WEBTPA HDHP 1

The EHN service area applies to residents of Southern California and Dallas/Fort Worth as described on the prior page. If you reside in one of the EHN service areas listed on the prior page and choose one of the WebTPA medical plans, the following benefit chart applies to you for the 2027 plan year.

WEBTPA HDHP 1

Plan Details

Carrier: WebTPA
Plan Type: HDHP
Network: EHN / Aetna
Out-of-Network Coverage: Yes
HSA Eligible: Yes

Your Contributions

Coverage Tier	MONTHLY CONTRIBUTIONS
Employee Only	$265.52
Employee + Spouse	$736.95
Employee + Child(Ren)	$555.44
Employee + Family	$1,002.93

Coverage Tier: Employee Only
MONTHLY CONTRIBUTIONS: $265.52

Coverage Tier: Employee + Spouse
MONTHLY CONTRIBUTIONS: $736.95

Coverage Tier: Employee + Child(Ren)
MONTHLY CONTRIBUTIONS: $555.44

Coverage Tier: Employee + Family
MONTHLY CONTRIBUTIONS: $1,002.93

Covered Services

For Residents Within Designated EHN Service Area

Services	EHN PROVIDER	AETNA NETWORK	OUT-OF-NETWORK
Calendar Year Deductible & Coinsurance - Individual	$2,000	$2,600	$3,300
Calendar Year Deductible & Coinsurance - Family	$4,000¹	$5,200¹	$6,600¹
Coinsurance (Plan Pays)	90%	70%	50%
Calendar Year Out-Of-Pocket Maximum (Includes Deductible) - Individual	$5,000	$6,200	Unlimited
Calendar Year Out-Of-Pocket Maximum (Includes Deductible) - Family	$10,000	$12,400	Unlimited
Preventive Care ^	No charge	No charge	50%**
Primary Care	10%*	30%*	50%**
Specialist Services	10%*	30%*	50%**
Urgent Care	10%*	30%*	50%**
Emergency Room	$200 + 20%*	$200 + 20%*	$200 + 20%*
Surgery	10%*	30%*	50%**
Surgery Through Lantern Surgery Care	0%****	0%****	N/A

Services: Calendar Year Deductible & Coinsurance - Individual
EHN PROVIDER: $2,000
AETNA NETWORK: $2,600
OUT-OF-NETWORK: $3,300

Services: Calendar Year Deductible & Coinsurance - Family
EHN PROVIDER: $4,000¹
AETNA NETWORK: $5,200¹
OUT-OF-NETWORK: $6,600¹

Services: Coinsurance (Plan Pays)
EHN PROVIDER: 90%
AETNA NETWORK: 70%
OUT-OF-NETWORK: 50%

Services: Calendar Year Out-Of-Pocket Maximum (Includes Deductible) - Individual
EHN PROVIDER: $5,000
AETNA NETWORK: $6,200
OUT-OF-NETWORK: Unlimited

Services: Calendar Year Out-Of-Pocket Maximum (Includes Deductible) - Family
EHN PROVIDER: $10,000
AETNA NETWORK: $12,400
OUT-OF-NETWORK: Unlimited

Services: Preventive Care ^
EHN PROVIDER: No charge
AETNA NETWORK: No charge
OUT-OF-NETWORK: 50%**

Services: Primary Care
EHN PROVIDER: 10%*
AETNA NETWORK: 30%*
OUT-OF-NETWORK: 50%**

Services: Specialist Services
EHN PROVIDER: 10%*
AETNA NETWORK: 30%*
OUT-OF-NETWORK: 50%**

Services: Urgent Care
EHN PROVIDER: 10%*
AETNA NETWORK: 30%*
OUT-OF-NETWORK: 50%**

Services: Emergency Room
EHN PROVIDER: $200 + 20%*
AETNA NETWORK: $200 + 20%*
OUT-OF-NETWORK: $200 + 20%*

Services: Surgery
EHN PROVIDER: 10%*
AETNA NETWORK: 30%*
OUT-OF-NETWORK: 50%**

Services: Surgery Through Lantern Surgery Care
EHN PROVIDER: 0%****
AETNA NETWORK: 0%****
OUT-OF-NETWORK: N/A

*After Deductible
**After deductible and subject to out-of-network reimbursement limitations
****Deductible and coinsurance may be waived for surgeries performed through Lantern Surgery Care. Refer to the SPD for more information
1If you choose to enroll you and your dependents in the HDHP 1 plan, you must meet the entire family deductible before the plan starts to pay benefits for any covered member. The deductible can be met by one person or all family members combined
^Please refer to the SPD for preventive services with a capped benefit
^^The employer HSA contribution is a dollar-for-dollar match of the amount you contribute, up to these limits

For Residents Outside of Designated EHN Service Area

Services	AETNA IN-NETWORK	OUT-OF-NETWORK
Calendar Year Deductible - Individual	$2,200	$3,300
Calendar Year Deductible - Family	$4,400¹	$6,600¹
Coinsurance (Plan Pays)	80%	50%
Calendar Year Out-Of-Pocket Maximum (Includes Deductible) - Individual	$6,000	Unlimited
Calendar Year Out-Of-Pocket Maximum (Includes Deductible) - Family	$12,000	Unlimited
Preventive Care^	No charge	50%**
Primary Care	20%*	50%**
Specialist Services	20%*	50%**
Urgent Care	20%*	50%**
Diagnostic Care	20%*	50%**
Emergency Room	20%*	20%*
Surgery	20%*	50%**
Surgery Through Lantern Surgery Care	0%****	N/A

Services: Calendar Year Deductible - Individual
AETNA IN-NETWORK: $2,200
OUT-OF-NETWORK: $3,300

Services: Calendar Year Deductible - Family
AETNA IN-NETWORK: $4,400¹
OUT-OF-NETWORK: $6,600¹

Services: Coinsurance (Plan Pays)
AETNA IN-NETWORK: 80%
OUT-OF-NETWORK: 50%

Services: Calendar Year Out-Of-Pocket Maximum (Includes Deductible) - Individual
AETNA IN-NETWORK: $6,000
OUT-OF-NETWORK: Unlimited

Services: Calendar Year Out-Of-Pocket Maximum (Includes Deductible) - Family
AETNA IN-NETWORK: $12,000
OUT-OF-NETWORK: Unlimited

Services: Preventive Care^
AETNA IN-NETWORK: No charge
OUT-OF-NETWORK: 50%**

Services: Primary Care
AETNA IN-NETWORK: 20%*
OUT-OF-NETWORK: 50%**

Services: Specialist Services
AETNA IN-NETWORK: 20%*
OUT-OF-NETWORK: 50%**

Services: Urgent Care
AETNA IN-NETWORK: 20%*
OUT-OF-NETWORK: 50%**

Services: Diagnostic Care
AETNA IN-NETWORK: 20%*
OUT-OF-NETWORK: 50%**

Services: Emergency Room
AETNA IN-NETWORK: 20%*
OUT-OF-NETWORK: 20%*

Services: Surgery
AETNA IN-NETWORK: 20%*
OUT-OF-NETWORK: 50%**

Services: Surgery Through Lantern Surgery Care
AETNA IN-NETWORK: 0%****
OUT-OF-NETWORK: N/A

*After Deductible
**After deductible and subject to out-of-network reimbursement limitations
****Deductible and coinsurance may be waived for surgeries performed through Lantern Surgery Care. Refer to the SPD for more information
1If you choose to enroll you and your dependents in the HDHP 1 plan, you must meet the entire family deductible before the plan starts to pay benefits for any covered member. The deductible can be met by one person or all family members combined
^Please refer to the SPD for preventive services with a capped benefit
^^The employer HSA contribution is a dollar-for-dollar match of the amount you contribute, up to these limits.

Pharmacy Benefits

For Residents Within Designated EHN Service Area

Tier	EHN PROVIDER	AETNA NETWORK	OUT-OF-NETWORK
Rx Calendar Year Out-Of-Pocket Maximum - Individual	Included in medical	Included in medical	N/A
Rx Calendar Year Out-Of-Pocket Maximum - Family	Included in medical	Included in medical	N/A
Generic	20%*; $15 min to $45 max	20%*; $15 min to $45 max	Not covered
Preferred Brand	20%*; $40 min to $120 max	20%*; $40 min to $120 max	Not covered
Non-Preferred Brand	20%*; $55 min to $165 max	20%*; $55 min to $165 max	Not covered

Tier: Rx Calendar Year Out-Of-Pocket Maximum - Individual
EHN PROVIDER: Included in medical
AETNA NETWORK: Included in medical
OUT-OF-NETWORK: N/A

Tier: Rx Calendar Year Out-Of-Pocket Maximum - Family
EHN PROVIDER: Included in medical
AETNA NETWORK: Included in medical
OUT-OF-NETWORK: N/A

Tier: Generic
EHN PROVIDER: 20%*; $15 min to $45 max
AETNA NETWORK: 20%*; $15 min to $45 max
OUT-OF-NETWORK: Not covered

Tier: Preferred Brand
EHN PROVIDER: 20%*; $40 min to $120 max
AETNA NETWORK: 20%*; $40 min to $120 max
OUT-OF-NETWORK: Not covered

Tier: Non-Preferred Brand
EHN PROVIDER: 20%*; $55 min to $165 max
AETNA NETWORK: 20%*; $55 min to $165 max
OUT-OF-NETWORK: Not covered

*After Deductible
***90-day supply through mail order is available at 2.5x the retail copay for PPO and 2x the retail copay for HDHP1 and HDHP2

For Residents Outside of Designated EHN Service Area

Tier	AETNA IN-NETWORK	OUT-OF-NETWORK
Rx Calendar Year Out-Of-Pocket Maximum - Individual	Included in medical	N/A
Rx Calendar Year Out-Of-Pocket Maximum - Family	Included in medical	N/A
Generic	20%*; $15 min, $45 max	Not covered
Preferred	20%*; $40 min, $120 max	Not covered
Non-Preferred	20%*; $55 min, $165 max	Not covered

Tier: Rx Calendar Year Out-Of-Pocket Maximum - Individual
AETNA IN-NETWORK: Included in medical
OUT-OF-NETWORK: N/A

Tier: Rx Calendar Year Out-Of-Pocket Maximum - Family
AETNA IN-NETWORK: Included in medical
OUT-OF-NETWORK: N/A

Tier: Generic
AETNA IN-NETWORK: 20%*; $15 min, $45 max
OUT-OF-NETWORK: Not covered

Tier: Preferred
AETNA IN-NETWORK: 20%*; $40 min, $120 max
OUT-OF-NETWORK: Not covered

Tier: Non-Preferred
AETNA IN-NETWORK: 20%*; $55 min, $165 max
OUT-OF-NETWORK: Not covered

*After Deductible
***90-day supply through mail order is available at 2.5x the retail copay for PPO and 2x the retail copay for HDHP1 and HDHP2

Plan Notes

ACE’s HSA employer contribution is a dollar-for-dollar match, up to $600 (Employee) or $1,200 (Family). You must make an employee contribution in order to receive the employer contribution.
Lantern will waive the deductible once the IRS minimum is incurred and coinsurance on the HDHP 1 and HDHP 2 plans.
The Prescription Drug Program for the WebTPA plans is coordinated through CVS/Caremark, with specialty pharmacy coordinated through Vivio.