Ohio Plan guide

(1)

Quality health plans & benefits

Healthier living

Financial well-being

Intelligent solutions

The health of business,

well planned

64.10.302.1-OH (9/12)

Ohio 2–100

Plan guide

Plans effective December 1, 2011

For businesses with 2-100 eligible employees

www.aetna.com

(2)

Team with Aetna for the health of your business

Introducing a new suite of products and services designed

specifically for companies with 2 to 100 employees.

You can count on us to provide health plans

that help simplify decision making and plan

administration so you can focus on the health

of your business.

We are committed to helping employers build healthy

businesses. In today’s rapidly changing economy, we recognize the need for less expensive, less complex health plan choices. Now, we offer a variety of newly streamlined medical and dental benefits and insurance plans to provide more affordable options and to help simplify plan selection and administration.

In this guide:

5 Small business commitment 5 Benefits for every stage of life 6 Medical overview

8 Managing health care expenses 12 Medical plan options

22 Dental overview 24 Dental plan options 32 Life & disability overview 35 Life & disability plan options 37 Underwriting guidelines 45 Product specifications 56 Limitations and exclusions 59 Group enrollment checklist

6

4.

4

4.

30

2

.1

-O

H

(9

/1

2)

6

4

.4

3.

30

2

.1

-O

H

(9

/1

(3)

3

As you may know, the Affordable Care Act (ACA, or

Health Care Reform law) includes changes that are

being phased in over a number of years. The latest

set of changes includes additional benefits for certain

Women’s Preventive Health Services.

When plans renew or are effective on or after August 1, 2012, all of the following women’s health services will be considered preventive (some were already covered). These services generally will be covered at no cost share, when provided in network: • Well-woman visits (annually and now including prenatal visits) • Screening for gestational diabetes

• Human papillomavirus (HPV) DNA testing • Counseling for sexually transmitted infections

• Counseling and screening for human immunodeficiency virus (HIV)

• Screening and counseling for interpersonal and domestic violence

• Breastfeeding support, supplies and counseling

• Generic formulary contraceptives are covered without member cost-share (for example, no copayment). Certain religious organizations or religious employers may be exempt from offering contraceptive services

Women’s preventive health benefits

New changes effective August 1, 2012

6

4.

4

4.

30

2

.1

-O

H

(9

/1

2)

6

4

.4

3.

30

2

.1

-O

H

(9

/1

(4)

Employers and their employees can benefit from…

• Affordable plan options

• Online self-service tools and capabilities

• Enhanced services for consumer-directed health plans • 24-hour access to Employee Assistance Program services • Preventive care covered 100%

• Aetna disease management and wellness programs

We know it’s about...

Options

We provide a variety of health plan options to help meet your employees’ needs, including medical, dental, disability and life insurance.

And, with access to a wide network of health care providers, you can be sure that employees have options in how they access their health care.

Medical plans

• HSA-compatible plans • Traditional plans

• PPO or indemnity plans available upon request Dental plans

• DMO®

• PPO • PPO Max

• Freedom-of-Choice plan design option • Preventive

Life and disability plans • Basic life

• Supplemental life • AD&D Ultra®

• Supplemental AD&D Ultra • Dependent life

• Short-term disability • Long-term disability

Simplicity

We know that the health of your business is your top priority. Our streamlined plans and variety of services make it easier for you to focus on your business by simplifying administration and management.

We make it easy to manage health insurance benefits with simplified enrollment, billing, and claims processing so you can focus on what matters most.

Trust

We work hard to provide health plan solutions you can trust. Our account executives, underwriters, and customer service representatives are committed to providing small businesses and their employees with service and care they can trust.

Aetna resources are designed to fortify the health

of your business

• Track medical claims and take advantage of online services with our secure Aetna Navigator®_{website. It features}

automated enrollment, personal health records, and printable temporary member ID cards.

• Get real cost and health information to help make the right care decision with an online Cost of Care Estimator.

• Manage health records online with the Personal Health Record. • Use the Aetna Health ConnectionsSM_{Disease Management}

Program, which provides personal support to members to help them manage their conditions.

• Get 24/7 access to a nurse to help with personal health-related questions.

• Help members work toward health goals with wellness initiatives, such as the Simple Steps To A Healthier Life®

online program.

• Take advantage of discount programs for vision, dental, and general health care that encourage use of plan offerings.

(5)

5 We understand that your business has unique needs. That’s why we have streamlined our plan options for employers with

2 to 100 employees. We are committed to providing you with value and quality you can count on. Our variety of products and services allows you to focus on the health of your business.

Basic plans

• Provide basic benefits for your employees • Limit the expense to your business

• Allow employees to buy up and share more of the cost

Value plans

• Encourage employees to make responsible health care decisions • Provide tools and resources to support consumerism

• Provide an innovative plan design

Standard plans

• Provide standard benefits plans • Limit the financial impact on employees

Health insurance benefits for every stage of life

For young individuals and couples without children… • Lower monthly payments

• Modest out-of-pocket costs • Quality preventive care • Prescription drug coverage • Financial protection HSA-compatible plans Dental plan options

For married couples and single parents with teens and college-aged children…

• Checkups and care for injuries and illness

• Preventive care and screenings that promote a healthy lifestyle • National network of health care providers

Traditional plans HSA-compatible plans Packaged Life and Disability Dental plan options

For married couples and single parents with young children or teens…

• Lower fees for office visits • Lower monthly payments • Caps on out-of-pocket expenses

• Quality preventive care for the entire family Traditional plans

Basic Life and STD Dental plan options

For men and women 55 years of age and over with no children at home…

• Financial security

• Quality prescription drug coverage • Hospital inpatient/outpatient services • Emergency care

HSA-compatible plans Dental plan options

Choose from plans that are designed

for the health of your business

(6)

Aetna Medical Overview

We are committed to putting

the employee at the center of

everything we do. You can count

on us to provide health plans

that help simplify decision

making and plan administration

so you can focus on the health

of your business.

(7)

7

Medical

Overview

Provider network*

Aetna Health Network Option and Aetna Open Access Managed Choice POS Plan Provider Network

Cleveland/

NE Ohio Columbus Toledo/ NW Ohio Cincinnati/Dayton Ashland Coshocton Allen* Adams Ashtabula Delaware Auglaize(partial) _Brown

Carroll Fairfield Crawford Butler Columbiana Fayette Erie Champaign Cuyahoga Franklin Fulton Clark Geauga Guernsey Hancock Clermont Holmes Hocking Hardin Clinton Huron(partial) _Knox _Henry _Greene

Lake Licking Huron(partial) _Hamilton

Lorain Madison Lucas Highland Mahoning Marion Logan Medina Morgan Miami Portage Morrow Montgomery Richland Muskingum Preble Stark Noble Shelby Summit Perry Warren Trumbull Pickaway

Tuscarawas Pike Wayne Ross Scioto Union

Aetna Open Access Managed Choice POS Plan Provider Network

Columbus Cincinnati/Dayton Toledo/ NW Ohio E. Ohio Athens Darke Auglaize Belmont Gallia Defiance Harrison Jackson Mercer Jefferson Meigs Paulding Lawrence Vinton Van Wert Monroe

Williams Washington Wyandot

Aetna Health Network Option

SM

For groups with employees primarily in Ohio metropolitan areas. Aetna Health Network Option (HNOption) is a two-tiered product that allows members to access care in or out of network. Members have lower out-of-pocket costs when they use the in-network tier of the plan. Member cost sharing increases if members decide to go out of network. Members may go to their PCP or to a participating specialist without a referral. It is their choice, each time they seek care.

Aetna Open Access

®

_{Managed Choice}

®

_POS

For groups with employees in rural areas of Ohio, where Aetna HNOption is not available; also for out-of-state employees in a Managed Choice POS service area. Managed Choice members can access any recognized provider for covered services

without a referral. Each time members seek health care, they have the freedom to choose either network providers at lower out-of-pocket costs, or non-network providers at higher out-of-pocket costs.

*Network subject to change.

The federal health care reform legislation, known as the Patient Protection and Affordable Care Act, was signed into law on March 23, 2010. A number of new reforms were effective September 23, 2010, including coverage for dependents up to age 28, elimination of lifetime benefit, dollar maximums, restriction of annual dollar maximums on essential health benefits, removal of cost sharing for preventive services and elimination of pre-existing condition exclusions for dependent children under 19 years of age. Your benefits program complies with the new reform legislation.

(8)

Multi-Option Offerings*

Greater employee choice

You can offer any two or three of the available plan designs. For groups with 51-100 eligible employees, Triple option requires underwriting approval and is available as long as one of the plans is an HSA or HRA plan.

Flexibility and affordability

You can create a customized benefits package from any of our plan types and plan designs. We offer a variety of plans at different price points. Plus, you may designate a level of contribution that meets your budget.

Total freedom

We offer plan choices that range in price and benefits to meet each individual employee’s needs, whether they are lower premiums or lower out-of-pocket costs at the time services are received.

Easy administration

Setting up this program is simple:

1. You choose up to three plans to offer on the Employer Application.

2. You choose how much to contribute.

3. Each employee chooses the plan that’s right for him or her.

Multi-Option Offerings

Plan choices 2 to 4 enrolled employees Choice of one plan

5 to 50 enrolled employees Choice of up to 3 plans, minimum of 1 employee in each plan

51 to 100 enrolled employees One of the plans must be an HSA or HRA when offering a triple option and requires underwriting approval.

Employer contribution

2 to 50 eligible employees 50% of employee-only premium or a minimum defined contribution of $120 per employee per month.

51 to 100 eligible employees 75% of the employee-only premium or 50% of the total group premium. Employer funding 2 to 100 eligible employees You cannot fund the deductible in excess of 50% annually whether through

an HRA, HSA or any other arrangement.

Rating Options

2 to 9 enrolled employees Tabular

10 to 50 enrolled employees Option of tabular or composite 51 to 100 enrolled employees Composite

(9)

9

Administrative Fees

Fee description Fee

HSA

Initial set-up $0

Monthly fees $0

POP

Initial set-up* $175

Renewal $100

HRA and FSA** Initial set-up*

2–25 Employees $350

Renewal fee

Monthly fees*** $5.25 per participant

Additional set-up fee for “stacked” plans (those electing an Aetna HRA

and FSA simultaneously)

$150

Participation fee for “stacked” participants $10.25 per participant

Minimum fees

1–25 Employees $25 per month minimum

26–100 Employees $50 per month minimum

TRA

Annual fee $350

Transit Monthly fees $4.25 per participant

Parking Monthly fees $3.15 per participant

COBRA Annual fee

Per employee per month

20 – 50 Employees $0.88

51 – 100 Employees $1.02

Initial notice fee $1.50 per notice

(includes notices at time of implementation and during ongoing administration)

Health Reimbursement Arrangement (HRA)

The Aetna HealthFund®_{HRA combines the protection of a}

deductible-based health plan with a health fund that pays for eligible health care services. The member cannot contribute to the HRA, and you have control over HRA plan designs and fund rollover. The fund is available to an employee for qualified expenses on the plan’s effective date.

The HRA and the HSA provide members with financial support for higher out-of-pocket health care expenses. Our consumer-directed health products and services give members the information and resources they need to help make informed health care decisions for themselves and their families, while helping lower your costs.

Underlying plan policy

Aetna premium rates assume no underlying plans are present and deductible is funded at no more than 50 percent annually. An underlying or wrap-around plan is a plan that either partially or completely subsidizes any member cost sharing outside of a federally qualified Health Reimbursement Account (HRA) or Health Savings Account (HSA). Member cost sharing includes but is not limited to copays, deductibles and/or member coinsurance balances. (Employee- funded Flexible Spending Accounts are not considered underlying plans.) You must prove that no such underlying plans are present and that they are not funding the deductible in excess of 50 percent annually, whether through an HRA, or HSA on the new business final rates and renewal plan sponsor signature pages.

COBRA Administration

Aetna COBRA administration offers a full range of notification, documentation and record-keeping processes that can assist you with managing the complex billing and notification processes that are required for COBRA compliance, while also helping to save you time and money.

* Non-discrimination testing provided annually after open enrollment for POP and FSA only. Additional off-cycle testing available at employee request for $100 fee. Non-discrimination testing only available for FSA and POP products.

**Aetna FSA pricing is inclusive for POP. Debit cards are available for FSA only. Contact Aetna for further information.

*** For HRA, if the employer opts out of Streamline, the fee is increased $1.50 per participant. For FSA, the debit card is available for an additional $1 per participant per month. Mailing reimbursement checks direct to employee homes is an additional $1 per participant per month.

Aetna HealthFund HRAs are subject to employer-defined use and forfeiture rules, and are unfunded liabilities of your employer. Fund balances are not vested benefits. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Information is subject to change.

(10)

Section 125 Cafeteria Plans and Section 132 Transit

Reimbursement Accounts

Your employees can reduce their taxable income, and you can pay less in payroll taxes. There are three ways to save:

Premium only plan (POP)

Employees can pay for their portion of the group health insurance expenses on a pretax basis.

Flexible spending account (FSA)

FSAs give employees a chance to save for health expenses with pretax money. Health Care Spending Accounts allow employees to set aside pretax dollars to pay for out-of-pocket expenses, as defined by the IRS. Dependent Care Spending Accounts allow participants to use pretax dollars to pay child or elder care expenses.

Transit reimbursement account (TRA)

TRAs allow participants to use pretax dollars to pay transportation and parking expenses for the purpose of commuting to and from work.

No Cost Health Incentive Credit*

Members can earn $50 in just a few simple steps Members earn a $50 credit towards their out-of-pocket expenses when they:

- Complete or update their health assessment on Simple Steps To A Healthier Life® _{program, and}

- Complete one online wellness program

If the employee’s spouse is covered under the plan, he or she is also eligible for the same incentive credit. So a family could save $100 in out-of-pocket expenses each year. Incentive rewards will be credited towards the deductible and maximum out-of-pocket limit. This program is included at no additional cost on all plans except the HSA-compatible plans.

Save a Copay

®

_Program

Now Aetna Pharmacy Management is giving your employees an additional way to save!

Our Save a Copay program encourages your Aetna members to use certain generic drugs in place of their brand-name counterparts.

Here’s how the program works:

- Members who switch to certain preferred generic

medications from selected brand-name drugs will make no copayments for six months after they make the change. - At the end of the initial six-month period, members will be

responsible for paying the lowest applicable copay outlined in their pharmacy benefits plans.

- Members must use a participating retail or mail-order pharmacy. With other pharmacies, the program will not apply. - If the member’s pharmacy benefits plan has a deductible,

such as a high-deductible health plan, the member must meet the deductible first before he or she can benefit from the Save a Copay program.

We preselect eligible members, so there is no enrollment process.

Employee Assistance Program (EAP)**

Our EAP is a confidential program that gives employees and members of their household access to useful services and support to help them manage the everyday challenges of work and home.

The EAP is available at no charge to members and their family members and includes:

Choice — They’ll find a range of resources to help them balance their personal and professional lives.

Easy access — EAP representatives can be reached anytime toll free at 1-866-672-5417 or on the web at www.aetnaeap.com. Professional assistance — Our workplace-trained specialists provide confidential phone support, assessing needs and recommending an appropriate course of action. Employees and their household members receive up to three phone consultations per member in a calendar year.

You can also take advantage of EAP Resources:

Management and human resources assistance — You get unlimited phone consultations with workplace-trained clinicians who can provide help in dealing with complex employee issues that may arise.

Online tools — You can also get online tools and materials to encourage employees to use the EAP by visiting

www.aetnaeap.com (enter your company ID and select the “Promotional Materials” link).

(11)

11

Health Savings Account (HSA)

No set-up or administrative fees

The Aetna HealthFund HSA, when coupled with a HSA-compatible high-deductible health benefits and health insurance plan, is a tax-advantaged savings account. Once enrolled, account contributions can be made by you and/or your employees. The HSA can be used to pay for qualified expenses, tax free. Member’s HSA Plan

HSA Account • You own your HSA • Contribute tax free

• You choose how and when to use your dollars • Roll it over each year and let it grow

• Earns interest, tax free Today

• Use for qualified expenses with tax free dollars Future

• Plan for future and retiree health-related costs High-deductible health plan

• Eligible in-network preventive care services will not be subject to the deductible

• You pay 100% until deductible is met, then only pay a share of the cost

(12)

Aetna Traditional Medical Plans*

Aetna Plan Options $250 80% $500 90%

Networks Available Aetna Health Network Option

Aetna Open Access Managed Choice POS

Aetna Health Network Option

Group Size Availability 2-100 2-100

Member Benefits In Network Out of Network1 _{In Network} _{Out of Network}1

PCP Referrals Required No N/A No N/A

Plan Coinsurance

(applies to most services) 80% 60% 90% 70%

Calendar-Year Deductible

(Accumulates separately in/out of network)

$250 Individual/ $750 Family $500 Individual/ $1,500 Family $500 Individual/ $1,500 Family $1,000 Individual/ $3,000 Family Calendar-Year Out-of-Pocket Maximum

(Includes deductible, excludes copayments and member coinsurance payments for DME, accumulates separately in/out of network)

$2,000 Individual/ $4,000 Family $4,000 Individual/ $8,000 Family $2,500 Individual/ $5,000 Family $5,000 Individual/ $10,000 Family

Lifetime Maximum Benefit Unlimited Unlimited

Primary Physician Office Visit $20 copay,

deductible waived 60% $20 copay, deductible waived 70%

Specialist Office Visit $40 copay,

Outpatient Lab $40 copay,

Outpatient X-ray $40 copay,

Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET scans; precertification required)

80% 60% 90% 70%

Well-Child Exams

(Age and frequency schedules apply) $0 copay, deductible waived 60% $0 copay, deductible waived 70%

Physical Exams — Adults

(Limited to one exam every 12 months) $0 copay, deductible waived 60% $0 copay, deductible waived 70%

Routine Gyn

(Limited to one exam every 365 days) $0 copay, deductible waived 60% $0 copay, deductible waived 70%

Routine Mammography

(Limited to one baseline mammogram for covered females age 35-39 and one per calendar year for covered females age 40 and above)

$0 copay,

Inpatient Hospital 80% 60% 90% 70%

Outpatient Surgery 80% 60% 90% 70%

Emergency Room

(Copay waived if admitted) deductible waived$250 copay, deductible waived$250 copay,

Urgent Care $50 copay,

deductible waived

60% $50 copay,

deductible waived

70% Chiropractic

(Limited to 12 visits per calendar year)

$40 copay, deductible waived

60% $40 copay,

deductible waived

70% Physical Therapy/Occupational Therapy/Speech

Therapy (Limited to 40 combined visits per calendar year)

60% $40 copay,

deductible waived

70% Prescription Drugs

Retail: per 30-day supply

Mail Order: two and a half times retail copay, 31-90-day supply, includes insulin

$10 Generic Formulary $35 Brand Formulary $60 Non-Formulary $150 Self-Injectables

Not covered2 _{$10 Generic Formulary}

$35 Brand Formulary $60 Non-Formulary $150 Self-Injectables

Not covered

90-Day Rx Transition of Coverage (TOC) for prior

(13)

13

See page 21 for Important Plan Provisions.

Aetna Traditional Medical Plans*

Aetna Plan Options $500 80% $1,000 90%

$500 Individual/ $1,500 Family $1,000 Individual/ $3,000 Family $1,000 Individual/ $3,000 Family $2,000 Individual/ $6,000 Family Calendar-Year Out-of-Pocket Maximum

80% 60% 90% 70%

Routine Gyn

$0 copay,

Emergency Room

deductible waived

60% $50 copay,

deductible waived

60% $50 copay,

deductible waived

60% $50 copay,

deductible waived

Not covered

(14)

Aetna Traditional Medical Plans*

Aetna Plan Options $1,000 80% $1,000 70%

Aetna Open Access Managed Choice POS Aetna Choice PPO

Plan Coinsurance (applies to most services)

80% 60% 70% 50%

(Accumulates separately in/out of network) $1,000 Individual/ $3,000 Family $2,000 Individual/ $6,000 Family $1,000 Individual/ $3,000 Family $2,000 Individual/ $6,000 Family Calendar-Year Out-of-Pocket Maximum

$4,000 Individual/

$8,000 Family $8,000 Individual/ $16,000 Family $6,000 Individual/ $12,000 Family $12,000 Individual/ $24,000 Family

deductible waived

60% $30 copay,

deductible waived

50%

deductible waived

60% $50 copay,

deductible waived

50%

deductible waived

60% $50 copay,

deductible waived

50%

deductible waived

60% $50 copay,

deductible waived

50% Outpatient Complex Imaging

(CAT, MRI, MRA/MRS and PET scans; precertification required)

80% 60% 70% 50%

(Age and frequency schedules apply)

60% $0 copay,

deductible waived

50% Physical Exams — Adults

(Limited to one exam every 12 months)

60% $0 copay,

deductible waived

50% Routine Gyn

(Limited to one exam every 365 days)

60% $0 copay,

deductible waived

50% Routine Mammography

60% $0 copay,

deductible waived

50%

Inpatient Hospital 80% 60% 70% after $1,000 per

admit copay

50%

Emergency Room

deductible waived

60% $50 copay,

deductible waived

60% $50 copay,

deductible waived

60% $50 copay,

deductible waived

Not covered

(15)

15

Aetna Traditional Medical Plans*

Networks Available Aetna Health Network Option Aetna Health Network Option

80% 60% 70% 50%

$4,000 Individual/

deductible waived

60% $30 copay,

deductible waived

50%

deductible waived

60% $50 copay,

deductible waived

50%

deductible waived

60% $50 copay,

deductible waived

50%

deductible waived

60% $50 copay,

deductible waived

80% 60% 70% 50%

60% $0 copay,

deductible waived

60% $0 copay,

deductible waived

50% Routine Gyn

60% $0 copay,

deductible waived

60% $0 copay,

deductible waived

50%

Inpatient Hospital 80% 60% 70% after $1,000 per

admit copay

50%

Emergency Room

deductible waived

60% $50 copay,

deductible waived

60% $50 copay,

deductible waived

60% $50 copay,

deductible waived

Not covered $20 Generic Formulary

Not covered

(16)

Aetna Traditional Medical Plans*

$2,000 Individual/ $6,000 Family $4,000 Individual/ $12,000 Family $2,500 Individual/ $7,500 Family $5,000 Individual/ $15,000 Family Calendar-Year Out-of-Pocket Maximum

90% 70% 100% 70%

Routine Gyn

$0 copay,

Emergency Room

deductible waived

70% $65 copay,

deductible waived

70% $55 copay,

deductible waived

70% $55 copay,

deductible waived

Not covered

(17)

17

Aetna Traditional Medical Plans*

(Includes deductible, excludes copayments and member coinsurance payments for DME, Accumulates separately in/out of network)

80% 60% 100% 70%

Routine Gyn

$0 copay,

Emergency Room

deductible waived

60% $65 copay,

deductible waived

60% $55 copay,

deductible waived

60% $55 copay,

deductible waived

Not covered

(18)

Aetna Traditional Medical Plans*

Aetna Plan Options $5,000 80%

Group Size Availability 2-100

Member Benefits In Network Out of Network1

PCP Referrals Required No N/A

80% 50%

(Accumulates separately in/out of network) $5,000 Individual/ $15,000 Family $10,000 Individual/ $30,000 Family Calendar-Year Out-of-Pocket Maximum

(Includes deductible, excludes copayments and member coinsurance payments for DME, Accumulates separately in/out of network)

$10,000 Individual/

$20,000 Family $20,000 Individual/ $40,000 Family

Lifetime Maximum Benefit Unlimited

deductible waived

50%

deductible waived

50%

deductible waived

50%

deductible waived

80% 50%

50% Routine Gyn

50%

Inpatient Hospital 80% 50%

Outpatient Surgery 80% 50%

Emergency Room (Copay waived if admitted)

deductible waived 50%

Chiropractic

(Limited to 12 visits per calendar year) $55 copay, deductible waived 50% Physical Therapy/Occupational Therapy/Speech

Therapy (Limited to 40 combined visits per calendar year) $55 copay, deductible waived 50%

Prescription Drugs Retail: per 30-day supply

Not covered

(19)

19

Aetna HSA-Compatible Medical Plans*

Aetna Plan Options HSA $2,500 80% HSA $3,500 100%

(Includes deductible and copayments, accumulates separately in/out of network)

Primary Physician Office Visit 80% 50% 100% 70%

Specialist Office Visit 80% 50% 100% 70%

Outpatient Lab 80% 50% 100% 70%

Outpatient X-ray 80% 50% 100% 70%

80% 50% 100% 70%

50% $0 copay,

deductible waived

50% $0 copay,

deductible waived

70% Routine Gyn

(Limited to one exam per calendar year)

50% $0 copay,

deductible waived

50% $0 copay,

deductible waived

70%

Emergency Room (Copay waived if admitted)

80% 100%

Urgent Care 80% 50% 100% 70%

Chiropractic

80% 50% 100% 70%

Physical Therapy/Occupational Therapy/Speech Therapy (Limited to 40 combined visits per calendar year)

80% 50% 100% 70%

$15 Generic Formulary $35 Brand Formulary $60 Non-Formulary $150 Self-Injectables after integrated medical deductible

$35 Brand Formulary $60 Non-Formulary $150 Self-Injectables after integrated medical deductible

Not covered

(20)

Aetna HSA-Compatible Medical Plans*

Aetna Plan Options HSA $5,000 100% HSA $5,000 80%

Networks Available Aetna Health Network Option Aetna Health Network Option

100% 70% 80% 50%

(Includes deductible and copayments, accumulates separately in/out of network)

$5,950 Individual/

Primary Physician Office Visit 100% 70% 80% 50%

Specialist Office Visit 100% 70% 80% 50%

Outpatient Lab 100% 70% 80% 50%

Outpatient X-ray 100% 70% 80% 50%

100% 70% 80% 50%

Routine Gyn

(Limited to one exam per calendar year) $0 copay, deductible waived 70% $0 copay, deductible waived 50%

$0 copay,

Emergency Room

(Copay waived if admitted) 100% 80%

Urgent Care 100% 70% 80% 50%

Chiropractic

(Limited to 12 visits per calendar year) 100% 70% 80% 50%

Physical Therapy/Occupational Therapy/Speech Therapy

(Limited to 40 combined visits per calendar year) 100% 70% 80% 50%

$15 Generic Formulary $35 Brand Formulary $60 Non-Formulary $150 Self-Injectables after integrated medical deductible

Not covered $15 Generic Formulary

$35 Brand Formulary $60 Non-Formulary $150 Self-Injectables after integrated medical deductible

Not covered

(21)

21

Footnotes

* This is a partial description of the benefits available; for more information, refer to the specific plan design summary. The dollar amount copayments indicate what the member is required to pay, and the percentage coinsurance indicates what Aetna is required to pay. The deductible applies to all medical benefits unless otherwise stated.

1_{We cover the cost of services based on whether doctors are}

“in network” or “out of network.” We want to help members understand how much Aetna pays for your out-of-network care. At the same time, we want to make it clear how much more they will need to pay for this “out-of-network” care. Members may choose a provider (doctor or hospital) in the Aetna network. They may choose to visit an out-of-network provider. If a member chooses a doctor who is out of network, the Aetna health plan may pay some of that doctor’s bill. Most of the time, members will pay a lot more money out of pocket if they choose to use an out-of-network doctor or hospital.

When a member chooses out-of-network care, the plan limits the amount it will pay. This limit is called the “recognized” or “allowed” amount. When members choose out-of-network care, the plan “recognizes” an amount based on what Medicare pays for these services.

The government sets the Medicare rate.

Doctors set their own rate to charge. It may be higher – sometimes much higher – than what the Aetna plan “recognizes.” The doctor may bill for the dollar amount that the plan doesn’t “recognize.” The member must also pay any copayments, coinsurance and deductibles under the plan. No dollar amount above the “recognized charge” counts toward the deductible or out-of-pocket maximums. To learn more about how we pay out-of-network benefits, visit www.aetna.com. Type “how Aetna pays” in the search box. Members can avoid these extra costs by getting their care from our broad network of health care providers. Go to www.aetna.com and click on “Find a Doctor” on the left side of the page. Members can also log in to their Aetna Navigator member site.

This applies when members choose to get care out of network. When they have no choice (for example: emergency room visit after a car accident, or for other emergency services), we will pay the bill as if they got care in network. Members pay cost sharing and deductibles for their in-network level of benefits. They contact us if the provider asks them to pay more. Members are not responsible for any outstanding balance billed by providers for emergency services beyond cost sharing and deductibles.

2_{For plans using the Aetna Open Access Managed Choice}

or PPO network, out-of-network prescription drugs are covered at 70 percent after the in-network copayment.

3_{Transition of coverage helps members of new groups transition}

to Aetna by providing a 90-calendar day opportunity, beginning on the group’s initial effective date, during which time approval requirements will not apply to certain drugs. Once the 90 calendar days have expired, prior authorization edits will apply to all drugs requiring precertification approval as listed in the formulary guide. Members who have claims paid for a drug requiring approval during the transition of coverage period may continue to receive this drug after the 90 calendar days and will not be required to obtain an approval.

Note: For a summary list of Limitations and Exclusions, refer to pages 56-57.

Some benefits are subject to limitations or visit maximums. Members or providers may be required to precertify, or obtain prior approval for certain services, such as non-emergency hospital care.

(22)

Aetna Dental Plans

Choose from a variety

of plan design options that

help you offer a dental

benefits and dental

insurance plan that’s just

right for employees.

(23)

23

1_{MayoClinic.com. “Oral health: A window to your overall health.” Available online at}_{www.mayoclinic.com/health/dental/DE00001}_{. Accessed May 2010.} 2_{R.C. Williams, A.H. Barnett, N. Claffey, M. Davis, R. Gadsby, M. Kellett, G.Y.H. Lip, and S. Thackray. “The potential impact of periodontal disease on general health:}

a consensus view.” Current Medical Research and Opinion, Vol. 24, No. 6, 2008, 1635-1643. *DMI may not be available in all states.

** Dual Option does not apply to Preventive and Voluntary Dental plans (2-9 group size).

The Mouth Matters

SM

Research suggests that serious gum disease, known as periodontitis, may be associated with many health problems. This is especially true if gum disease continues without treatment.1,2_{Now, here’s the good news. Researchers are}

discovering that a healthy mouth may be important to your overall health.1,2

The Aetna Dental/Medical IntegrationSM_{program* is available}

at no additional charge if you have both medical and dental coverages with us. The program focuses on those who are pregnant or have diabetes, coronary artery disease (heart disease) or cerebrovascular disease (stroke) and have not had a recent dental visit. We educate at-risk members about the impact oral health care can have on their condition. Our member outreach has been proven to successfully motivate those at-risk members who do not normally seek dental care to visit the dentist. Once at the dentist, these at-risk members will receive enhanced dental benefits including an extra cleaning and full coverage for certain periodontal services.

The Dental Maintenance Organization (DMO

®

₎

Members select a primary care dentist to coordinate their care from the available managed dental network. Each family member may choose a different primary care dentist and may switch dentists at any time by using Aetna Navigator or with a call to Member Services. If specialty care is needed, a member’s primary care dentist can refer the member to a participating specialist. However, members may visit orthodontists without a referral. There are minimal claim forms to file, and benefits are not subject to deductibles or annual maximums.

Preferred Provider Organization (PPO) plan

Members can choose a dentist who participates in the network or choose a licensed dentist who does not. Participating dentists have agreed to offer our members covered services at a

negotiated rate and will not balance bill members.

PPO Max plan

While the PPO Max plan uses the PPO network, when members use out-of-network dentists, the service will be covered based on the PPO fee schedule, rather than the usual charge. The member will share in more of the costs and may be balance-billed. This plan offers members a quality dental insurance plan with a significantly lower premium that encourages in-network usage.

Freedom-of-Choice plan design option

Get maximum flexibility with our two-in-one dental plan design. The Freedom-of-Choice plan design option provides the administrative ease of one plan, yet members get to choose between the DMO and PPO plans on a monthly basis. One blended rate is paid. Members may switch between the plans on a monthly basis by calling Member Services. Plan changes must be made by the 15th of the month to be effective the following month.

Dual Option plan**

In the Dual Option plan design, the DMO must be packaged with any one of the PPO plans. Members may choose between the DMO and PPO offerings at annual enrollment.

Voluntary Dental option (2-9)

The Voluntary Dental option provides a solution to meet the individual needs of members in the face of rising health care costs. Administration is easy, and members benefit from low group rates and the convenience of payroll deductions. You choose how the plan is funded. It can be entirely member-paid, or employers can contribute up to 50 percent.

Dental

(24)

2-9 Standard Dental Plans

Option 1 DMO Access

Option 2 Freedom-of-Choice — Monthly selection between

the DMO and the PPO Option 3 PPO Max 1000 Option 4 PPO Max 1500

DMO plan 42

(DMO Access) DMO Plan 100/90/60 PPO Max Plan 100/70/40 PPO Max Plan 100/50/50 PPO Max Plan 100/80/50

Office Visit Copay $10 $5 N/A N/A N/A

Annual Deductible per Member

(Does not apply to diagnostic and preventive services)

None None $50; 3X Family

Maximum $50; 3X Family Maximum $50; 3X Family Maximum

Annual Maximum Benefit Unlimited Unlimited $1,000 $1,000 $1,500

Diagnostic Services Oral Exams

Periodic oral exam No Charge 100% 100% 100% 100%

Comprehensive oral exam No Charge 100% 100% 100% 100%

Problem-focused oral exam No Charge 100% 100% 100% 100%

X-rays

Bitewing - single film No Charge 100% 100% 100% 100%

Complete series No Charge 100% 100% 100% 100%

Preventive Services

Adult cleaning No Charge 100% 100% 100% 100%

Child cleaning No Charge 100% 100% 100% 100%

Sealants - per tooth $10 100% 100% 100% 100%

Fluoride application - with cleaning No Charge 100% 100% 100% 100%

Space maintainers $100 100% 100% 100% 100%

Basic Services

Amalgam filling - 2 surfaces $32 90% 70% 50% 80%

Resin filling - 2 surfaces, anterior $55 90% 70% 50% 80%

Oral Surgery

Extraction - exposed root or erupted tooth $30 90% 70% 50% 80%

Extraction of impacted tooth - soft tissue $80 90% 70% 50% 80%

Major Services*

Complete upper denture $500 60% 40% 50% 50%

Partial upper denture (resin base) $513 60% 40% 50% 50%

Crown - Porcelain with noble metal1 _$488 _60% _40% _50% _50%

Pontic - Porcelain with noble metal1 _$488 _60% _40% _50% _50%

Inlay - Metallic (3 or more surfaces) $463 60% 40% 50% 50%

Oral Surgery

Removal of impacted tooth - partially bony $175** 60% 40% 50% 80%

Endodontic Services

Bicuspid root canal therapy $195 90% 40% 50% 80%

Molar root canal therapy $435** 60% 40% 50% 80%

Periodontic Services

Scaling and root planing - per quadrant $65 90% 40% 50% 80%

Osseous surgery - per quadrant $445** 60% 40% 50% 80%

(25)

25

See page 30 for footnotes.

2-9 Standard Dental Plans

Option 5 Freedom-of-Choice Monthly selection between

the DMO and the PPO Active PPO PlanOption 6 Option 7 PPO 1500

Option 8 Aetna Dental Preventive CareSM

PPO Max

DMO Plan 100/90/60

PPO Plan 100/70/40 (90th OON)

Preferred Plan 100/80/50

Non-Preferred Plan 80/60/40 (90th OON)

PPO Plan 100/80/50 (90th OON)

PPO Max 100/0/0

Office Visit Copay $10 N/A N/A N/A N/A N/A

(Does not apply to diagnostic and preventive services) None $50; 3X Family Maximum $50; 3X Family Maximum $50; 3X Family Maximum $50; 3X Family Maximum None

Annual Maximum Benefit Unlimited $1,000 $1,500 $1,000 $1,500 Unlimited

Periodic oral exam 100% 100% 100% 80% 100% 100%

Comprehensive oral exam 100% 100% 100% 80% 100% 100%

Problem-focused oral exam 100% 100% 100% 80% 100% 100%

X-rays

Bitewing - single film 100% 100% 100% 80% 100% 100%

Complete series 100% 100% 100% 80% 100% 100%

Adult cleaning 100% 100% 100% 80% 100% 100%

Child cleaning 100% 100% 100% 80% 100% 100%

Sealants - per tooth 100% 100% 100% 80% 100% 100%

Fluoride application - with cleaning 100% 100% 100% 80% 100% 100%

Space maintainers 100% 100% 100% 80% 100% 100%

Basic Services

Amalgam filling - 2 surfaces 90% 70% 80% 60% 80% Not Covered

Resin filling - 2 surfaces, anterior 90% 70% 80% 60% 80% Not Covered

Oral Surgery

Extraction - exposed root or erupted tooth 90% 70% 80% 60% 80% Not Covered

Extraction of impacted tooth - soft tissue 90% 70% 80% 60% 80% Not Covered

Major Services*

Complete upper denture 60% 40% 50% 40% 50% Not Covered

Partial upper denture (resin base) 60% 40% 50% 40% 50% Not Covered

Crown - Porcelain with noble metal1 _60% _40% _50% _40% _50% _{Not Covered}

Pontic - Porcelain with noble metal1 _60% _40% _50% _40% _50% _{Not Covered}

Inlay - Metallic (3 or more surfaces) 60% 40% 50% 40% 50% Not Covered

Oral Surgery

Removal of impacted tooth - partially bony 60% 40% 50% 40% 50% Not Covered

Bicuspid root canal therapy 90% 40% 50% 40% 50% Not Covered

Molar root canal therapy 60% 40% 50% 40% 50% Not Covered

Scaling and root planing - per quadrant 90% 40% 50% 40% 50% Not Covered

Osseous surgery - per quadrant 60% 40% 50% 40% 50% Not Covered

Orthodontic Services* Not covered Not covered Not Covered Not Covered Not Covered Not Covered

(26)

2-9 Voluntary Dental Plans

Option 1 DMO Access

Voluntary Option 2 Freedom-of-Choice Monthly selection between

the DMO and the PPO

Voluntary Option 3 PPO Max

Option 4 Aetna Dental Preventive CareSM_{PPO Max}

DMO Plan 42 DMO Plan

100/90/60 PPO Plan 100/70/40 PPO Plan 100/80/50 PPO Max 100/0/0

Office Visit Copay $15 $10 N/A N/A N/A

(Does not apply to diagnostic and preventive services) None None $75; 3X Family Maximum $75; 3X Family Maximum None

Annual Maximum Benefit Unlimited Unlimited $1,000 $1,500 Unlimited

Periodic oral exam No Charge 100% 100% 100% 100%

Comprehensive oral exam No Charge 100% 100% 100% 100%

Problem-focused oral exam No Charge 100% 100% 100% 100%

X-rays

Bitewing - single film No Charge 100% 100% 100% 100%

Complete series No Charge 100% 100% 100% 100%

Adult cleaning No Charge 100% 100% 100% 100%

Child cleaning No Charge 100% 100% 100% 100%

Sealants - per tooth $10 100% 100% 100% 100%

Fluoride application - with cleaning No Charge 100% 100% 100% 100%

Space maintainers $100 100% 100% 100% 100%

Basic Services

Amalgam filling - 2 surfaces $32 90% 70% 80% Not Covered

Resin filling - 2 surfaces, anterior $55 90% 70% 80% Not Covered

Oral Surgery

Extraction - exposed root or erupted tooth $30 90% 70% 80% Not Covered

Extraction of impacted tooth - soft tissue $80 90% 70% 80% Not Covered

Major Services*

Complete upper denture $500 60% 40% 50% Not Covered

Partial upper denture (resin base) $513 60% 40% 50% Not Covered

Crown - Porcelain with noble metal1 _$488 _60% _40% _50% _{Not Covered}

Pontic - Porcelain with noble metal1 _$488 _60% _40% _50% _{Not Covered}

Inlay - Metallic (3 or more surfaces) $463 60% 40% 50% Not Covered

Oral Surgery

Removal of impacted tooth - partially bony $175** 60% 40% 50% Not Covered

Bicuspid root canal therapy $195 90% 40% 50% Not Covered

Molar root canal therapy $435** 60% 40% 50% Not Covered

Scaling and root planing - per quadrant $65 90% 40% 50% Not Covered

Osseous surgery - per quadrant $445** 60% 40% 50% Not Covered

(27)

27

See page 31 for footnotes.

10-100 Standard and Voluntary Dental Plan Selections

Option 1A DMO Coinsurance

Option 2A

Freedom-of-Choice PPO Max Monthly selection between the

DMO and the PPO Max

Option 3A

Freedom-of-Choice PPO 90th Monthly selection between the

DMO and the PPO

DMO Plan 100/100/60

PPO Plan Max 100/80/50

DMO Plan 100/100/60

100/90/60 (90th OON)

Office Visit Copay $5 $5 N/A $5 N/A

(Does not apply to diagnostic and preventive services) None None $50; 3X Family Maximum None $50; 3X Family Maximum

Annual Maximum Benefit Unlimited Unlimited $1,000 Unlimited $1,500

Periodic oral exam 100% 100% 100% 100% 100%

Comprehensive oral exam 100% 100% 100% 100% 100%

Problem-focused oral exam 100% 100% 100% 100% 100%

X-rays

Bitewing - single film 100% 100% 100% 100% 100%

Complete series 100% 100% 100% 100% 100%

Adult Cleaning 100% 100% 100% 100% 100%

Child Cleaning 100% 100% 100% 100% 100%

Sealants - per tooth 100% 100% 100% 100% 100%

Fluoride application - with cleaning 100% 100% 100% 100% 100%

Space maintainers 100% 100% 100% 100% 100%

Basic Services

Amalgam filling - 2 surfaces 100% 100% 80% 100% 90%

Resin filling - 2 surfaces, anterior 100% 100% 80% 100% 90%

Bicuspid root canal therapy 100% 100% 80% 100% 90%

Scaling & root planing - per quadrant 100% 100% 80% 100% 90%

Oral Surgery

Extraction - exposed root or erupted tooth 100% 100% 80% 100% 90%

Extraction of impacted tooth - soft tissue 100% 100% 80% 100% 90%

Major Services

Complete upper denture 60% 60% 50% 60% 60%

Partial upper denture (resin base) 60% 60% 50% 60% 60%

Crown - Porcelain with noble metal 60% 60% 50% 60% 60%

Pontic - Porcelain with noble metal 60% 60% 50% 60% 60%

Inlay - Metallic (3 or more surfaces) 60% 60% 50% 60% 60%

Oral Surgery

Removal of impacted tooth - partially bony 60% 60% 80% 60% 90%

Molar root canal therapy 60% 60% 80% 60% 90%

Osseous surgery - per quadrant 60% 60% 80% 60% 90%

Orthodontic Services $2,300 copay $2,300 copay 50% $2,300 copay 50%