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					                                                     Trinity College
                                       Aetna Retiree Medicare D Health Plan – 2006
All participants must enroll in Medicare Parts A & B. Under the Trinity Plan, Medicare is the primary insurer for covered services
except prescription drugs; coverage for prescription drugs is not tied to Medicare. Participants in the Aetna Retiree Medicare D Health
Plan need not enroll in any other Medicare Part D plan. For benefits other than prescription drugs, Medicare pays 80% of covered
expenses, both for hospitalizations and physicians’ fees. The Trinity Plan pays 80% of the balance (i.e. of the remaining 20%) once
the deductible has been met. Please visit the Medicare on line at www.medicare.gov for more information on Medicare coverage.



                  Plan Features                                                    Participant Payments

Deductible (per calendar year for Medical only – $250 per covered member. Unless otherwise indicated, the deductible must be
does not apply to prescription drugs)            met in order for benefits to be paid under the plan. Once individual deductibles
                                                 are met, co-payments will then apply for the remainder of the calendar year.
Out of Pocket Maximum (per calendar year for     $1,000 per covered member. Only those out-of-pocket expenses incurred in the
Medical only). Certain member cost sharing       form of co-insurance payments (except deductibles and/or penalty assessments)
elements may not apply toward the payment limit. may be used to satisfy the $1,000 per person calendar year maximum. Does not
                                                 apply to prescription drug out-of-pocket expenses.
Certification Requirements                       Certification for certain types of care must be obtained to avoid a reduction in
                                                 benefits paid for that care. Certification is required for such things as hospital
                                                 admissions, treatment facility admissions, convalescent facility admissions, home
                                                 health care, hospice care and private duty nursing.
Member Coinsurance – Applies to all expenses     20%. This represents 20% of the balance not paid by Medicare. Trinity’s plan
unless otherwise stated.                         pays 80% of covered expenses not paid by Medicare, except for prescription
                                                 drugs.
Lifetime Maximum Benefit                         $250,000 – Medical only – does not include prescription drugs or payments made
                                                 by Medicare.
Primary Care Physician Selection                 No restrictions -may use any licensed physician anywhere.

Referral Requirement                                 None – participants have total freedom of choice regarding providers including
                                                     hospitals and physicians.
               General Provisions

Pre-Existing Condition Rule                      None


                  Preventive Care

Routine Adult Physical Exams/Immunizations       Plans pays 80% of balance after Medicare payment and deductible.
1 exam every 12 months
Routine Gynecological Care Exams                 Plan pays 80% of balance after Medicare payment and deductible.
Includes pap smear and related lab fees
Routine Mammograms                               Plan pays 80% of balance after Medicare payment and deductible.
1 mammogram per calendar year
Colorectal Cancer Screening                      Member cost sharing is based on the type of service performed and where the
                                                 service is rendered; deductible waived.
Routine Eye Exams                                Not covered.

Routine Hearing Exams                            Not covered.


               Physician Services

Office Visits (non-surgical) to Non-Specialist   Plan covers 80% of balance after Medicare payment and deductible.

Specialist Office Visits                         Plan covers 80% of balance after Medicare payment and deductible.

Office Visits for Surgery                        Plan covers 80% of balance after Medicare payment and deductible.

Allergy Testing                                  Plan covers 80% of balance after Medicare payment and deductible.

Allergy Injections                               Plan covers 80% of balance after Medicare payment and deductible.
               Diagnostic Procedures

Diagnostic Laboratory and X-ray           Plan covers 80% of balance after Medicare payment and deductible.


             Emergency Medical Care

Emergency Room                            Plan covers 80% of balance after Medicare payment and deductible.

Non-emergency Care in an Emergency Room   Plan covers 50% of balance after Medicare payment and deductible.

Ambulance                                 Plan covers 80% of balance after Medicare payment and deductible.


                   Hospital Care

Inpatient Coverage                        Plan covers 80% of balance after Medicare payment and deductible.

Outpatient Hospital Expenses              Plan covers 80% of balance after Medicare payment and deductible.
(including surgery)

              Mental Health Services

Inpatient                                 Plan covers 80% of balance after Medicare payment and deductible.
(60 day calendar year max)
Outpatient                                Plan covers 50% of balance after Medicare payment and deductible.
(40 visits per calendar year)

            Alcohol/Drug Abuse Services

Inpatient                                 Plan covers 80% of balance after Medicare payment and deductible.
Outpatient                                           Plan covers 50% of balance after Medicare payment and deductible.


                  Other Services

Convalescent Facility                                Plan covers 80% of balance after Medicare payment and deductible.
Limited to 100 days per calendar year.
Home Health Care                                     Plan covers 80% of balance after Medicare payment and deductible.
Limited to 120 visits per calendar year.
Hospice Care – Inpatient                             Plan covers 80% of balance after Medicare payment and deductible..
Limited to 30 days per lifetime.
Hospice Care – Outpatient                            Plan covers 50% of balance after Medicare payment and deductible.
Up to a maximum benefit of $5,000.
Private Duty Nursing – Outpatient                    Plan covers 80% of balance after Medicare payment and deductible.
Limited to 70 eight hour shifts per calendar year.
Outpatient Short-Term Rehabilitation                 Plan covers 80% of balance after Medicare payment and deductible.
Includes speech, physical, and occupational
therapy.
Durable Medical Equipment                            Plan covers 80% of balance after Medicare payment and deductible.

Diabetic Supplies                                    Plan covers 80% of balance after Medicare payment and deductible.


     Prescription Drugs –Medicare Part D

Prescription Drug Calendar Year Deductible           None – Prescription drugs are covered from first dollar; out-of- pocket
                                                     expenditures are not counted toward the deductible that must be met for medical
                                                     services
Initial Coverage Limit (ICL) for all but generic     $2,250, which amount is calculated according to the actual cost of the
drugs                                                prescription drugs.
Coverage Gap for Generic Drugs                       No gap in coverage for generic drugs – prescriptions are covered at regular co-
                                                     pays until individual participant has spent $3,600 in actual out-of-pocket
                                                     expenses.
Coverage Gap for Brand Name or Non-                   No coverage available for brand name or non-formulary drugs once the actual
formulary Drugs once $2,250 limit is reached)         total cost amounts to $2,250. To continue using brand name or formulary drugs
                                                      after the $2,250 limit is reached, participants must pay for the full cost of the
                                                      prescription until their total out of pocket expenses for prescription drugs in a
                                                      calendar year totals $3,600, at which point medications are covered under the
                                                      catastrophic coverage benefit.
Catastrophic Coverage Benefits start when             Participants pay the greater of $2.00 or 5% of the actual cost for generic or
participant has incurred $3,600 out-of-pocket costs   preferred prescription drugs. Participant cost for any other prescription drug is
                                                      the greater of $5.00 or 5% of actual cost.
Mandatory Generic                                     Yes. If the member or the physician requests brand-name when generic is
                                                      available, the member pays the generic co-payment plus the difference in cost
                                                      between the generic price and the brand name price.

          Co-Pays (Retail 30 day supply)

Generic                                               $10.00

Preferred Brand                                       $20.00

Non-Preferred                                         $35.00


  Co-Pays (Mail Order – 31 to 90 day supply)

Generic                                               $20.00

Preferred Brand                                       $40.00

Non-Preferred                                         $70.00

				
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