6-Exhibit D-1 - SBC Aetna Medical ACO Plan 20240901.pdf

Schertz-Cibolo-Universal City Independent School District

Effective Date: 09-01-2024 Aetna Open Access® Aetna SelectSM

PLAN DESIGN & BENEFITS

ADMINISTERED BY AETNA LIFE INSURANCE COMPANY

PLAN FEATURES MAXIMUM SAVINGS STANDARD SAVINGS

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) $2,000 per Individual $2,000 per Individual $4,000 per Family $4,000 per Family Covered expenses add up toward both your maximum savings and standard savings deductible at the same time.

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 40% Applies to all expenses except as noted.

Out-of-pocket limit (per calendar year)

$5,000 per Individual $5,000 per Individual

$10,000 per Family $10,000 per Family Covered expenses add up toward both your maximum savings and standard savings out-of-pocket limit at the same time.

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.

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.

Primary care physician selection Optional Not Applicable Referral requirement Not required Not required 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 MAXIMUM SAVINGS STANDARD SAVINGS

Routine adult physical exams/ immunizations

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

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

Women's health Covered 100%; no deductible Covered 100%; no 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 Covered 100%; no deductible Routine digital rectal exam Covered 100%; no deductible Covered 100%; no deductible

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

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

PHYSICIAN SERVICES MAXIMUM SAVINGS STANDARD SAVINGS

Office visits to primary care physician (PCP)

$15 office visit copay; no deductible 40%; after deductible

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

Telehealth consultation with non-specialist

$15 office visit copay; no deductible 40%; after deductible

Specialist office visits $50 office visit copay; no deductible 40%; after deductible Telehealth consultation with specialist

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

Hearing exams Not Covered Not Covered Walk-in clinics $15 copay; no deductible 40%; after deductible Designated Walk-in clinics Designated Walk-in clinics Covered 100%; no deductible 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.

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

Designated Walk-in clinics Designated Walk-in clinics Covered 100%; no deductible 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 MAXIMUM SAVINGS STANDARD SAVINGS

Diagnostic X-ray (Other than complex imaging services)

20%; after deductible 20%; after deductible

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

Diagnostic laboratory 20%; after deductible 20%; 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 20%; 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 MAXIMUM SAVINGS STANDARD SAVINGS

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

Not Covered

Emergency room 20% after $300 copay; after deductible

20% after $300 copay; after deductible

Copay waived if admitted Non-emergency care in an emergency room

Not Covered Not Covered

Emergency use of ambulance 20%; after deductible 20%; after deductible Non-emergency use of ambulance Not Covered

HOSPITAL CARE MAXIMUM SAVINGS STANDARD SAVINGS

Inpatient coverage 20%; after deductible 40% after $500 copay; 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 40% after $500 copay; 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 40%; 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 40% after $250 copay; 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 40% after $250 copay; 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 MAXIMUM SAVINGS STANDARD SAVINGS

Inpatient 20%; after deductible 40% after $500 copay; 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 Covered 100%; no deductible Covered 100%; no deductible Mental health telehealth consultations

Covered 100%; no deductible Covered 100%; no deductible

Other mental health services

Covered 100%; no deductible 40%; 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 MAXIMUM SAVINGS STANDARD SAVINGS

Inpatient 20%; after deductible 40% after $500 copay; 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 20%; 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 Covered 100%; no deductible Covered 100%; no deductible Substance abuse telehealth consultations

Covered 100%; no deductible Covered 100%; no deductible

Other substance abuse services Covered 100%; no deductible 20%; 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 MAXIMUM SAVINGS STANDARD SAVINGS

Spinal manipulation therapy $50 copay; no deductible 40%; after deductible Limited to 20 visits per year Outpatient short-term rehabilitation

$15 copay; no deductible

$15 copay; no deductible

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

Habilitative physical therapy Refer to MBH Outpatient Mental

Health All Other Refer to MBH Outpatient Mental Health All Other

Habilitative occupational therapy Refer to MBH Outpatient Mental Health All Other

Refer to MBH Outpatient Mental Health All Other

Habilitative speech therapy Refer to MBH Outpatient Mental Health All Other

Refer to MBH Outpatient Mental Health All Other

Autism related physical therapy Refer to MBH Outpatient Mental Health All Other

Refer to MBH Outpatient Mental Health All Other

Autism related occupational therapy

Refer to MBH Outpatient Mental Health All Other

Refer to MBH Outpatient Mental Health All Other

Autism related speech therapy Refer to MBH Outpatient Mental Health All Other

Refer to MBH Outpatient Mental Health All Other

Autism related behavioral therapy Refer to MBH Outpatient Mental Health

Refer to MBH Outpatient Mental Health

These benefits are combined with outpatient mental health visits Autism related applied behavior analysis

Covered 100%; no deductible 20%; after deductible

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

OTHER SERVICES MAXIMUM SAVINGS STANDARD SAVINGS

Skilled nursing facility 40%; after deductible 40%; 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 20%; 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 20%; 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 20%; 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.

Durable medical equipment 20%; after deductible 20%; after deductible Hearing Aids 20%; after deductible

1 per 3 year per ear 20%; after deductible

Prosthetics 20% after deductible 40%; after deductible Orthotics (excludes foot orthotics, orthopedic shoes and supportive devices of the feet)

20% after deductible 40% 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 $50 copay; no deductible 40%; after deductible Infusion therapy - outpatient hospital/freestanding facility

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

Your cost sharing 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.

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

$50 copay; no deductible for gene therapy drugs, if applicable

$50 copay; no deductible for gene therapy drugs, if applicable

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

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

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

In-network coverage is only available at Institutes of Excellence (IOE) contracted facility.

Bariatric surgery

Not Covered Not Covered

FAMILY PLANNING MAXIMUM SAVINGS STANDARD SAVINGS

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 20%; after deductible 40%; after deductible Tubal ligation Covered 100%; no deductible Covered 100%; no 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.

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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