Tennessee 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-TN (11/12)

Tennessee 2–100

plan guide

Plans effective January 1, 2013

For businesses with 2–100 eligible employees

www.aetna.com

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

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You can count on us to provide health plans

that 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 insurance plans to provide more affordable options and to simplify plan selection and administration.

In this guide:

5 Small business commitment

5 Benefits for every stage of life

6 Medical overview

7 Provider network

10 Managing health care expenses

11 Medical plan options

17 Dental overview

19 Dental plan options

25 Life & disability overview 28 Life & disability plan options

35 Underwriting guidelines

44 Product specifications 55 Limitations and exclusions

57 Group enrollment checklist

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.

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Women’s preventive health benefits

New changes effective August 1, 2012

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.

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Employers can expect more

• 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 • Traditional plans • 100 percent plans

• Consumer-directed health plans • HSA-compatible plans

Dental plans • DMO • PPO

• Freedom-of-Choice plan design • Dual Option

• Voluntary options for dental Life and disability plans

• Basic term life insurance, supplemental life, spouse and dependent life, and AD&D • Flexible disability options

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.

Members get free access to these resources

Our plans allow members to:

• Track medical claims and take advantage of online services with our secure Aetna Navigator®_{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. • Use the Aetna Health ConnectionsSM_{disease management}

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

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

• 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.

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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.

Our health plan options are designed with the health

of your business in mind

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 - Traditional Plans (12-06, 12-07, 12-08, 12-09, 12-10, 12-11) - Consumer-Directed Plans (12-31, 12-41)

Value plans

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

• Provide innovative plan design

- HSA-Compatible Plans (12-21, 12-22, 12-23) - Consumer-Directed Plans (12-31)

Traditional plans

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

- Traditional Plans (12-01, 12-02, 12-03, 12-04, 12-05)

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 health plans HSA-compatible 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

Consumer-directed health plans Traditional plans

100% 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

Consumer-directed health plans HSA-compatible plans

We are committed to the

health of your business

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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.

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Medical

Overview

Wellness on Us

SM

Wellness for employees means a healthier business for employers. Our small business health benefits and insurance plans in Tennessee offer $0 copays for in-network eye exams on top of $0 copays for in-network preventive care. It’s one more way for us to help employees get a step closer to better health. See what employees can get for $0:

Immunizations $0 copay

Routine vision exams $0 copay

Routine physicals $0 copay

Child wellness visits $0 copay

Routine mammogram $0 copay

Routine ob/gyn visits $0 copay

Product Name Product Description PCP Required Referrals Required Network

Aetna Open Access®

Managed Choice®

(MC OA)

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. No No Managed Choice POS (Open Access) Traditional Choice® (Indemnity)

This 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

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

*Network subject to change.

PPO = Preferred Provider Organization MC OA = Managed Choice Open Access

Provider network*

7 PPO and MC OA Plans

Anderson Bedford Benton Bledsoe Blount Bradley Campbell Cannon Carroll Carter Cheatham Chester Claiborne Cocke Coffee Crockett Davidson Decatur Dekalb Dickson Dyer Fayette Franklin Gibson Giles Grainger Greene Grundy Hamblen Hamilton Hancock Hardeman Hardin Hawkins Haywood Henderson Henry Houston Humphreys Jefferson Johnson Knox Lake Lauderdale Lawrence Lewis Lincoln Loudon McMinn McNairy Macon Madison Marion Marshall Maury Meigs Montgomery Moore Morgan Obion Roane Robertson Rutherford Scott Sequatchie Sevier Shelby Smith Stewart Sullivan Sumner Tipton Trousdale Unicoi Union Van Buren Warren Washington Weakley Williamson Wilson PPO only Clay Cumberland Fentress Hickman Jackson Monroe Overton Perry Pickett Polk Putnam Rhea Wayne White

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Consumer Flex Choice

Consumer Flex Choice makes it possible for a Small Group employer to tailor benefits to better meet the needs of their employees. Consumer Flex Choice allows a Small Group employer to offer their employees as many medical plan designs as they would like (using the current portfolio). This means you can offer a variety of plan designs to your employees to meet their specific health care needs.

What are the advantages of Consumer Flex Choice? Employers can manage costs. Your contribution is based on the least expensive plan in the portfolio, regardless of the plans selected or how many plans are offered.

Employees can manage choice. Employees can select the benefits plan that meets their individual needs.

Employees and their families want different things from their medical plans. For instance, if an employer has employees who fit the “basic buyer” profile, they may want a medical plan where they share in more of the cost, but employees who are “value seekers” may want a plan with more investment options, such as an HSA-compatible plan. Still other employees may prefer a more traditional plan with fixed costs. With Consumer Flex Choice, you can manage your costs and provide flexibility in choice for your employees.

Easy administration

Employer contribution. 50 percent of the employee-only cost of the lowest cost plan in the portfolio (even if the you do not select that plan).

Standard participation underwriting guidelines apply: • For non-contributory plans, 100 percent participation is

required, excluding valid waivers.

• For contributory plans, 75 percent of eligible employees, excluding valid waivers.

At least one employee must be enrolled in each plan offered.

Simply Savings

Simply Savings* is the Aetna suite of plans designed specifically for small businesses. Simply Savings offers reduced minimum participation and employer contribution requirements. Simply Savings offers the following advantages: Lower participation and contribution requirements Value plans have lower participation and contribution requirements, except when offered with a non-Simply Savings plan.**

Greater employee choice

You can offer up to three of the Simply Savings plans. Flexibility and affordability

By choosing a Simply Savings plan, you are now able to offer benefits to help meet the needs of your employees.

Total freedom

We are committed to providing solutions to help meet the needs of small businesses. You can now offer quality coverage at affordable prices.

Easy administration

Setting up this program is simple:

• You choose up to three of the Simply Savings plans to offer on the Employer Application.

• You choose how much to contribute.

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

Simply Savings

Target audience Small businesses

Simply Savings plans available

12-07 ($2,000 deductible)

12-22 (HSA with $3,000 deductible) 12-31 ($10,000 plan)

Plan choices Up to 3 of the Simply Savings plans

Minimum participation

4 or more enrolled employees

Employer contribution

25% of the employee premium or $50 per employee per month Employee

participation

50%

*Available with four or more enrolled employees.

**If an employer chooses a Simply Savings plan to offer with a non-Simply Savings plan, the standard participation and contribution requirements on the non-Simply Savings plan will apply to both plans offered.

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Administrative Fees

Fee description Fee

HSA Initial setup $0 Monthly fees $0 POP* Initial setup** $175 Monthly fees $100

HRA and FSA*** fees Initial setup** 2–25 Employees $350 26–50 Employees $450 51–100 Employees $550 Renewal fee 2–25 Employees $225 26–50 Employees $275 51–100 Employees $325

Monthly fees† _{$5.25 per participant}

Additional setup fee for “stacked” plans

(those electing an Aetna HRA and FSA simultaneously)

$150

Participation fee for “stacked” participants $10.25 per participant Minimum fees

0–25 Employees $25 per month minimum 26–100 Employees $50 per month minimum

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)

TRA

Annual fee $350

Transit monthly fees $4.25 per participant

Parking monthly fees $3.15 per participant

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. 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 to reduce your costs.

COBRA administration

Aetna COBRA administration offers a full range of notification, documentation and record-keeping processes that can help you manage the complex billing and notification processes that are required for COBRA compliance, while also saving time and money.

Section 125 Cafeteria Plans and Section 132 Transit

Reimbursement Accounts

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.

*First-year POP fees waived with the purchase of medical with five plus enrolled employees.

**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 you opt 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. Initial setup fee for HRA is waived.

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A way to manage health

care expenses

Health Savings Account (HSA)

No setup 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, you or the employee can make account contributions. Employees can use the HSA to pay for qualified expenses tax free.

Member’s HSA Plan

The HSA Plan allows members to: • Own their HSA

• Contribute tax free

• Choose how and when to use their dollars • Roll it over each year and let it grow • Earn interest, tax free

Today

Use for qualified expenses with tax-free dollars Future

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

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

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

• After members meet the out-of-pocket maximum, the plan pays 100%

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 the HSA-compatible plans.

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Traditional Deductible and Coinsurance Plans (2–100 Employees)

Plan Options 12-01 12-02 12-03 12-04

In-Network Services

Coinsurance 80% 80% 80% 80%

Annual Deductible: Individual/Family $500/$1,000 $1,000/$2,000 $1,000/$2,000 $1,500/$3,000

Type of Deductible Embedded Embedded Embedded Embedded

Annual Out of Pocket (OOP): Individual/Family

(Deductible applies to OOP) $2,500/$5,000 $2,500/$5,000 $3,000/$6,000 $3,000/$6,000

Wellness On UsSM

Preventive Care, including annual Adult Physicals, Well-Women Visits, Mammograms, Colorectal Cancer Screening and other preventive care services

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

Vision Screening Services (1 time every 12 months) $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived

Prescription Lens Allowance $125 every 24 months $125 every 24 months $125 every 24 months $125 every 24 months

Physician Services

Primary Care Physician Office Visit $25, deductible waived $25, deductible waived $30, deductible waived $25, deductible waived

Specialist Office Visit $50, deductible waived $50, deductible waived $60, deductible waived $50, deductible waived

Walk-In Clinic Visit $25, deductible waived $25, deductible waived $30, deductible waived $25, deductible waived

Mental Health Outpatient Visits (25 visits per year –

Mental Health Parity applies to groups over 50)

Inpatient Services

Hospital Inpatient 80%, deductible applies 80%, deductible applies 80%, deductible applies 80%, deductible applies

Mental Health Inpatient (30 days per year –

Mental Health Parity applies to groups over 50) 80%, deductible applies 80%, deductible applies 80%, deductible applies 80%, deductible applies

Outpatient/Other Services

Diagnostic Lab $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived

Diagnostic X-ray $50, deductible waived $50, deductible waived $60, deductible waived $50, deductible waived

Diagnostic Complex Imaging (CAT, MRI, MRA/MRS

and PET scans) 80%, deductible applies 80%, deductible applies 80%, deductible applies 80%, deductible applies

Outpatient Surgery 80%, deductible applies 80%, deductible applies 80%, deductible applies 80%, deductible applies

Emergency Room (copay waived if admitted) $250, deductible waived $250, deductible waived $250, deductible waived $250, deductible waived

Urgent Care $75, deductible waived $75, deductible waived $75, deductible waived $75, deductible waived

Outpatient Rehabilitative Therapy (60 visits per year,

includes physical therapy, occupational therapy, speech therapy and chiropractic/subluxation services)

80%, deductible applies 80%, deductible applies 80%, deductible applies 80%, deductible applies

Pharmacy

Retail Pharmacy Copay (Aetna Specialty Pharmacy

available at 30% with a minimum copay of $30 and maximum copay of $120)

$10/$30/$60 $10/$30/$60 $10/$30/$60 $10/$30/$60

Mail-Order Drugs (MOD) (31-90 day supply –

retail/MOD)

2X 2X 2X 2X

Out-of-Network (OON) Services

Coinsurance 50% 50% 50% 50%

Annual Deductible: Individual/Family $1,000/$2,000 $2,000/$4,000 $2,000/$4,000 $3,000/$6,000

(Deductible applies to OOP) $7,500/$15,000 $7,500/$15,000 $9,000/$18,000 $9,000/$18,000

Emergency Room Paid as in-network

benefits Paid as in-network benefits Paid as in-network benefits Paid as in-network benefits

Retail Pharmacy 70% after copay 70% after copay 70% after copay 70% after copay

Plan Options Available

Managed Choice Open Access (MC OA) X X X X

Preferred Provider Organization (PPO) X X

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Traditional Deductible and Coinsurance Plans (2–100 Employees)

Plan Options 12-05 12-06 12-07 12-08

Coinsurance 80% 80% 80% 80%

Type of Deductible Embedded Embedded Embedded Embedded

(Deductible applies to OOP)

$3,500/$7,000 $3,500/$7,000 $4,000/$8,000 $4,000/$8,000

Vision Screening Services (1 time every 12 months) $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived

Prescription Lens Allowance $125 every 24 months $125 every 24 months $125 every 24 months $125 every 24 months

Primary Care Physician Office Visit $30, deductible waived $25, deductible waived $30, deductible waived $25, deductible waived

Specialist Office Visit $60, deductible waived $50, deductible waived $60, deductible waived $50, deductible waived

Walk-In Clinic Visit $30, deductible waived $25, deductible waived $30, deductible waived $25, deductible waived

Mental Health Parity applies to groups over 50) $60, deductible waived $50, deductible waived $60, deductible waived $50, deductible waived

Hospital Inpatient 80%, deductible applies 80%, deductible applies 80%, deductible applies 80%, deductible applies

Diagnostic Lab $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived

Diagnostic X-ray $60, deductible waived $50, deductible waived $60, deductible waived $50, deductible waived

and PET scans) 80%, deductible applies 80%, deductible applies 80%, deductible applies 80%, deductible applies

Outpatient Surgery 80%, deductible applies 80%, deductible applies 80%, deductible applies 80%, deductible applies

Emergency Room (copay waived if admitted) $250, deductible waived $250, deductible waived $300, deductible waived $250, deductible waived

Urgent Care $75, deductible waived $75, deductible waived $100, deductible waived $75, deductible waived

Pharmacy

$10/$30/$60 $10/$30/$60 $15/$45/$60 $10/$30/$60

retail/MOD) 2X 2X 2X 2X

Out-Of-Network (OON) Services

Coinsurance 50% 50% 50% 50%

$10,500/$21,000 $10,500/$21,000 $12,000/$24,000 $12,000/$24,000

Emergency Room Paid as in-network

benefits Paid as in-network benefits Paid as in-network benefits Paid as in-network benefits

Retail Pharmacy 70% after copay 70% after copay 70% after copay 70% after copay

Managed Choice Open Access (MC OA) X X X X

Preferred Provider Organization (PPO)

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Traditional Deductible and Coinsurance Plans (2–100 Employees)

Plan Options 12-09 12-10 12-11

Coinsurance 80% 80% 80%

Annual Deductible: Individual/Family $2,500/$5,000 $3,000/$6,000 $3,000/$6,000

Type of Deductible Embedded Embedded Embedded

$5,000/$10,000 $5,000/$10,000 $6,000/$12,000

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

Vision Screening Services (1 time every 12 months) $0, deductible waived $0, deductible waived $0, deductible waived

Prescription Lens Allowance $125 every 24 months $125 every 24 months $125 every 24 months

Primary Care Physician Office Visit $30, deductible waived $25, deductible waived $30, deductible waived

Specialist Office Visit $60, deductible waived $50, deductible waived $60, deductible waived

Walk-In Clinic Visit $30, deductible waived $25, deductible waived $30, deductible waived

Hospital Inpatient 80%, deductible applies 80%, deductible applies 80%, deductible applies

Mental Health Parity applies to groups over 50) 80%, deductible applies 80%, deductible applies 80%, deductible applies

Diagnostic Lab $0, deductible waived $0, deductible waived $0, deductible waived

Diagnostic X-ray $60, deductible waived $50, deductible waived $60, deductible waived

and PET scans)

80%, deductible applies 80%, deductible applies 80%, deductible applies

Outpatient Surgery 80%, deductible applies 80%, deductible applies 80%, deductible applies

Emergency Room (copay waived if admitted) $300, deductible waived $250, deductible waived $300, deductible waived

Urgent Care $100, deductible waived $75, deductible waived $100, deductible waived

Pharmacy

$15/$45/$60 $10/$30/$60 $15/$45/$60

retail/MOD) 2X 2X 2X

Out-of-Network (OON) Services

(Deductible applies to OOP) $15,000/$30,000 $15,000/$30,000 $18,000/$36,000

Emergency Room Paid as in-network benefits Paid as in-network benefits Paid as in-network benefits

Retail Pharmacy 70% after copay 70% after copay 70% after copay

Managed Choice Open Access (MC OA) X X X

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HSA–Compatible Plans (2–100 Employees)

Plan Options 12-21 (HDHP) 12-22 (HDHP) 12-23 (HDHP)

$4,000/$8,000 $5,000/$10,000 $6,000/$12,000

Primary Care Physician Office Visit 80%, deductible applies 80%, deductible applies 80%, deductible applies

Specialist Office Visit 80%, deductible applies 80%, deductible applies 80%, deductible applies

Walk-In Clinic Visit 80%, deductible applies 80%, deductible applies 80%, deductible applies

Mental Health Parity applies to groups over 50) 80%, deductible applies 80%, deductible applies 80%, deductible applies

Diagnostic Lab 80%, deductible applies 80%, deductible applies 80%, deductible applies

Diagnostic X-ray 80%, deductible applies 80%, deductible applies 80%, deductible applies

and PET scans) 80%, deductible applies 80%, deductible applies 80%, deductible applies

Emergency Room (copay waived if admitted) 80%, deductible applies 80%, deductible applies 80%, deductible applies

Urgent Care 80%, deductible applies 80%, deductible applies 80%, deductible applies

Pharmacy

$10/$30/$60 includes Preventive

Care Waiver $10/$30/$60 includes Preventive Care Waiver $10/$30/$60 includes Preventive Care Waiver

$12,000/$24,000 $15,000/$30,000 $18,000/$36,000

Emergency Room Paid as in-network benefits Paid as in-network benefits Paid as in-network benefits

Retail Pharmacy 70% after copay 70% after copay 70% after copay

Managed Choice Open Access (MC OA) X X X

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100% Plans and Indemnity Plan (2–100 Employees)

Plan Options 12-31 12-41 12-80

Coinsurance 100% 100% 80%

$10,000/$10,000 $5,000/$10,000 $5,000/$10,000

Primary Care Physician Office Visit $30, deductible waived $25, deductible waived 80%, deductible applies

Specialist Office Visit $75, deductible waived $50, deductible waived 80%, deductible applies

Walk-In Clinic Visit $30, deductible waived $25, deductible waived 80%, deductible applies

Mental Health Parity applies to groups over 50) $75, deductible waived $50, deductible waived 80%, deductible applies

Diagnostic Lab 100%, deductible applies $0, deductible waived 80%, deductible applies

Diagnostic X-ray 100%, deductible applies $50, deductible waived 80%, deductible applies

and PET scans) 100%, deductible applies 100%, deductible applies 80%, deductible applies

Emergency Room (copay waived if admitted) 100%, deductible applies $250, deductible waived 80%, deductible applies

Urgent Care 100%, deductible applies $75, deductible waived 80%, deductible applies

100%, deductible applies $50, deductible waived 80%, deductible applies

Pharmacy

$20/$50/$70 $10/$30/$60 $15/$45/$65

Coinsurance 70% 70%

Same as in-network benefits

Annual Deductible: Individual/Family $10,000/$20,000 $10,000/$20,000

$15,000/$30,000 $15,000/$30,000

Emergency Room Paid as in-network benefits Paid as in-network benefits

Retail Pharmacy 70% after copay 70% after copay

Managed Choice Open Access (MC OA) X X

Preferred Provider Organization (PPO) Indemnity Only

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This is a partial description of plans and 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 copayments indicate what Aetna is required to pay.

NOTE: 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. For a summary list of Limitations and Exclusions, refer to page 55.

Copays apply to the out-of-pocket maximum (OOP) on all plans except Plan 12-41. Members must continue to pay applicable copays after OOP is met under Plan 12-41. Prescription drug cost sharing does not apply to the OOP, and members must continue to pay applicable prescription drug cost sharing after the OOP is met on all plans except HSA-compatible plans (prescription drug cost sharing applies to the HSA-compatible plans, OOP).

Mandatory Generic (MG) with Dispensed as Written Override (DAW) – Member pays the applicable coinsurance only, if the physician requires brand. If the member requests brand when a generic is available, the member pays the applicable coinsurance plus the difference between the generic price and the brand. Plan includes contraceptive drugs and devices obtainable from a pharmacy and diabetic supplies. Precertification included. For all HSA-compatible plans (12-21, 12-22, 12-23), the full cost of the drug is applied to the deductible before any benefits are considered for payment under the pharmacy plan; however, the deductible is waived for certain preventive medications. A full list of these drugs is available on Aetna Navigator.

Unless otherwise indicated, the deductible must be met prior to benefits being payable. All covered expenses accumulate toward the preferred and non-preferred deductible separately. Once the family deductible is met by any combination of family members, all family members will be considered as having met their deductible for the remainder of the calendar year. No one family member may contribute more than the individual deductible amount to the family deductible.

Members may choose providers in the Aetna network (physicians and facilities), or they may visit an out-of-network provider. Typically, members will pay substantially more money out of their own pockets if they choose to use an out-of-network doctor or hospital. The out-of-network provider will be paid based on Aetna’s “recognized charge.” This is not the same as the billed charge from the doctor. Aetna pays a percentage of the recognized charge, as defined in the plan. The recognized charge for out-of-network hospitals, doctors and other out-of-network health care providers is a percentage (100 percent or above) of the rate that Medicare pays them.

You may have to pay the difference between the out-of-network provider’s billed charge and Aetna’s recognized charge, plus any coinsurance and deductibles due under the plan. Note that any amount the doctor or hospital bills you above Aetna’s recognized charge does not count toward your deductible or out-of-pocket maximums. This benefit applies when you choose to get care out of network.

When you have no choice in the doctors you see (for example, an emergency room visit after a car accident), your deductible and coinsurance for the in-network level of benefits will be applied, and you should contact Aetna if your doctor asks you to pay more. Generally, you are not responsible for any outstanding balance billed by your doctors in an emergency situation.

Footnotes

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Aetna Dental Overview

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.

(18)

Dental

Overview

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_{Now, here’s the good news. Researchers are}

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

The Aetna Dental/Medical IntegrationSM_{(DMI) program,*}

available at no additional charge to plan sponsors who have both medical and dental coverages 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

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.

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.

Aetna Dental Preventive Care

SM

_plan

The Preventive Care plan is a lower-cost dental plan that covers preventive and diagnostic procedures.

Dual Option plan**

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

1 _{MayoClinic.com. “Oral health: A window to your overall health.”}_{www.mayoclinic.com/health/dental/DE00001 [article online]. February 5, 2011.}

Accessed November 2012.

*DMI may not be available in all states.

**Dual Option does not apply to Voluntary Dental plans in the 2–9 group and all Preventive Dental Plans.

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19

Standard Dental Plans (2–9 Employees)

Option 1 Option 2 Option 3

Low — Passive PPO 100/80/50 Medium — Passive PPO 100/80/50 High — Passive PPO 100/80/50

Office Visit Copay N/A N/A N/A

Annual Deductible per Member

(does not apply to Diagnostic & Preventive services) $50; 3X Family Maximum $50; 3X Family Maximum $50; 3X Family Maximum

Annual Maximum Benefit $1,000 $1,500 $2,000

Diagnostic Services Oral Exams

Periodic oral exam 100% 100% 100%

Comprehensive oral exam 100% 100% 100%

Problem-focused oral exam 100% 100% 100%

X-rays

Bitewing – single film 100% 100% 100%

Complete series 100% 100% 100%

Preventive Services

Adult cleaning 100% 100% 100%

Child cleaning 100% 100% 100%

Sealants – per tooth 100% 100% 100%

Fluoride application – with cleaning 100% 100% 100%

Space maintainers 100% 100% 100%

Basic Services

Amalgam filling – 2 surfaces 80% 80% 80%

Resin filling – 2 surfaces, anterior 80% 80% 80%

Oral Surgery

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

Major Services*

Complete upper denture 50% 50% 50%

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

Crown – Porcelain with noble metal 50% 50% 50%

Pontic – Porcelain with noble metal 50% 50% 50%

Inlay – Metallic (3 or more surfaces) 50% 50% 50%

Oral Surgery

Removal of impacted tooth – partially bony 50% 80% 80%

Endodontic Services

Bicuspid root canal therapy 50% 80% 80%

Molar root canal therapy 50% 80% 80%

Periodontic Services

Scaling & root planing – per quadrant 50% 80% 80%

Osseous surgery – per quadrant 50% 80% 80%

Orthodontic Services Not covered Not covered Not covered

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

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Standard Dental Plans (2–9 Employees)

Option 4 Option 5

High — Active PPO In Network 100/90/60

High — Active PPO Out of Network 80/60/50

Passive PPO Aetna Dental Preventive Care

Office Visit Copay N/A N/A N/A

(does not apply to Diagnostic & Preventive services)

$50; 3X Family Maximum $50; 3X Family Maximum None

Annual Maximum Benefit $2,000 $1,500 None

Periodic oral exam 100% 80% 100%

Comprehensive oral exam 100% 80% 100%

Problem-focused oral exam 100% 80% 100%

X-rays

Bitewing – single film 100% 80% 100%

Complete series 100% 80% 100%

Adult cleaning 100% 80% 100%

Child cleaning 100% 80% 100%

Sealants – per tooth 100% 80% 100%

Fluoride application – with cleaning 100% 80% 100%

Space maintainers 100% 80% 100%

Basic Services

Amalgam filling – 2 surfaces 90% 60% Not covered

Resin filling – 2 surfaces, anterior 90% 60% Not covered

Oral Surgery

Extraction – exposed root or erupted tooth 90% 60% Not covered Extraction of impacted tooth – soft tissue 90% 60% Not covered

Major Services*

Complete upper denture 60% 50% Not covered

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

Oral Surgery

Removal of impacted tooth – partially bony 90% 60% Not covered

Bicuspid root canal therapy 90% 60% Not covered

Molar root canal therapy 90% 60% Not covered

Scaling & root planing – per quadrant 90% 60% Not covered

Osseous surgery – per quadrant 90% 60% Not covered

Orthodontic Services Not covered Not covered Not covered

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

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Voluntary Dental Plans (3–9 Employees)

Voluntary Option 1 Voluntary Option 2 Voluntary Option 3 Voluntary Option 4

Low — Passive PPO 100/80/50 Medium — Passive PPO 100/80/50 High — Passive PPO 100/80/50

Passive PPO Aetna Dental Preventive Care

Office Visit Copay N/A N/A N/A N/A

(does not apply to Diagnostic & Preventive services) $75; 3X Family Maximum $75; 3X Family Maximum $75; 3X Family Maximum None

Annual Maximum Benefit $1,000 $1,500 $2,000 None

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%

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 80% 80% 80% Not covered

Resin filling – 2 surfaces, anterior 80% 80% 80% Not covered

Oral Surgery

Extraction – exposed root or erupted tooth 80% 80% 80% Not covered Extraction of impacted tooth – soft tissue 80% 80% 80% Not covered

Major Services*

Complete upper denture 50% 50% 50% Not covered

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

Oral Surgery

Removal of impacted tooth – partially bony 50% 80% 80% Not covered

Bicuspid root canal therapy 50% 80% 80% Not covered

Molar root canal therapy 50% 80% 80% Not covered

Scaling & root planing – per quadrant 50% 80% 80% Not covered Osseous surgery – per quadrant 50% 80% 80% Not covered

Orthodontic Services Not covered Not covered Not covered Not covered

Orthodontic Lifetime Maximum Does not apply Does not apply Does not apply Not covered

21

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Standard and Voluntary Plan Selections (10–100 Employees)

Option 1A

DMO Access Option 1BDMO Coinsurance

Option 2A

Freedom-of-Choice — Monthly selection between the DMO and PPO

Copay plan 42 DMO 100/80/50 100/100/50 PPO Plan 100/80/50

Office Visit Copay $10 $5 $5 None

(Does not apply to diagnostic and preventive services)

None None None $50; 3X Family

Maximum

Annual Maximum Benefit Unlimited None None $1,000

Periodic oral exam No charge 100% 100% 100%

Comprehensive oral exam No charge 100% 100% 100%

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

X-rays

Bitewing – single film No charge 100% 100% 100%

Complete series No charge 100% 100% 100%

Adult cleaning No charge 100% 100% 100%

Child cleaning No charge 100% 100% 100%

Sealants – per tooth $10 100% 100% 100%

Fluoride application – with cleaning No charge 100% 100% 100%

Space maintainers (Fixed) $100 100% 100% 100%

Basic Services

Amalgam filling – 2 surfaces $32 80% 100% 80%

Resin filling – 2 surfaces, anterior $55 80% 100% 80%

Bicuspid root canal therapy $195 80% 100% 80%

Scaling & root planing – per quadrant $65 80% 100% 80%

Oral Surgery

Extraction – exposed root or erupted tooth $30 80% 100% 80% Extraction of impacted tooth – soft tissue $80 80% 100% 80%

Major Services*

Complete upper denture $500 50% 50% 50%

Crown – Porcelain with noble metal1 _$488 _50% _50% _50%

Pontic – Porcelain with noble metal1 _$488 _50% _50% _50%

Inlay – Metallic (3 or more surfaces) $463 50% 50% 50%

Oral Surgery

Removal of impacted tooth – partially bony $175** 50% 50% 50%

Molar root canal therapy $435** 50% 50% 50%

Osseous surgery – per quadrant $445** 50% 50% 50%

Orthodontic Services* (optional) $2,300 copay $2,300 copay $2,300 copay 50%

Orthodontic Lifetime Maximum Does not apply Does not apply Does not apply $1,000

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Standard and Voluntary Plan Selections (10–100 Employees)

Option 3A

Preventive care Option 4APPO 1000 Option 5APPO 1000 Plus Option 6APPO 1500

PPO 100/0/0 PPO 1000 Plan 100/80/50

PPO 1000 Plan 100/80/50

PPO 1500 Plan 100/80/50

Office Visit Copay N/A None None None

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

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

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%

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 (Fixed) 100% 100% 100% 100%

Basic Services

Amalgam filling – 2 surfaces Not covered 80% 80% 80% Resin filling – 2 surfaces, anterior Not covered 80% 80% 80%

Bicuspid root canal therapy Not covered 50% 80% 80%

Scaling & root planing – per quadrant Not covered 50% 80% 80%

Oral Surgery

Extraction – exposed root or erupted tooth Not covered 80% 80% 80% Extraction of impacted tooth – soft tissue Not covered 80% 80% 80%

Major Services*

Complete upper denture Not covered 50% 50% 50%

Crown – Porcelain with noble metal1 _{Not covered} _50% _50% _50%

Pontic – Porcelain with noble metal1 _{Not covered} _50% _50% _50%

Inlay – Metallic (3 or more surfaces) Not covered 50% 50% 50%

Oral Surgery

Removal of impacted tooth – partially bony Not covered 50% 80% 50%

Molar root canal therapy Not covered 50% 80% 50%

Osseous surgery – per quadrant Not covered 50% 80% 50%

Orthodontic Services* (optional) Not covered 50% 50% 50%

Orthodontic Lifetime Maximum Does not apply $1,000 $1,000 $1,000

23

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2–9 Standard Dental Plan footnotes

*Coverage Waiting Period: Must be an enrolled member of the Plan for 12 months before becoming eligible for coverage of any Major Service.

All Endodontic, Periodontic and Oral Surgical services are covered as Basic Services on the PPO in Plan Options 2, 3 & 4. Out-of-Network plan payments are limited by geographic area on Plan Options 1–5 to the prevailing fees at the 80th_percentile.

Plan features and availability may vary by location and are subject to change. Information is believed to be accurate as of the production date; however, it is subject to change.

Above list of covered services is representative. Full list with limitations as determined by Aetna appears in the plan booklet/ certificate. For a summary list of Limitations and Exclusions, refer to page 56.

3–9 Voluntary Dental Plan footnotes

*Coverage Waiting Period: Must be an enrolled member of the Plan for 12 months before becoming eligible for coverage of any Major Service.

All Endodontic and Periodontic services are covered as Basic Services on the PPO in Plan Options 2 & 3.

Out-of-Network plan payments are limited by geographic area on Plan Options 1–4 to the prevailing fees at the 80th_percentile.

Above list of covered services is representative. Full list with limitations as determined by Aetna appears in the plan booklet/ certificate. For a summary list of Limitations and Exclusions, refer to page 56.

10–100 Standard and Voluntary Dental Plan footnotes *Coverage Waiting Period applies to Voluntary PPO plans:

Must be an enrolled member of the Plan for 12 months before becoming eligible for coverage of any Major Service including Orthodontic Services. Does not apply to DMO or Standard plans.

**Specialist procedures are not covered by the plan when performed by a participating Specialist. However, the service is available to the member at a discount.

1_{There will be an additional patient charge for the actual cost}

for gold/high noble metal for these procedures for the DMO in Plan Options 1A and 2A.

Fixed dollar copay amounts on the DMO including office visit and ortho copays, are member responsibility. The DMO in Plan Options 1A & 1B can be offered with any of the PPO plans in Plan Options 4A–6A in a Dual Option package.

All Endodontic and Periodontic services are covered as Major Services on the PPO in Plan Option 4A. Most Oral Surgery, Endodontic and Periodontic services are covered as Basic Services on the DMO in Plan Options 1A, 1B & 2A, and on the PPO in Plan Options 2A & 6A. General Anesthesia along with all Oral Surgery, Endodontic and Periodontic services are covered as Basic Services on the PPO in Plan Option 5A.

Out-of-Network plan payments are limited by geographic area on the PPO in Plan Options 2A–6A to the prevailing fees at the 80th_percentile.

Voluntary Plans: If there is a lapse in coverage, members may not re-enroll in the plan for a period of two years from the date of termination. If they are eligible for coverage at that time, they may re-enroll, subject to all provisions of the plan, including, but not limited to, the Coverage Waiting Period.

Orthodontic coverage is available for dependent children only in Plan Options 1A, 1B, 2A, 4A and 6A. Orthodontic coverage is available for adults and dependent children in Plan Option 5A (must choose the plan with orthodontic coverage).

DMO Access: Apart from the DMO network and DMO plan of benefits, members under this plan also have access to the Aetna Dental Access Network. This network provides access to providers who participate in the Aetna Dental Access Network and have agreed to charge a negotiated discounted fee. Members can access this network for any service. However, the DMO benefits do not apply in situations where the Dentist participates in both the Aetna Dental Access Network and the Aetna DMO network. DMO benefits take precedence over all other discounts, including discounts through the Aetna Dental Access network.

Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/ certificate. For a summary list of Limitations and Exclusions, refer to the Small Business Solutions brochure.

Footnotes

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Aetna Life & Disability Overview

Group life and disability is

an affordable way to provide life

insurance and disability benefits to

employees that will help them

establish financial protection for

themselves and their families.

(26)

Life & Disability

Overview

Life insurance

We know that life insurance is an important part of the benefits package you offer your employees. That’s why our products and programs are designed to meet your needs for:

• Flexibility • Added value • Cost-efficiency • Experienced support

We help you give employees what they’re looking for in lifestyle protection, through our selected group life insurance options. And we look beyond the benefit payout to include useful enhancements through the Aetna Life EssentialsSM_program.

So what’s the bottom line? A portfolio of value-packed products and programs to attract and retain workers — while making the most of the benefits dollars you spend.

Giving you (and your employees) what you want

Employees are looking for cost-efficient plan features and value-added programs that help them make better decisions for themselves and their dependents.

For groups with 51–100 eligible employees, please consult your Aetna Representative.

Our life insurance plans come with a variety of features including:

Accelerated death benefit — Also referred to as a “living benefit,” the accelerated death benefit provides payment to terminally ill employees or spouses. This payment can be up to 75 percent of the life insurance benefit.

Premium waiver provision — Employee coverage may stay in effect up to age 65 without premium payments if an employee becomes permanently and totally disabled while insured due to an illness or injury prior to age 60.

Optional dependent life — This feature allows employees to add optional additional coverage for eligible spouses and children for employers with 10 or more employees. This employee-paid benefit enables employees to cover their spouses and dependent children.

Our fresh approach to life

With Aetna Life EssentialsSM_{, your employees have access to}

programs during their active lives to help promote healthy, fulfilling lifestyles. In addition, Aetna Life Essentials provides for critical caring and support resources for often overlooked needs during the end of one’s life. And we also include value for beneficiaries and their loved ones well beyond the financial support from a death benefit.

AD&D Ultra

®

AD&D Ultra is standardly included with our small group life and disability insurance or benefits plan and provides employees and their families with the same coverage as a typical accidental death and dismemberment plan — and then some. It includes extra, no-cost features, such as coverage for education or child care expenses that make this protection even more valuable. Benefits include: • Death • Dismemberment • Loss of sight • Loss of speech • Loss of hearing • Third-degree burns • Paralysis

• Exposure and disappearance • Passenger restraint and airbag

• Education benefit for dependent child and/or spouse • Child care benefit

• Coma benefit

• Repatriation of remains benefit • Total disability benefit

(27)

Disability Insurance

Finding disability insurance or benefits plans for you and your employees isn’t difficult. Many companies offer them.

The challenge is finding the right plan — one that will meet the distinct needs of your business.

Our comprehensive approach to disability helps give us a clear understanding of what you and your employees need — and then helps meet those needs. You’ll get the right resources, the right support and the right care for your employees at the right time:

• Our clinically based disability model ensures claims and duration guidelines are fact-based with objective benchmarks. • We offer a holistic approach that takes the whole person

into account.

• We give you 24-hour access to claims information.

• We provide return-to-work programs to help ensure employees are back to work as soon as it’s medically safe to do so.

• We employ vocational rehabilitation and ergonomic specialists who can help restore employees back to health and productive employment.

Integrated Health and Disability

With Aetna One Core, our Integrated Health and Disability program, we can link medical and disability data to resolve claims more quickly, and may get your employees back to work sooner:

• The program is HIPAA-compliant, so medical and disability staff can share clinical information and work jointly with the employee to help address medical and disability issues. • Referrals between health case managers and their disability

counterparts help ensure better consistency and integration. • The program is available at no additional cost when a member

has both medical and disability coverage from Aetna.

For a summary list of Limitations and Exclusions, refer to page 56.

Life insurance policies and Disability insurance plans/policies are offered and/or underwritten by Aetna Life Insurance Company (Aetna).

(28)

Life and disability products are underwritten or administered by Aetna Life Insurance Company.

Term Life Plan Options for 2–50 Lives

2–9 Employees 10–50 Employees

Basic Life Schedule Flat $10,000, $15,000, $20,000, $50,000 Flat $10,000, $15,000, $20,000, $50,000, $75,000, $100,000, $125,000

Guaranteed Issue $20,000 10–25 employees $75,000

26–50 employees $100,000

Disability Provision Premium Waiver 60 Premium Waiver 60

Age Reduction Schedule Original life amount reduces to 65% at age 65; 40% at age 70; 25% at age 75

Original life amount reduces to 65% at age 65; 40% at age 70; 25% at age 75

Accelerated Death Benefit Up to 75% of life amount for terminal illness Up to 75% of life amount for terminal illness

Conversion Included Included

AD&D Ultra

AD&D Schedule Matches life benefit Matches life benefit

Additional Features Passenger restraint and airbag, education benefit for your child and/or spouse, child care, repatriation of remains, coma, total disability, 365-day covered loss period

Passenger restraint and airbag, education benefit for your child and/or spouse, child care, repatriation of remains, coma, total disability, 365-day covered loss period

Optional Dependent Term Life

Spouse Amount Not available $5,000

Child Amount Not available $2,000

Disability Plan Options for 2–50 Lives

Short Term Benefits Plan Option 1 Plan Option 2

Plan Amount Choice of flat $100 increments to a maximum

of $500 weekly Choice of flat $100 increments to a maximum of $500 weekly

Benefits Start — Accident 1 day 8 days

Benefits Start — Illness 8 days 8 days

Maximum Benefit Period 26 weeks 26 weeks

Maternity Benefit Maternity treated same as any other disability but is subject to pre-existing. If pregnant before the effective date, the pregnancy is not covered unless she has prior creditable coverage.

Maternity treated same as any other disability but is subject to pre-existing. If pregnant before the effective date, the pregnancy is not covered unless she has prior creditable coverage.

Pre-Existing Conditions Rule 3/12 3/12

Actively at Work Rule Applies Applies

Other Income Offset Integration N/A N/A

Definition of Disability Earnings loss of 20% or more Earnings loss of 20% or more