no benefits will be paid. If you are
admitted to the hospital or if surgery is performed, you must
notify Aetna within 48 hours.
page 17 of 20
Health Spending Accounts
Dental & Vision
DCSA
Generic Prescription – A prescription medication that is not
made under a trademark, but which contains the same chemical
properties as its brand-name counterpart. Generics are a lowercost alternative that can save you and the Plan money. If your
doctor prescribes a brand-name medication, ask if a generic is
right for you.
In-Network Provider – The facilities, providers, suppliers,
and pharmacies that Aetna and CVS/caremark™ have contracted
with to provide health care services. These are providers who
participate in Aetna Choice® POS II (Open Access) network.
Network providers have negotiated lower rates for services in
order to save you and the Plan money.
Maintenance Choice Prescription – The CVS/caremark™
program that provides you with two choices for receiving your
maintenance medications: via convenient home delivery through
Mail Order or by purchasing a 90-day supply through your local
CVS pharmacy. The Medical Plan requires all maintenance
medications to be purchased through Maintenance Choice.
Other Covered Services – Medical Plan services such as
hospital services, mental health services, inpatient or outpatient
surgery, chiropractic or other therapy services, etc. These services
are generally subject to the Plan’s deductible and coinsurance.
Out-of-Pocket Maximum – This is the total amount you
will pay on your own. Once you reach the Plan’s out-of-pocket
maximum, the Plan will pay 100 percent of covered services. The
out-of-pocket maximum includes the Plan’s deductible, copays,
and coinsurance.
The In-Network and Out-of-Network out-of-pocket maximums
are separate and do not cross-accumulate. If you have a medical
situation that involves In-Network and Out-of-Network services,
you’ll pay toward both maximums separately.
Preventive Drug List – A list of preventive prescriptions
established by CVS/caremark™ and approved for copayments
while meeting your deductible in High Deductible Health Plans
(the Core 60 Plan). If your prescription is included on this list, it
will be subject to the standard copayment, including minimums
and maximums, that would apply after you reach your deductible.
Find this list on the Benefits website.
Appendix
Primary Care Physician/Office Visit – Visit your
Primary Care Physician regarding all of your health issues
and for help managing your overall health. Your Primary Care
Physician should handle your annual physical, any health
concerns, and coordinate treatment plans.
Reasonable and Customary (Recognized) Charges
The amount paid for a medical service in a geographic area based
on what providers in that area usually charge for the same or
similar medical service. This amount is determined by Aetna
or CVS/caremark™, as applicable. Reasonable and Customary
(Recognized) Charges are typically only applied when Outof-Network providers are used for the purpose of determining
provider and participant reimbursement amounts.
Specialist Office Visit – If you need to see a Specialist, use
DocFind on the aetna.com website and look for the blue star; this
designates the Provider as a member of the Aexcel® Network,
which means they have been recognized by Aetna as a highquality, cost-effective provider.
Urgent Care Clinic – Facilities for treatment of non-lifethreatening injuries or illnesses, such as fractures, whiplash,
sport injuries, falls, cuts and minor lacerations, allergies,
infections, and minor burns. These are often freestanding
buildings that have a physician on site and accept walk-ins. Costs
are typically higher than Retail Walk-In Clinics or a Primary
Care Physician visit.
Walk-In Clinics – Non-emergency health facilities, usually
located inside retail stores, such as CVS MinuteClinic®. Visit one
of these clinics if you have the need for immediate care that is not
urgent (cold/flu symptoms, rashes, or basic infections), or if you
need a wellness exam or a routine physical.
24-Hour Nurseline – Aetna offers its Plan members a free,
24-Hour Nurseline to help you anytime — day or night. Just
call (800) 556-1555 and select the option to speak with a nurse.
You’ll be connected to a trained professional who can explain
medical procedures and treatment options and determine if you
need immediate care or if you can wait to see your doctor during
normal business hours.
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How To
2016 Updates
Medical
Appendix
Examples of Claims
SPECIALIST OFFICE VISIT
Member goes to an In-Network Orthopedic surgeon for an office visit.
The cost of the office visit is $400. Member has Associate-only coverage.
Core 60
•
Member must meet the $2,000 deductible (HSA can be used to pay
toward the cost)
•
If the member has not met the deductible, he pays $400
•If the member has met the deductible, he pays 40% of the cost:
40% X $400 = $160
Select 70
•
Member must meet $1,700 deductible (HRA pays for $200 of the cost)
•
If the member has not met the deductible, he pays $200 ($400-$200)
•After the member has met the deductible, he pays 30% of the remaining
cost: 30% X $400= $120
Premium 80
• Member pays $50 copay
page 18 of 20
Dental & Vision
Health Spending Accounts
DCSA
Appendix
OUTPATIENT SURGERY CLAIM
Member has outpatient surgery at an In-Network facility. Total cost is $10,000.
Member has Family coverage. In the Core 60 Plan, the deductible for the level of coverage
must be met before the Plan starts to pay benefits. In the Select 70 and Premium 80 Plans, only
the individual deductible must be met before the Plan starts to pay benefits.
Core 60
•
Member must meet the $6,000 deductible (HSA can be used to pay toward the cost)
•
If the member has not met the deductible, he pays $6,000
•
After the member has met the deductible, member pays 40% of the remaining
cost: $10,000 total cost - $6,000 Family deductible = $4,000 X 40% = $1,600.
Member pays the total of $6,000 + $1,600 = $7,600. Since the out-of-pocket maximum
is $6,550, member only pays $6,550.
Select 70
•
Member must meet the $1,700 individual deductible (HRA pays for $600 of the cost)
•
If the member has not met the individual deductible, he pays $1,100 ($1,700-$600)
•
fter the member has met the individual deductible, member pays 30% of the A
remaining cost: $10,000 total cost - $1,700 deductible = $8,300 X 30% = $2,490.
Member pays the total of $1,100 + $2,490 = $3,590.
Premium 80
•
Member must meet the $600 individual deductible
•
If the member has not met the individual deductible, he pays $600
•
fter the member has met the individual deductible, member pays 20% of the
A
remaining cost: $10,000 total cost - $600 deductible = $9,400 X 20% = $1,880.
Member pays the total of $600 + $1,880 = $2,480.
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2016 Updates
Medical
Health Spending Accounts
Dental & Vision
DCSA
Appendix
Appendix
EXAMPLES OF CL AIMS cont’d
HAVING A BABY
Member is having a baby at an In-Network hospital. The total cost of the
delivery is $7,500. Member has Associate-only coverage.
Core 60
•
Member must meet the $2,000 deductible (HSA can be used to pay toward the cost)
•
If the member has not met the deductible, she pays $2,000
•After the member has met the deductible, she pays 40% of the remaining cost: $7,500
total cost - $2,000 deductible = $5,500 X 40% = $2,200. Member pays
the total of $2,000 + $2,200 = $4,200.
Select 70
•
Member must meet the $1,700 deductible (HRA account pays for $200 of the cost)
•
If the member has not met the deductible, she pays $1,500
•After the member has met the deductible, she pays 30% of the remaining cost: $7,500
total cost - $1,700 deductible = $5,800 X 30% = $1,740. Member pays the total of
$1,500 + $1,740 = $3,240.
Premium 80
•
Member must meet the $600 deductible
•
If the member has not met the deductible, she pays $600
•
After the member has met the deductible, she pays 20% of the remaining cost:
$7,500 - $600 deductible = $6,900 X 20% = $1,380. Member pays the total of
$600 + $1,380 = $1,980.
page 19 of 20
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2016 Updates
Medical
Health Spending Accounts
Dental & Vision
DCSA
Appendix
Appendix
Who to Contact
If you need more information or copies of the
Open Enrollment materials, please contact the
MYKMXHR Service Center at (888) 695-6947
or visit benefits.carmax.com.
Eligibility and Process Questions
MYKMXHR Service Center:
(888) 695-6947
Aetna Choice® POS II Medical Plan
Member Services: (866) 498-5004
Online: aetna.com
EyeMed Vision Care Plan
Member Services: (866) 723-0514
Online: eyemedvisioncare.com
For questions about your Health Spending
Account, your Health Savings Account or your
Day Care Savings Account
WageWorks® Member Services:
(877) 924-3967
Online: wageworks.com/carmax
For contact information for our other benefit
providers, please refer to “Connections @A
Glance” at benefits.carmax.com.
CVS/caremark™ — Prescription Drug Program
Member Services: (855) 361-8564
Online: caremark.com
Aetna Dental PPO Plan
Member Services: (866) 498-5004
Online: aetna.com
page 20 of 20
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