Washington, DC Plan guide

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Quality health plans & benefits

Healthier living

Financial well-being

Intelligent solutions

The health of business,

well planned.

64.10.302.1-DC A (7/12)

Washington, DC

2–100 Plan guide

Plans effective August 1, 2012

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Health/dental benefits and health/dental insurance plans, life and disability insurance plans are offered, underwritten and/or administered by Aetna Health Inc., Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna).

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 eligible employees.

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You can count on Aetna to provide health plans that

help simplify decision making and plan administration

so you can focus on the health of your business.

Aetna is 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, Aetna offers a variety of newly streamlined health 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 10 Medical plan options

22 Dental overview 24 Dental plan options 33 Life & disability overview 36 Life & disability plan options 39 Underwriting guidelines 47 Product specifications 57 Limitations and exclusions

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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

With Aetna, 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 • Traditional plans • Consumer-directed plans 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

• Packaged life and disability plans

Simplicity

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

Aetna makes 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 businesses and their employees with service they can trust.

Aetna resources are designed to fortify the health

of your business

• Track medical claims and take advantage of online services with your Aetna Navigator®_{secure member 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 (PHR).

• Use the Aetna Health ConnectionsSM_{Disease Management}

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

• Leverage 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.}

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We understand that your business has unique needs. That’s why we 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.

Aetna’s health plan options are designed with the

health of your business in mind

Basic plans

• Basic benefits for your employees • Limit the expense to your business

• Allow employees to buy up and share more of the cost - DC Health Network Only 3.4 (25/10%)

- DC Health Network Option 3.4 (25/10%) - DC PPO 3.4 (25/10%)

Value plans

• Encourage employee responsibility in their health care decisions • Tools and resources to support consumerism

• Innovative plan design

- DC Health Network Only HSA Comp 1.4 (1500 Ded) - DC PPO HSA-Compatible 1.4 (1500 Ded)

Traditional plans

• Standard benefits plans

• Limit the financial impact on employees - DC Health Network Only 2.4 (20/500A) - DC Health Network Option 2.4 (20/500A) - DC PPO 2.4 (20/500A)

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 Consumer-directed plans

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

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

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

Traditional plans

Consumer-directed plans

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Aetna Medical Overview

At Aetna, we are committed

to putting the employee at

the center of everything we do.

You can count on Aetna to

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Plan Name Product Description PCP Required Referrals Required Network Health

Network Only

A health maintenance organization (HMO) uses a network of participating providers. Each family member may select a primary care physician (PCP) participating in the Aetna network to provide routine and preventive care and help coordinate the member’s total health care. Members never need a referral when visiting a participating specialist for covered services. Only services rendered by a participating provider are covered, except for emergency or urgently needed care.

Yes/ Optional No Aetna Health Network OnlySM (Open Access) Health Network Option

Health Network Option 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 directly to a participating specialist without a referral. It is their choice, each time they seek care.

Yes/ Optional No Aetna Health Network OptionSM (Open Access)

PPO PPO plan 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.

No No Open

Choice®

PPO

Indemnity The indemnity plan option is available for employees who live outside the plan’s network service area. Members coordinate their own health care and may access any recognized provider for covered services without a referral.

No No N/A

Medical

Overview

Aetna High Deductible plans (HSA-Compatible)

These insurance plan options are compatible with a Health Savings Account (HSA). They provide employers and their qualified employees with an affordable tax-advantaged solution that allows them to better manage their qualified medical and dental expenses.

• Employees can build a savings fund to help cover their future medical and dental expenses. HSA accounts can be funded by the employer or employee and are portable.

• Fund contributions may be tax deductible (limits apply). • When funds are used to cover qualified out-of-pocket medical

and dental expenses, they are not taxed.

Group Situs

Medical and dental benefits and rates are based on the group’s headquarters location, subject to applicable state laws. Eligible employees who live or work in CT, DC, DE, MD, NJ, NY, PA and VA (the situs region) will receive the same rates and benefits as the headquarters location.

Multi State Solution

We offer a multi state solution to make it easier for businesses like yours to do business with us. We believe it brings more

consistency across medical benefits offerings to employers with employees in multiple locations.

Employers based in Washington, DC can offer DC PPO plans to their employees who live and work outside of the “situs” region. The situs region comprises of the following eight states - CT, DC, DE, MD, NJ, NY, PA and VA.

The rates and benefits will match those offered in Washington, DC If the out-of-situs employee lives in a non-network area, the employee will be enrolled in an indemnity plan. Plan sponsors will need to continue to meet underwriting guidelines, subject to all applicable state laws.

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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 HRA: $0; FSA: $350 26–50 employees HRA: $0; FSA: $450 51–100 employees HRA: $0; FSA: $550

Renewal fee

1–25 employees $225 26–50 employees $275 51–100 employees $325

Monthly fees*** $5.25 per participant

Additional set-up fee for “stacked” plans

(for 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

Transit Reimbursement Account (TRA)

Annual fee $350

Transit monthly fees $4.25 per participant

Parking monthly fees $3.15 per participant

COBRA Annual fee

20–50 employees $100 51–100 employees $175

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)

Monthly fee $0.88 per employee

No Cost Health Incentive Credit

†

Members can earn $50 in just a few simple steps

Members earn a $50 credit toward their out-of-pocket expenses when they:

• Complete or update their Health Assessment on Simple Steps To A Healthier Life, 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 toward the deductible and maximum out-of-pocket limit. This program is included at no additional cost on all plans, except Health Network Only plans 1.4 - 2.4 and all HSA-compatible plans.

Health Savings Account (HSA)

No set-up or administrative fees

The Aetna HealthFund®_{HSA, when coupled with an}

HSA-compatible high-deductible health benefits and health insurance plan, is a tax-advantaged savings account. Once enrolled, account contributions can be made by the employee and/or employer. The HSA can be used to pay for qualified expenses tax free.

Member’s HSA plan

• 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

• Meet out-of-pocket maximum, then plan pays 100%

* Nondiscrimination testing provided annually after open enrollment for POP and FSA only. Additional off-cycle testing available at employer request for $100 fee. Nondiscrimination 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.

†_{Not applicable to HSA-compatible plans.}

Aetna HealthFund HRAs are subject to employer-defined use and forfeiture rules, and are unfunded liabilities of the 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 subject to change.

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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 employers 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. Aetna’s

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 employers’ costs.

COBRA administration

Aetna COBRA administration offers a full range of notification, documentation and record-keeping processes that can help employers manage the complex billing and notification processes required for COBRA compliance, while also helping to save them time and money.

Section 125 Cafeteria Plans and Section 132 Transit

Reimbursement Accounts

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

Premium-Only plans (POP)

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

Flexible Savings 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)

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Traditional - Health Network Only Plan Options

Plan Options DC Health Network Only 1.4 (20/250A)+ DC Health Network Only 2.4 _(20/500A)+

Member Benefits In-Network In-Network

No referral needed No referral needed

Member Coinsurance N/A N/A

Plan Year Deductible N/A N/A

Plan Year Out-of-Pocket Maximum3 _{$1,500 per member}

$3,000 family $2,000 per member $4,000 family

Lifetime Maximum Benefit Unlimited Unlimited

Preventive Care

Well-Baby/Child/Adult Physical Exams

(Age and frequency schedules apply)

$0 copay $0 copay

Routine Gyn Exams

(Limited to one exam and pap smear per 365 days) $0 copay $0 copay

Routine Mammograms $0 copay $0 copay

Routine Eye Exam

(One exam per 24 months) $0 copay $0 copay

Aetna VisionSM_{Discount Program} _Included _Included

Primary Physician Office Visit4 _{$20 copay} _{$20 copay}

Specialist Office Visit4 _{$30 copay} _{$40 copay}

Outpatient Services – Lab $0 copay $0 copay

Outpatient Services – X-ray $30 copay $40 copay

Outpatient Complex Imaging

(MRA/MRS, MRI, PET and CAT scans) $100 copay $200 copay

Chiropractic Services

(20 visits per plan year) $10 copay $10 copay

Outpatient Physical/Occupational Therapy

(Physical and occupational therapy combined, 30 visits per plan year)

$30 copay $40 copay

Outpatient Speech Therapy

Durable Medical Equipment

($5,000 plan year maximum)

50% 50%

Inpatient Hospital $250 copay per admission $500 copay per admission

Outpatient Surgery $50 copay $300 copay

Emergency Room (Copay waived if admitted) $150 copay $200 copay

Urgent Care $50 copay $75 copay

Prescription Drugs◊_{(Includes 90-day transition of coverage (TOC) for prior authorization}5₎

Prescription Drugs: 30-day supply6 _{Option 1: $10/$25/$50}

Option 2: $10/$35/$60

$10/$35/$60

Prescription Drugs: 31- to 90-day supply6 _{Option 1: $20/$50/$100}

Option 2: $20/$70/$120 $20/$70/$120

Aetna Specialty CareRxSM_{Drugs: 30-day supply} _{Option 1: $100 copay}

Option 2: $200 copay $200 copay

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See pages 20–21 for footnotes.

Traditional - Health Network Only Plan Options

Plan Options DC Health Network Only 3.4 (25/10%)+ DC Health Network Only 4.4 _(25/30%)+

Plan Year Deductible N/A N/A

$5,000 family $3,000 per member $6,000 family

Preventive Care

(Age and frequency schedules apply)

$0 copay $0 copay

(Limited to one exam and pap smear per 365 days) $0 copay $0 copay

Routine Mammograms $0 copay $0 copay

(One exam per 24 months) $0 copay $0 copay

Primary Physician Office Visit4 _{$25 copay} _{$25 copay}

Specialist Office Visit4 _{$50 copay} _{$50 copay}

Outpatient Services – Lab $0 copay $0 copay

Outpatient Services – X-ray $50 copay $50 copay

(MRA/MRS, MRI, PET and CAT scans) $200 copay $200 copay

$50 copay $50 copay

50% 50%

Inpatient Hospital 10% 30%

Outpatient Surgery 10% 30%

Emergency Room (Copay waived if admitted) $200 copay $200 copay

Urgent Care $75 copay $75 copay

Prescription Drugs: 30-day supply6 _$10/$35/$60 _$10/$35/$60

Prescription Drugs: 31- to 90-day supply6 _$20/$70/$120 _$20/$70/$120

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12See pages 20–21 for footnotes.

Traditional - Health Network Option Plan Options

Plan Options DC Health Network Option 1.4 (20/250A)+ DC Health Network Option 2.4 _(20/500A)+

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

No referral needed No referral needed No referral needed No referral needed

Member Coinsurance N/A 20% after deductible N/A 30% after deductible

Plan Year Deductible2 _N/A _{$500 per member}

$1,000 family

N/A $500 per member $1,000 family

$3,000 family $3,000 per member $6,000 family $2,000 per member $4,000 family $3,500 per member $7,000 family

Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited

Preventive Care

(Age and frequency schedules apply. In-network and out-of-network combined.)

$0 copay 20% after deductible $0 copay 30% after deductible

(Limited to one exam and pap smear per 365 days. In-network and out-of-network combined.)

$0 copay 0%, deductible waived $0 copay 0%, deductible waived

Routine Mammograms $0 copay 0%, deductible waived $0 copay 0%, deductible waived

(One exam per 24 months.

In-network and out-of-network combined.)

Aetna VisionSM_{Discount Program} _Included _{Not covered} _Included _{Not covered}

Primary Physician Office Visit4 _{$20 copay} _{20% after deductible} _{$20 copay} _{30% after deductible}

Specialist Office Visit4 _{$30 copay} _{20% after deductible} _{$40 copay} _{30% after deductible}

Outpatient Services – Lab $0 copay 20% after deductible $0 copay 30% after deductible

Outpatient Services – X-ray $30 copay 20% after deductible $40 copay 30% after deductible

(MRA/MRS, MRI, PET and CAT scans) $100 copay 20% after deductible $200 copay 30% after deductible

(20 visits per plan year.

(Physical and occupational therapy combined, 30 visits per plan year. In-network and out-of-network combined.)

($5,000 plan year maximum.

50% 50% after deductible 50% 50% after deductible

Inpatient Hospital $250 copay per admission 20% after deductible $500 copay per admission 30% after deductible

Outpatient Surgery $50 copay 20% after deductible $300 copay 30% after deductible

Emergency Room

(Copay waived if admitted) $150 copay $150 copay, deductible waived $200 copay $200 copay, deductible waived

Urgent Care $50 copay 20% after deductible $75 copay 30% after deductible

Option 2: $10/$35/$60

Not covered $10/$35/$60 Not covered

Option 2: $20/$70/$120

Not covered $20/$70/$120 Not covered

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Traditional - Health Network Option Plan Option

Plan Options DC Health Network Option 3.4 (25/10%)+

Member Benefits In-Network Out-of-Network1

Member Coinsurance N/A 30% after deductible

Plan Year Deductible2 _N/A _{$1,000 per member}

$2,000 family

$5,000 family

$4,000 per member $8,000 family

Preventive Care

$0 copay 30% after deductible

(Limited to one exam and pap smear per 365 days. In-network and out-of-network combined.)

$0 copay 0%, deductible waived

Routine Mammograms $0 copay 0%, deductible waived

Aetna VisionSM_{Discount Program} _Included _{Not covered}

Primary Physician Office Visit4 _{$25 copay} _{30% after deductible}

Specialist Office Visit4 _{$50 copay} _{30% after deductible}

Outpatient Services – Lab $0 copay 30% after deductible

Outpatient Services – X-ray $50 copay 30% after deductible

(MRA/MRS, MRI, PET and CAT scans) $200 copay 30% after deductible

50% 50% after deductible

Inpatient Hospital 10% 30% after deductible

Outpatient Surgery 10% 30% after deductible

Emergency Room

(Copay waived if admitted)

$200 copay $200 copay, deductible waived

Urgent Care $75 copay 30% after deductible

Prescription Drugs: 30-day supply6 _$10/$35/$60 _{Not covered}

Prescription Drugs: 31- to 90-day supply6 _$20/$70/$120 _{Not covered}

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Traditional - PPO Plan Options

Plan Options DC PPO 1.4 (20/250A)+ _{DC PPO 2.4 (20/500A)}+

Member Coinsurance 0% 20% after deductible 0% 30% after deductible

Plan Year Deductible2 _N/A _{$500 per member}

$1,000 family

N/A $500 per member $1,000 family

$3,000 family $3,000 per member $6,000 family $2,000 per member $4,000 family $3,500 per member $7,000 family

Preventive Care

(Limited to one exam and pap smear per plan year. In-network and out-of-network combined.)

$0 copay 0%, deductible waived $0 copay 0%, deductible waived

Routine Mammograms $0 copay 0%, deductible waived $0 copay 0%, deductible waived

Primary Physician Office Visit $20 copay 20% after deductible $20 copay 30% after deductible

Specialist Office Visit $30 copay 20% after deductible $40 copay 30% after deductible

Outpatient Services – Lab $30 copay 20% after deductible $40 copay 30% after deductible

Outpatient Services – X-ray $30 copay 20% after deductible $40 copay 30% after deductible

(MRA/MRS, MRI, PET and CAT scans) $100 copay 20% after deductible $200 copay 30% after deductible

Chiropractic Services (20 visits per plan year.

In-network and out-of-network combined.) $10 copay 20% after deductible $10 copay 25% after deductible

Outpatient Speech Therapy (30 visits per plan year.

In-network and out-of-network combined.) $30 copay 20% after deductible $40 copay 30% after deductible

Durable Medical Equipment ($5,000 plan year maximum.

50% 50% after deductible 50% 50% after deductible

Inpatient Hospital $250 copay per admission 20% after deductible $500 copay per admission 30% after deductible

Outpatient Surgery $50 copay 20% after deductible $300 copay 30% after deductible

Emergency Room

(Copay waived if admitted) $150 copay $150 copay, deductible waived $200 copay $200 copay, deductible waived

Urgent Care $50 copay 20% after deductible $75 copay 30% after deductible

Option 2: $10/$35/$60 Option 1: $10/$25/$50 plus 30% Option 2: $10/$35/$60 plus 30% $10/$35/$60 $10/$35/$60 plus 30%

Option 2: $20/$70/$120 Not covered $20/$70/$120 Not covered

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Traditional - PPO Plan Option

Plan Options DC PPO 3.4 (25/10%)+

Member Benefits In-Network Out-of-Network1

Member Coinsurance 10% 30% after deductible

Plan Year Deductible2 _N/A _{$1,000 per member}

$2,000 family

$5,000 family

Preventive Care

(Limited to one exam and pap smear per plan year. In-network and out-of-network combined.)

$0 copay 0%, deductible waived

Routine Mammograms $0 copay 0%, deductible waived

Aetna VisionSM_{Discount Program} _Included _{Not covered}

Primary Physician Office Visit $25 copay 30% after deductible

Specialist Office Visit $50 copay 30% after deductible

Outpatient Services – Lab $50 copay 30% after deductible

Outpatient Services – X-ray $50 copay 30% after deductible

(MRA/MRS, MRI, PET and CAT scans) $200 copay 30% after deductible

50% 50% after deductible

Inpatient Hospital 10% 30% after deductible

Outpatient Surgery 10% 30% after deductible

Emergency Room

(Copay waived if admitted)

$200 copay $200 copay, deductible waived

Urgent Care $75 copay 30% after deductible

Prescription Drugs: 30-day supply6 _$10/$35/$60 _{$10/$35/$60 plus 30%}

Prescription Drugs: 31- to 90-day supply6 _$20/$70/$120 _{Not covered}

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Traditional - Indemnity Plan Option

Plan Options DC Indemnity 1.4 (500 Ded)+

Member Benefits Out-of-Network1

No referral needed

Member Coinsurance 30% after deductible

Plan Year Deductible2 _{$500 per member}

$1,000 family

$6,000 family

Lifetime Maximum Benefit Unlimited

Preventive Care

(Age and frequency schedules apply) 0%, deductible waived

(Limited to one exam and pap smear per plan year.)

0%, deductible waived

Routine Mammograms 0%, deductible waived

(One exam per 24 months)

0%, deductible waived

Aetna VisionSM_{Discount Program} _Included

Primary Physician Office Visit 30% after deductible

Specialist Office Visit 30% after deductible

Outpatient Services – Lab 30% after deductible

Outpatient Services – X-ray 30% after deductible

(MRA/MRS, MRI, PET and CAT scans)

30% after deductible

(20 visits per plan year)

($5,000 plan year maximum) 50% after deductible

Inpatient Hospital 30% after deductible

Outpatient Surgery 30% after deductible

Emergency Room 30% after deductible

Urgent Care 30% after deductible

Prescription Drugs: 30-day supply6 _$10/$35/$60

Prescription Drugs: 31- to 90-day supply6 _$20/$70/$120

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Consumer-Directed - Health Network Only

and PPO Consumer Directed Plan Options

Plan Options DC Health Network Only CD 1.4 (2000 Ded)+ _{DC PPO Consumer Directed 1.4 (1000 Ded)}+

Member Benefits In-Network In-Network Out-of-Network1

No referral needed No referral needed No referral needed

Member Coinsurance N/A 20% after deductible 50% after deductible

Plan Year Deductible2 _{$2,000 per member}

$4,000 family

$8,000 family $3,000 per member $6,000 family $5,000 per member $10,000 family

Lifetime Maximum Benefit Unlimited Unlimited Unlimited

Preventive Care

$0 copay, deductible waived $0 copay, deductible waived 50% after deductible

(Health Network Only: Limited to one exam and pap smear per 365 days. PPO CD: Limited to one exam and pap smear per plan year. In-network and

out-of-network combined.)

$0 copay, deductible waived $0 copay, deductible waived 0%; deductible waived

Routine Mammograms $0 copay, deductible waived $0 copay, deductible waived 0%; deductible waived

PPO CD: In-network and out-of-network combined.)

$0 copay, deductible waived $0 copay, deductible waived 50% after deductible

Aetna VisionSM_{Discount Program} _Included _Included _{Not covered}

Primary Physician Office Visit4 _{$25 copay, deductible waived} _{$30 copay, deductible waived} _{50% after deductible}

Specialist Office Visit4 _{$50 copay, deductible waived} _{$50 copay, deductible waived} _{50% after deductible}

Outpatient Services – Lab $0 copay after deductible 20% after deductible 50% after deductible

Outpatient Services – X-ray $50 copay after deductible 20% after deductible 50% after deductible

(MRA/MRS, MRI, PET and CAT scans) $200 copay after deductible 20% after deductible 50% after deductible

PPO CD: In-network and out-of-network combined.)

$10 copay after deductible 20% after deductible 25% after deductible

(Physical and occupational therapy combined, 30 visits per plan year. PPO CD: In-network and out-of-network combined.)

$50 copay after deductible 20% after deductible 50% after deductible

PPO CD: In-network and out-of-network combined.) $50 copay after deductible 20% after deductible 50% after deductible

PPO CD: In-network and out-of-network combined.) 50% after deductible 50% after deductible 50% after deductible

Inpatient Hospital 30% after deductible 20% after deductible 50% after deductible

Outpatient Surgery 30% after deductible 20% after deductible 50% after deductible

Emergency Room (Copay waived if admitted) $200 copay after deductible 20% after deductible 20% after deductible

Urgent Care $75 copay after deductible 20% after deductible 50% after deductible

Prescription Drugs: 30-day supply6 _$10/$35/$60 _$10/$35/$60 _{$10/$35/$60 plus 30%}

Prescription Drugs: 31- to 90-day supply6 _$20/$70/$120 _$20/$70/$120 _{Not covered}

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Consumer-Directed - Health Network Only

HSA-Compatible Plan Options

Plan Options DC Health Network Only HSA Comp 1.4 (1500 Ded)+ DC Health Network Only _{HSA Comp 2.4 (2500 Ded)}+

Plan Year Deductible2 _{$1,500 individual}

$3,000 family

$2,500 individual $5,000 family

Plan Year Out-of-Pocket Maximum3 _{$3,000 individual}

$6,000 family $5,000 individual $10,000 family

Preventive Care

$0 copay, deductible waived $0 copay, deductible waived

(Limited to one exam and pap smear per 365 days)

$0 copay, deductible waived $0 copay, deductible waived

Routine Mammograms $0 copay, deductible waived $0 copay, deductible waived

(One exam per 24 months) $0 copay, deductible waived $0 copay, deductible waived

Primary Physician Office Visit4 _{$20 copay after deductible} _{$30 copay after deductible}

Specialist Office Visit4 _{$40 copay after deductible} _{$50 copay after deductible}

Outpatient Services – Lab $40 copay after deductible $50 copay after deductible

Outpatient Services – X-ray $40 copay after deductible $50 copay after deductible

(MRA/MRS, MRI, PET and CAT scans) $200 copay after deductible $200 copay after deductible

$10 copay after deductible $10 copay after deductible

50% after deductible 50% after deductible

Inpatient Hospital $500 copay per admission

after deductible $300 copay per day, 5-day copay maximum per admission, after deductible

Outpatient Surgery $300 copay after deductible $200 copay after deductible

Emergency Room

(Copay waived if admitted) $200 copay after deductible $200 copay after deductible

Urgent Care $75 copay after deductible $75 copay after deductible

Prescription Drugs: 30-day supply6 _$10/$35/$60

after integrated deductible

$10/$35/$60

Prescription Drugs: 31- to 90-day supply6 _$20/$70/$120

$20/$70/$120

Aetna Specialty CareRxSM_{Drugs: 30-day supply} _{$200 copay}

(19)

Consumer-Directed - PPO HSA-Compatible Plan Options

Plan Options DC PPO HSA-Compatible 1.4 (1500 Ded)+ DC PPO HSA-Compatible 2.4 _{(2500 Ded)}+

Member Coinsurance 0% after deductible 30% after deductible 0% after deductible 30% after deductible

Plan Year Deductible2 _{$1,500 individual}

$3,000 family $3,000 individual $6,000 family $2,500 individual $5,000 family $5,000 individual $10,000 family

Plan Year Out-of-Pocket Maximum3 _{$3,000 individual}

$6,000 family $6,000 individual $12,000 family $5,000 individual $10,000 family $10,000 individual $20,000 family

Preventive Care

$0 copay, deductible waived

30% after deductible $0 copay, deductible waived

Routine Gyn Exams (Limited to one exam and pap smear

per plan year. In-network and out-of-network combined.) $0 copay, deductible waived 0%, deductible waived $0 copay, deductible waived 0%, deductible waived

Routine Mammograms $0 copay, deductible

waived 0%, deductible waived $0 copay, deductible waived 0%, deductible waived

Routine Eye Exam (One exam per 24 months.

In-network and out-of-network combined.) $0 copay, deductible waived 30% after deductible $0 copay, deductible waived 30% after deductible

Primary Physician Office Visit $20 copay after

deductible 30% after deductible $30 copay after deductible 30% after deductible

Specialist Office Visit $40 copay after

Outpatient Services – Lab $40 copay after

Outpatient Services – X-ray $40 copay after

(MRA/MRS, MRI, PET and CAT scans) $200 copay after deductible 30% after deductible $200 copay after deductible 30% after deductible

In-network and out-of-network combined.) $10 copay after deductible 25% after deductible $10 copay after deductible 25% after deductible

$40 copay after

In-network and out-of-network combined.) $40 copay after deductible 30% after deductible $50 copay after deductible 30% after deductible

In-network and out-of-network combined.) 50% after deductible 50% after deductible 50% after deductible 50% after deductible

Inpatient Hospital $500 copay per

admission after deductible

30% after deductible $300 copay per day, 5-day copay maximum per admission, after deductible

Outpatient Surgery $300 copay after

Emergency Room

(Copay waived if admitted) $200 copay after deductible $200 copay after deductible $200 copay after deductible $200 copay after deductible

Urgent Care $75 copay after

Prescription Drugs: 30-day supply6 _{$10/$35/$60 after}

integrated deductible $10/$35/$60 plus 30% after integrated deductible

$10/$35/$60 after

integrated deductible $10/$35/$60 plus 30% after integrated deductible

Prescription Drugs: 31- to 90-day supply6 _{$20/$70/$120 after}

integrated deductible

Not covered $20/$70/$120 after integrated deductible

Not covered

Aetna Specialty CareRxSM_{Drugs: 30-day supply} _{$200 copay after}

integrated deductible

Not covered $200 copay after integrated deductible

(20)

20

All plan options (pages 10-19)

+_{This is a partial description of benefits available. For more}

information, refer to the specific plan design summary.

◊_{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.

1_{Health Network Option and PPO plans:}

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 Aetna pays 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 Aetna 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, Aetna limits the amount it will pay. This limit is called the “recognized” or “allowed” amount. When you choose out-of-network care, Aetna “recognizes” an amount based on what Medicare pays for these services. The government sets the Medicare rate. Your doctor sets his or her own rate to charge you. It may be higher – sometimes much higher – than what your Aetna plan “recognizes.” Your doctor may bill you for the dollar amount that Aetna doesn’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

www.aetna.com. Type “how Aetna pays” in the search box.

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 Aetna 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 Aetna 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.

Indemnity plan:

Payment for care is determined based upon the lower of: the provider’s usual charge for furnishing it; or the charge Aetna determines to be appropriate, based on factors such as the cost of providing the same or a similar service or supply and the manner in which charges for the service or supply are made. These charges are referred to in your plan as “reasonable” or “recognized” charges.

Some benefits are subject to limitations or visit maximums. Members or providers may be required to precertify or obtain prior approval for certain services.

Note: For a summary list of Limitations and Exclusions, refer to pages 57–58. Please refer to Aetna’s Producer World®_{website at}

www.aetna.com for more detailed benefits descriptions. Or for

more information, please contact your licensed agent or Aetna sales representative.

(21)

Traditional - Health Network Only, Health Network

Option, PPO and Indemnity plan options (pages

10-16) and Consumer Directed - Health Network Only

and PPO Consumer-Directed plan options (page 17)

2 _{Once the family deductible is met, all family members will be}

considered as having met their deductible for the remainder of the plan year. No one family member may contribute more than the individual deductible amount to the family deductible. Deductible credit and deductible carryover do not apply.

PPO Consumer-Directed Plan: All covered expenses

accumulate separately toward the in-network and out-of-network deductible.

3_{Once the family out-of-pocket maximum is met, all family}

members will be considered as having met their out-of-pocket maximum for the remainder of the plan year. No one family member may contribute more than the individual

out-of-pocket maximum amount to the family out-of-pocket maximum. Prescription drugs do not apply toward the out-of-pocket maximum.

Health Network Option and PPO Plans: All covered expenses

accumulate separately toward the in-network and out-of-network out-of-pocket maximum.

Health Network Only Consumer-Directed, Health Network Option, PPO, PPO Consumer-Directed and Indemnity Plans:

Deductible applies to the out-of-pocket maximum.

4 _{“No Referral” provision for Health Network Only and Health}

Network Option Plans:

A member will pay the primary physician office visit cost-share when the member obtains covered benefits from any

in-network primary care physician. Members will pay the specialist office visit cost-share when the member obtains covered benefits from any in-network specialist.

5 _{Transition of coverage for prior authorizations helps}

members of new groups to transition to Aetna by providing a 90-calendar-day opportunity, beginning on the group’s initial effective date, during which time prior authorization

requirements will not apply to certain drugs. Once the 90 calendar days have expired, prior authorization edits will apply to all drugs requiring prior authorization as listed in the formulary guide. Members who have claims paid for a drug requiring prior authorization during the transition-of-coverage period may continue to receive this drug after the 90 calendar days and will not be required to obtain a prior authorization for this drug.

6_{Contraceptives and diabetic supplies included.}

Consumer-Directed - Health Network Only and PPO

HSA-Compatible plan options (pages 18-19)

2_{All covered prescription drug and medical expenses, except}

in-network preventive care services, apply to the deductible. The individual deductible can only be met when a member is enrolled for self-only coverage with no dependent coverage. The family deductible can be met by a combination of family members or by any single individual within the family. Once the family deductible is met, all family members will be considered as having met their deductible for the remainder of the plan year. Deductible credit and deductible carryover do not apply.

PPO HSA-Compatible Plans: All covered expenses

accumulate separately toward the in-network and out-of-network deductible.

3_{All amounts paid as deductible, copayments, or coinsurance for}

covered services and supplies apply toward the out-of-pocket maximum. The individual out-of-pocket maximum can only be met when a member is enrolled for self-only coverage with no dependent coverage. The family out-of-pocket maximum can be met by a combination of family members or by any single individual within the family. Once the family out-of-pocket maximum is met, all family members will be considered as having met their out-of-pocket maximum for the remainder of the plan year.

PPO HSA-Compatible Plans: All covered expenses accumulate

separately toward the in-network and out-of-network out-of-pocket maximum.

4_{No Referral” provision for Health Network Only Plans:}

A member will pay the primary physician office visit cost-share when the member obtains covered benefits from any

participating primary care physician. Members will pay the specialist office visit cost-share when the member obtains covered benefits from any participating specialist.

5 _{Transition of coverage for prior authorizations helps}

members of new groups to transition to Aetna by providing a 90-calendar-day opportunity, beginning on the group’s initial effective date, during which time prior authorization

requirements will not apply to certain drugs. Once the 90 calendar days have expired, prior authorization edits will apply to all drugs requiring prior authorization as listed in the formulary guide. Members who have claims paid for a drug requiring prior authorization during the transition-of-coverage period may continue to receive this drug after the 90 calendar days and will not be required to obtain a prior authorization for this drug.

(22)

22

Aetna Dental Plans

Small-business decision

makers can choose from

a variety of plan design

options that help you offer

a dental benefits and dental

insurance plan that’s just

right for your employees.

(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 plans or Voluntary Dental 3–9 size plans.

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,* available at no}

additional charge to plan sponsors that have both medical and dental coverage with Aetna, 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 proactively educate those 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 via 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 virtually no 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 dental insurance 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 and prevailing 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 option. The Freedom-of-Choice plan design 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 may be packaged with any one of the PPO plans. Employees may choose between the DMO and PPO offerings at annual enrollment.

Voluntary Dental option

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. Employers choose how the plan is funded for 3–9 size. It can be entirely member paid or employers can contribute up to 50 percent. Voluntary is entirely member-paid for 10–100.

Aetna Dental Preventive Care

SM

_plan

The Preventive Care plan is a lower cost dental plan that covers preventive and diagnostic procedures. Members pay nothing for these services when visiting an Aetna PPO dentist.

Dental

(24)

24

Aetna Dental Plans 2–9

Option 1 Aetna Dental

Preventive CareSM _{Option 2}

Option 3 Freedom-of-Choice

Monthly selection between the DMO and PPO Max

Member Benefits PPO Max Plan – Aetna

Dental Preventive Care DMO Plan 100/80/50 DMO Plan 100/90/60 PPO Max Plan 100/70/40

Office Visit Copay N/A $5 $5 None

Annual Deductible per Member

(Does not apply to diagnostic & preventive services)

None None None $50;

3X Family maximum

Annual Maximum Benefit None None None $1,000

Diagnostic Services Oral Exams

Periodic oral exam 100% 100% 100% 100%

Comprehensive oral exam 100% 100% 100% 100%

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

X-rays

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

Complete series 100% 100% 100% 100%

Preventive Services

Adult cleaning 100% 100% 100% 100%

Child cleaning 100% 100% 100% 100%

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

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

Space maintainers 100% 100% 100% 100%

Basic Services

Amalgam filling - 2 surfaces Not covered 80% 90% 70% Resin filling - 2 surfaces, anterior Not covered 80% 90% 70%

Oral Surgery

Extraction - exposed root or erupted tooth Not covered 80% 90% 70% Extraction of impacted tooth - soft tissue Not covered 80% 90% 70%

Major Services*

Complete upper denture Not covered 50% 60% 40%

Partial upper denture (resin base) Not covered 50% 60% 40% Crown - Porcelain with noble metal Not covered 50% 60% 40% Pontic - Porcelain with noble metal Not covered 50% 60% 40% Inlay - Metallic (3 or more surfaces) Not covered 50% 60% 40%

Oral Surgery

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

Endodontic Services

Bicuspid root canal therapy Not covered 80% 90% 40%

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

Periodontic Services

Scaling & root planing - per quadrant Not covered 80% 90% 40% Osseous surgery - per quadrant Not covered 50% 60% 40%

Orthodontic Services Not covered Not covered Not covered Not covered

Orthodontic Lifetime Maximum Does not apply Does not apply Does not apply Does not apply

(25)

Aetna Dental Plans 2–9

Option 4 Option 5 Active PPO High-Option Plan Option 6

Member Benefits PPO Max Plan

100/80/50 Preferred Plan 100/80/50 Nonpreferred Plan 80/60/40 PPO 1500 Plan 100/80/50

Office Visit Copay None None None None

(Does not apply to diagnostic & preventive services) $50; 3X Family maximum $50; 3X Family maximum $50; 3X Family maximum $50; 3X Family maximum

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

X-rays

Adult cleaning 100% 100% 80% 100%

Child cleaning 100% 100% 80% 100%

Basic Services

Amalgam filling - 2 surfaces 80% 80% 60% 80%

Resin filling - 2 surfaces, anterior 80% 80% 60% 80%

Oral Surgery

Extraction - exposed root or erupted tooth 80% 80% 60% 80% Extraction of impacted tooth - soft tissue 80% 80% 60% 80%

Major Services*

Complete upper denture 50% 50% 40% 50%

Partial upper denture (resin base) 50% 50% 40% 50% Crown - Porcelain with noble metal 50% 50% 40% 50% Pontic - Porcelain with noble metal 50% 50% 40% 50% Inlay - Metallic (3 or more surfaces) 50% 50% 40% 50%

Oral Surgery

Removal of impacted tooth - partially bony 50% 50% 40% 50%

Bicuspid root canal therapy 50% 80% 60% 50%

Molar root canal therapy 50% 50% 40% 50%

Scaling & root planing - per quadrant 50% 80% 60% 50%

Osseous surgery - per quadrant 50% 50% 40% 50%

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26

Aetna Voluntary Dental Plans 3–9

Voluntary Option 1 Aetna Dental

Preventive Care Voluntary Option 2

Voluntary Option 3 Freedom-of-Choice

Monthly selection between the DMO and PPO Max

Member Benefits PPO Max Plan – Aetna

Dental Preventive Care DMO Plan 100/80/50 DMO Plan 100/90/60 PPO Max Plan 100/70/40

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

(Does not apply to diagnostic & preventive services)

None None None $75; 3X Family maximum

Annual Maximum Benefit None None None $1,000

X-rays

Adult cleaning 100% 100% 100% 100%

Child cleaning 100% 100% 100% 100%

Basic Services

Amalgam filling - 2 surfaces Not covered 80% 90% 70% Resin filling - 2 surfaces, anterior Not covered 80% 90% 70%

Oral Surgery

Extraction - exposed root or erupted tooth Not covered 80% 90% 70% Extraction of impacted tooth - soft tissue Not covered 80% 90% 70%

Major Services*

Complete upper denture Not covered 50% 60% 40%

Partial upper denture (resin base) Not covered 50% 60% 40% Crown - Porcelain with noble metal Not covered 50% 60% 40% Pontic - Porcelain with noble metal Not covered 50% 60% 40% Inlay - Metallic (3 or more surfaces) Not covered 50% 60% 40%

Oral Surgery

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

Bicuspid root canal therapy Not covered 80% 90% 40%

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

Scaling & root planing - per quadrant Not covered 80% 90% 40% Osseous surgery - per quadrant Not covered 50% 60% 40%

(27)

Aetna Voluntary Dental Plans 3–9

Voluntary Option 4

Member Benefits PPO Max Plan

100/80/50

Office Visit Copay N/A

(Does not apply to diagnostic & preventive services) $75; 3X Family maximum

Annual Maximum Benefit $1,500

Periodic oral exam 100% Comprehensive oral exam 100% Problem-focused oral exam 100%

X-rays

Bitewing - single film 100% Complete series 100%

Adult cleaning 100%

Child cleaning 100%

Sealants - per tooth 100% Fluoride application - with cleaning 100% Space maintainers 100%

Basic Services

Amalgam filling - 2 surfaces 80% Resin filling - 2 surfaces, anterior 80%

Oral Surgery

Extraction - exposed root or erupted tooth 80% Extraction of impacted tooth - soft tissue 80%

Major Services*

Complete upper denture 50% Partial upper denture (resin base) 50% Crown - Porcelain with noble metal 50% Pontic - Porcelain with noble metal 50% Inlay - Metallic (3 or more surfaces) 50%

Oral Surgery

Removal of impacted tooth - partially bony 50%

Bicuspid root canal therapy 50% Molar root canal therapy 50%

Scaling & root planing - per quadrant 50% Osseous surgery - per quadrant 50%

Orthodontic Services Not covered

Orthodontic Lifetime Maximum Does not apply