5-Exhibit D-3 - SBC Aetna Medical POS Plan 20240901.pdf

Schertz-Cibolo-Universal City Independent School District Effective Date: 09-01-2024

Aetna Choice® POS II -- ASC

PLAN DESIGN & BENEFITS

ADMINISTERED BY AETNA LIFE INSURANCE COMPANY

PLAN FEATURES IN-NETWORK OUT-OF-NETWORK

Benefit limitations - Some service or supplies have limits on them per year. There might be a maximum number of visits or days, or a dollar limit per year. In such cases, the benefit year begins on January 1 (unless otherwise noted).

Refer to your plan documents to learn more.

Deductible (per calendar year) $4,000 per Individual $15,000 per Individual

$8,000 per Family $30,000 per Family Covered expenses in-network add up towards your in-network deductible. Covered expenses out-of-network add up towards your out-of-network deductible.

You must first meet the deductible before the plan begins paying benefits, unless otherwise noted.

The amount you pay (cost sharing) for some medical services does not count toward your deductible. Prescription drug costs do not count toward the deductible. Refer to your plan documents for details.

Your family will have one deductible. You will meet it when the expenses of several family members add up to the family deductible. No one person will have to pay more than the individual deductible.

Member coinsurance You pay 20% You pay 50% Applies to all expenses except as noted.

Out-of-pocket limit (per calendar year)

$6,550 per Individual $18,000 per Individual

$13,100 per Family $36,000 per Family Covered expenses in-network add up towards your in-network out-of-pocket limit. Covered expenses out-of-network add up towards your out-of-network out-of-pocket limit.

Some of your cost sharing may not count toward the out-of-pocket limit.

Your pharmacy expenses count toward your out-of-pocket limit.

In-network expenses include coinsurance/copays and deductibles.

Out-of-network expenses include coinsurance and deductibles. Penalty amounts do not apply.

Your family will have one out-of-pocket limit. You will meet it when the expenses of several family members add up to the family out-of-pocket limit. No one person will have to pay more than the individual out-of-pocket limit amount.

Lifetime maximum Unlimited except where otherwise indicated.

Payment for out-of-network care** Does not apply Professional: Prevailing Charges

Facility: Facility Charge Review Primary care physician selection Encouraged Does not apply Precertification requirements - Some out-of-network services need approval by us in advance (precertification). Without this approval, we reduce benefits by 50%. Refer to your plan documents for a full list of services that need this approval.

Referral requirement Not required None Telehealth consultations - You can access covered services for telehealth visits from different kinds of providers in your plan. Log on to Aetna.com to see a list of telehealth providers. You'll also find more about your options, including cost share amounts.

PREVENTIVE CARE IN-NETWORK OUT-OF-NETWORK

Routine adult physical exams/ immunizations

Covered 100%; no deductible 50%; after deductible

1 exam per calendar year until age 65, then 1 exam per calendar year age 65 and older Routine well child exams/immunizations

Covered 100%; no deductible 50%; after deductible

• 7 exams in the first 12 months

• 3 exams from age 13 to 24 months

• 3 exams from age 25 to 36 months

• 1 exam every calendar year thereafter until age 22 Routine gynecological care exams Covered 100%; no deductible 50%; after deductible 1 exam and pap smear per calendar year, includes related fees.

Aetna Choice® POS II -- ASC

PLAN DESIGN & BENEFITS

ADMINISTERED BY AETNA LIFE INSURANCE COMPANY

Routine mammogram Covered 100%; no deductible 50%; after deductible

Women's health Covered 100%; no deductible 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.

Also includes contraceptive methods (ACA mandated contraceptives, including contraceptives and devices you can't get at a pharmacy), sterilization procedures (including tubal ligation), patient education and counseling. Limits may apply.

Pre-natal maternity Covered 100%; no deductible 50%; after deductible Routine digital rectal exam Covered 100%; no deductible 50%; after deductible

Prostate-specific antigen test Covered 100%; no deductible 50%; after deductible

Colorectal cancer screening Covered 100%; no deductible 50%; after deductible Recommended: For members age 45 and over Routine eye exams Not Covered Not Covered Routine hearing screening Covered 100%; no deductible 50%; after deductible

PHYSICIAN SERVICES IN-NETWORK OUT-OF-NETWORK

Office visits to primary care physician (PCP)

$40 office visit copay; no deductible 50%; after deductible

Includes services of an internist, general physician, family practitioner or pediatrician.

Telehealth consultation with non-specialist

$40 office visit copay; no deductible 50%; after deductible

Specialist office visits $60 office visit copay; no deductible 50%; after deductible Telehealth consultation with specialist

$60 office visit copay; no deductible 50%; after deductible

Hearing exams Not Covered Not Covered Walk-in clinics $40 copay; no deductible 50%; after deductible Designated Walk-in clinics Covered 100%; no deductible Walk-in clinics are free-standing health care facilities. Sometimes they may be within a pharmacy, drug store, supermarket, or other retail store. They offer some limited medical care and services.

Not walk-in clinics: Urgent care centers, emergency rooms, the outpatient department of a hospital, ambulatory surgical centers, and physician offices.

Telehealth consultations for non-emergency services through a walk-in clinic

Your cost sharing amount depends on the type of service and where you receive it.

50%; after deductible

Designated Walk-in clinics Covered 100%; no deductible We pay telehealth screenings and counseling services from a walk-in-clinic as a preventive care benefit.

Allergy testing Your cost sharing amount depends on the type of service and where you receive it.

Your cost sharing amount depends on the type of service and where you receive it.

Allergy injections Your cost sharing amount depends on the type of service and where you receive it.

Your cost sharing amount depends on the type of service and where you receive it.

DIAGNOSTIC PROCEDURES IN-NETWORK OUT-OF-NETWORK

Diagnostic X-ray (Other than complex imaging services)

Covered 100%; no deductible 50%; after deductible

When your physician performs and bills for this service at their office, you pay your office visit cost share amount.

Diagnostic laboratory Covered 100%; no deductible 50%; after deductible When your physician performs and bills for this service at their office, you pay your office visit cost share amount.

Diagnostic complex imaging 20%; after deductible 50%; after deductible When your physician performs and bills for this service at their office, you pay your office visit cost share amount.

EMERGENCY MEDICAL CARE IN-NETWORK OUT-OF-NETWORK

Urgent care provider $100 office visit copay; no deductible 50%; after deductible Non-urgent use of urgent care provider

Not Covered Not Covered

Emergency room 20% after $300 copay; no deductible Same as in-network care Copay waived if admitted Non-emergency care in an emergency room

Not Covered Not Covered

Emergency use of ambulance 20%; no 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 When you're admitted into a hospital for the care you need, your cost sharing amount counts toward all covered benefits you receive.

Inpatient maternity coverage (includes delivery and postpartum care)

20%; after deductible 50%; after deductible

When you're admitted into a hospital for the care you need, your cost sharing amount counts toward all covered benefits you receive.

Outpatient hospital 20%; after deductible 50%; after deductible When you receive outpatient care at a hospital but don't stay overnight, your cost sharing amount counts toward all covered benefits during your visit.

Outpatient surgery - hospital 20%; after deductible 50%; after deductible When you receive outpatient care at a hospital but don't stay overnight, your cost sharing amount counts toward all covered benefits during your visit.

Outpatient surgery - freestanding facility

20%; after deductible 50%; after deductible

When you receive outpatient care at a hospital but don't stay overnight, your cost sharing amount counts toward all covered benefits during your visit.

MENTAL HEALTH SERVICES IN-NETWORK OUT-OF-NETWORK

Inpatient 20%; after deductible 50%; after deductible When you're admitted into a hospital for the care you need, your cost sharing amount counts toward all covered benefits you receive.

Mental health office visits $40 copay; no deductible 50%; after deductible Mental health telehealth consultations

$40 office visit copay; no deductible 50%; after deductible

Other mental health services Covered 100%; no deductible 50%; after deductible When you receive outpatient care at a facility but don't stay overnight, your cost sharing amount counts toward all covered benefits during your visit.

SUBSTANCE ABUSE IN-NETWORK OUT-OF-NETWORK

Inpatient 20%; after deductible 50%; after deductible When you're admitted into a hospital for the care you need, your cost sharing amount counts toward all covered benefits you receive.

Residential treatment facility 20%; after deductible 50%; after deductible When you're admitted into a facility for the care you need, your cost sharing amount counts toward all covered benefits you receive.

Substance abuse office visits $40 copay; no deductible 50%; after deductible Substance abuse telehealth consultations

$40 office visit copay; no deductible 50%; after deductible

Other substance abuse services Covered 100%; no deductible 50%; after deductible When you receive outpatient care at a facility but don't stay overnight, your cost sharing amount counts toward all covered benefits during your visit.

THERAPY SERVICES IN-NETWORK OUT-OF-NETWORK

Spinal manipulation therapy $60 copay; no deductible 50%; after deductible Limited to 20 visits per year Outpatient short-term rehabilitation

$40 copay; no deductible 50%; after deductible

Limited to 60 visits per year Includes physical, occupational, and speech therapies.

Habilitative physical therapy Covered 100%; no deductible 50%; after deductible Habilitative occupational therapy Covered 100%; no deductible 50%; after deductible Habilitative speech therapy Covered 100%; no deductible 50%; after deductible Autism related physical therapy Covered 100%; no deductible 50%; after deductible Autism related occupational therapy

Covered 100%; no deductible 50%; after deductible

Autism related speech therapy Covered 100%; no deductible 50%; after deductible

Autism related behavioral therapy $60 copay; no deductible 50%; after deductible These benefits are combined with outpatient mental health visits Autism related applied behavior analysis

Covered 100%; no deductible 50%; after deductible

Your benefits for these services are the same as any other outpatient mental health other services benefit

OTHER SERVICES IN-NETWORK OUT-OF-NETWORK

Skilled nursing facility 20%; after deductible 50%; after deductible Limited to 60 days per year When you're admitted into a facility for the care you need, your cost sharing amount counts toward all covered benefits you receive.

Home health care 20%; after deductible 50%; after deductible Limited to 60 visits per year Private duty nursing not included.

Limited to three visits per day by staff from a home health care agency. One visit equals a period of four hours or less.

Hospice care - inpatient 20%; after deductible 50%; after deductible When you're admitted into a facility for the care you need, your cost sharing amount counts toward all covered benefits you receive.

Hospice care - outpatient 20%; after deductible 50%; after deductible When you receive outpatient care at a facility but don't stay overnight, your cost sharing amount counts toward all covered benefits during your visit.

Private duty nursing Not Covered Not Covered Durable medical equipment 20%; after deductible 50%; after deductible Hearing Aids 20%; after deductible

1 per 3 year per ear 50%; after deductible

Prosthetics 20%; after deductible 50%; after deductible Orthotics (excludes foot orthotics, orthopedic shoes and supportive devices of the feet)

20%; after deductible 50%; after deductible

Diabetic supplies -- (if not covered under the prescription drug benefit)

Covered same as any other medical expense.

Covered same as any other medical expense.

You pay your prescription drug cost sharing amount if you have prescription drug coverage. If not, you pay your PCP visit cost sharing amount.

You pay your prescription drug cost sharing amount if you have prescription drug coverage. If not, you pay your PCP visit cost sharing amount.

Infusion therapy - home/office $60 copay; no deductible 50%; after deductible Infusion therapy - outpatient hospital/freestanding facility

Your cost sharing amount depends on the type of service and where you receive it.

Your cost sharing amount depends on the type of service and where you receive it.

Gene-based, Cellular, and other Innovative Therapies (GCIT™)

Your cost sharing amount depends on the type of service and where you receive it.

Not Covered

$60 copay; no deductible for gene therapy drugs, if applicable

In-network coverage is provided at GCIT™ designated facilities only.

Transplants 20%; after deductible 50%; after deductible In-network coverage is only available at Institutes of Excellence (IOE) contracted facility.

Bariatric surgery Not Covered Not Covered

FAMILY PLANNING IN-NETWORK OUT-OF-NETWORK

Infertility treatment Your cost sharing amount depends on the type of service and where you receive it.

Your cost sharing amount depends on the type of service and where you receive it.

You have coverage for the diagnosis and treatment of the underlying cause of infertility.

Comprehensive infertility services Not Covered Not Covered Artificial insemination and ovulation induction Advanced Reproductive Technology (ART)

Not Covered Not Covered

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 amount depends on the type of service and where you receive it.

50%; after deductible

Tubal ligation Covered 100%; no deductible 50%; after deductible

GENERAL PROVISIONS

Dependents who are eligible to be on your plan

Spouse, children from birth to age 26. Student status of children does not matter.

**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.

You may choose a provider (doctor or hospital) in our network. You may choose to visit an out-of-network provider. If you choose a doctor who is out of network, your health plan may pay some of that doctor's bill. Most of the time, you will pay a lot more money out of your own pocket if you choose to use an out-of-network doctor or hospital.

When you choose out-of-network care, we limit the amount it will pay. This limit is called the "recognized" or "allowed" amount.

This amount is based on the out-of-network plan you or your employer picks.

• For doctors and other professionals the amount is based on the "prevailing" charges. We get this data from an external database.

• For hospitals and other facilities, the amount is based on the Facility Fee Schedule.

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.

You can avoid these extra costs by getting your care from Aetna's broad network of health care providers. Go to www.aetna.com and click on "Find a Doctor" on the left side of the page. If you are already a member, sign on to your Navigator member site.

This applies when you choose to get care out of network. When you have no choice (for example: emergency room visit after a car accident, or for other emergency services), we will pay the bill as if you got care in network. You pay cost sharing and deductibles for your in-network level of benefits. Contact us if your provider asks you to pay more.

You are not responsible for any outstanding balance billed by your providers for emergency services beyond your cost sharing and deductibles.

This way of paying out-of-network doctors and hospitals applies when you choose to get care out of network. When you have no choice (for example: emergency room visit after a car accident), we will pay the bill as if you got care in-network. You pay your plan's copayments and deductibles for your in-network level of benefits. Contact us if your provider asks you to pay more. You are not responsible for any outstanding balance billed by your providers for emergency services beyond your copayments and deductibles.

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. 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.

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.

• 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.

In case of emergency, call 911 or your local emergency hotline, or go directly to an emergency care facility.

Translation of this material into another language may be available. Please call Member Services at the number on the back of your ID card.

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.

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