virginia plan guide - health insurance plans | aetna...14.02.970.1-va a (6/10) aetna avenue® —...

14.02.970.1-VA A (6/10)

Aetna Avenue® — Your Destination for Small Business Solutions®

Virginia PLan gUiDE

PLANS EFFECTIVE October 1, 2010For businesses with 2-50 eligible employees

V I r g I N I A P L A N g U I D E

As a small business owner, providing value to your customers

and growing your business are your top priorities. Yet, today

health care is a business issue for every entrepreneur.

Small businesses need benefits and insurance plans that

fit their workplace. Aetna Avenue provides employers with a

choice of insurance benefits solutions. We know that choice,

ease and reputation are as valuable to employers as they are to

employees.

Aetna offers a variety of plans for small business — from

medical plans, to dental, life and disability plans.

Health care is a journey …

A E T N A AV E N U E I S T h E wAy

I N T h I S g U I D E :

2 Small business commitment

3 Benefits for every stage of life

5 Medical overview

8 Managing health care expenses

11 Medical plan options

24 Dental overview

27 Dental plan options

32 Life & disability overview

34 Life plan options

35 Life & disability plan options

36 Underwriting guidelines

42 Limitations and exclusions

Health benefits and health insurance, dental benefits/dental insurance, life insurance and disability insurance plans/policies are offered, underwritten or administered by Aetna Health Inc., Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). Each insurer has sole financial responsibility for its own products.

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C h O I C E

For business owners and employees

At Aetna, we provide employers a choice of insurance benefits plans. Within these benefits programs, employers can choose specific plan designs that fit business and employee needs. And, employees have access to a wide network of doctors and other providers ensuring that they have a choice in how they receive their health care.

Medical plans — supporting members on their health care journey

�Traditional plans

�Consumer-directed (HSA/HRA) plans

Dental, life and disability plans —providing valuable protection

�DMO®

�PPO

�PPO Max

� Freedom-of-Choice

�Preventive

�Basic term life insurance

�Disability plans

�Packaged life and disability plans

E A S E

Allowing you to focus on your business

Employers want to focus on their customers and growing their business — not the insurance benefits program. Aetna makes sure that our plan designs are easy to set-up, administer, use and provide support to ensure your success.

Administration — making it work for your business

Aetna’s plan designs automatically process health claim reimbursements, provide a password-protected website to keep track of accounts and are supported by knowledgeable service representatives. Secure and online, Aetna EnrollSM makes managing health benefits easy and eliminates time-consuming, expensive paper-based processes.

Aetna Navigator ® — our online resource for employers, members and providers

� DocFind® to locate doctors in the neighborhood

�Track medical claims online

� Discount programs for eye, dental and other health care

� Personal Health Record providing a complete picture of health

� Temporary ID cards available for members to print as needed

Aetna Health ConnectionsSM disease management — our newly redesigned capabilities offer support for over 30 conditions as well as integrated care for members with multiple conditions.

r E P U TAT I O N

In business it’s everything

Your reputation is important to your business. At Aetna, our reputation is just as important. With 150 years of experience, we value our name, products and services and focus on delivering the right solution for your small business — our reputation depends upon it.

Our account executives, underwriters and customer service representatives are committed to providing your small business the valuable service it deserves.


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Basic benefits for your employees

Limiting the expense to your business

Allowing employees to buy-up and share more of the cost

You might be a …

Basic buyer

These plans fit …Basic plans• VA HMO No-Referral 4.4 ($25/30%)• VA PPO Consumer Directed 1.4 ($1,000 Ded)

Employee responsibility

Consumerism’s ability to make a difference

Tools and resources to support consumerism

Innovative plan design

You might be a …

Value seeker

These plans fit …Consumer-directed health plans• VA HMO No-Referral HSA Compatible 1.4

($1,500 Ded)

• VA Health Network Option AHF HRA 1.4 ($2,500 Ded)

• VA PPO HSA Compatible 1.4 ($1,500 Ded)

Traditional benefits plans

Limiting the financial impact on employees

You might be a …

Traditionalist

These plans fit …Traditional plans• VA HMO No-Referral 1.4 ($20/$500) • VA PPO 1.4 ($20/$500)

Doyouvalue …

We know that small business owners’ insurance benefits

needs are often different than a larger employer. Aetna

Avenue focuses on employers with 2-50 employees and our

insurance benefits programs are designed to work for this size

group. We’ll work with you to determine the right plans for

your business and assist you through implementation.

A E T N A’ S M A r k E T M A P

Guiding your small business health care journey

Aetna’s market map is a resource for brokers and employers to help determine the right insurance benefits plan for their business. The market map asks specific questions related to the business and employee need in order to narrow the field of plan design choices.

A E T N A AV E N U E ’ S C O M M I T M E N T T O S M A L L B U S I N E S S E M P L O y E r S

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y O U N g FA M I L I E S

E S TA B L I S h E D FA M I L I E S

E M P T y N E S T E r S

y O U N g S I N g L E S

Consumer-directed (HSA/HRA plans)

Traditional plans

Traditional plans

Consumer-directed (HSA/HRA plans)

y O U N g S I N g L E S

Includes singles and couples without children

Ready to conquer the world? Thinking big thoughts? Well, one of those thoughts should be about health coverage. Since they’re probably on a budget, they might want an affordable policy with lower monthly payments and modest out-of-pocket costs that also provides for quality preventive care, prescription drug coverage and financial protection to help safeguard their assets.

y O U N g FA M I L I E S

Includes married couples and single parents with young children and teens

Children tend to get sick more than adults — which means employees and their pediatricians get to know each other quite well. It also means they’re probably looking for health coverage with lower fees for office visits, lower monthly payments and caps on their out-of-pocket expenses. And, of course, they can benefit from quality preventive care for the entire family.

ESTABLIShED FAMILIES

Includes married couples and single parents with teens and college-aged children

As the children get older, the entire family’s needs change. Time management is important for active parents and children. Teenagers still need checkups and care for injuries and illness, while parents need to start thinking about their own needs, like plan designs that cover preventive care and screenings and promote a healthy lifestyle. And college brings financial concerns to the forefront, as well as the need for a national network.

E M P T y N E S T E r S

Includes men and women age 55 and over with no children at home

The kids are leaving home. It’s a wistful time, but also an exciting one. What are the plans? Travel? Leisure? Reassessing health coverage needs? These employees are probably looking for a policy that combines financial security with quality coverage for prescriptions, hospital inpatient/outpatient services and emergency care.

h E A LT h I N S U r A N C E B E N E F I T S F O r E V E ry S TA g E O F L I F E

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g r E AT C O V E r A g E B E g I N S w I T h A S O L I D N E T w O r kWe offer a large and diverse network of health care professionals that provide quality and cost-effective care. Our pharmacy participation includes leading chains like Rite Aid, CVS®, Eckerd, Wal-Mart®, and many supermarket pharmacies.

Throughout the Capitol Region,* our provider network is comprised of:

� More than 9,000 primary care physicians, including internists, family practitioners and pediatricians

� More than 31,000 specialists, including 2,000 obstetricians and gynecologists

�More than 5,400 dental providers

�Over 130 hospitals

*Data as of 4/08. Actual provider count is dependent on specific network participation.

**Network subject to change.

County hMO & PPO PPOAlbemarle •Alexandria City •Alleghany •Amelia •Amherst •Appomattox •Arlington •Bedford •Bedford City •Bland •Botetourt •Bristol City •Buchanan •Buckingham •Campbell •Caroline •Carroll •Charles City •Charlotte •Charlottesville City •Chesapeake City •Chesterfield •Colonial Heights City •Clarke •Clifton Forge City •Covington City •Craig •Culpeper •Cumberland •Danville City •Dickenson •Dinwiddie •Essex •Fairfax •Fairfax City •Falls Church City •Fauquier •Floyd •Fluvanna •Franklin City •Franklin County •Frederick •Fredericksburg City •Galax City •Giles •Gloucester •Goochland •Grayson •Hampton City •Hanover •Henrico •Henry •Hopewell City •Isle of Wight •James City •King and Queen •King George •

County hMO & PPO PPOKing William •Lancaster •Lee •Loudon •Louisa •Lunenburg •Lynchburg City •Manassas City •Manassas Park City •Martinsville City •Mathews •Middlesex •Montgomery •Nelson •New Kent •Newport News City •Norfolk City •Northumberland •Norton City •Nottoway •Orange •Patrick •Petersburg City •Pittsylvania •Poquoson City •Portsmouth City •Powhatan •Prince Edward •Prince George •Prince William •Pulaski •Radford City •Richmond City •Roanoke •Roanoke City •Russell •Salem City •Scott •Shenandoah •Smyth •Southampton •Spotsylvania •Stafford •Suffolk City •Surry •Sussex •Tazewell •Virginia Beach City •Warren •Washington •Westmoreland •Winchester City •Williamsburg City •Wise •Wythe •York •

V I r g I N I A P r O V I D E r N E T w O r k * *


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Aetna Avenue

M E D I C A L O V E rV I E w

Product Name Product Description PCP

RequiredReferrals Required Network

Aetna hMO A health maintenance organization (HMO) uses a network of participating providers. Each family member selects a primary care physician (PCP) participating in the Aetna network. The PCP provides routine and preventive care and helps coordinate the member’s total health care. The PCP refers members to participating specialists and facilities for medically necessary specialty care. Only services provided or referred by the PCP are covered, except for emergency, urgently needed care or direct-access benefits, unless approved by the HMO in advance of receiving services.

Yes Yes HMO

Aetna hMO No-referral*

The Aetna HMO No-Referral plan 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 HMO (Open Access)

Aetna POS No-referral

The Aetna POS No-Referral plan 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 Choice® POS (Open Access)

Aetna health Network Option (SM) (Aetna healthFund®)

The HealthFund plan blends traditional health coverage with a fund benefit to help pay for eligible medical expenses. This health insurance plan offers members the freedom to seek care from any licensed health care professional without a referral, and a fund to help pay for services that are covered under the plan. Members can stretch their fund by seeking the most cost-effective care and services.

The healthFund plan provides:

� An opportunity to build the fund and apply it toward future medical expenses.

� Traditional coverage for eligible expenses over the fund amount.

� A cap that limits the total amount a member pays annually for eligible expenses.

how it works:

� Use the health fund to pay for medical expenses. Unused fund balance rolls over to next year’s fund balance, as long as the member remains in the plan and with his or her current employer.

� If the fund is depleted, the member pays for remaining or future expenses until the deductible is met.

� If the fund is depleted and the deductible is met, the base medical benefits plan begins — meaning the member pays a coinsurance and/or copayment for remaining covered expenses.

Yes/Optional

No Aetna Health Network Option (SM) (Aetna HealthFund)

Aetna 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

Aetna 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

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A E T N A h I g h D E D U C T I B L E h S A C O M PAT I B L E h M O N O - r E F E r r A L / P P O P L A N S *Aetna High Deductible HSA Compatible HMO No-Referral and PPO Health Plans are compatible with a Health Savings Account (HSA). HSA-compatible plans provide integrated medical and pharmacy benefits. Preventive care services are waived from the deductible.

HSAs 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 assist in covering 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.

Note: Employers and employees should consult with their tax advisor to determine eligibility requirements and tax advantages for participation in the HSA plan.

S M A L L g r O U P S I T U SAetna Small Group benefits and rates are based on the group/s headquarter location, subject to applicable small group reform 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 headquarter location.

A E T N A S M A L L g r O U P M U LT I - S TAT E S O L U T I O NAs part of Aetna’s commitment to make it easier for small businesses to do business with us, and bring more consistency across benefit offerings to employers with employees in multiple locations, Aetna offers a multi-state solution.

VA domiciled employers can offer a VA PPO plan to their employees who live and work outside the “situs” region. The “situs” region is comprised of the following eight states — CT, DC, DE, MD, NJ, NY, PA, and VA.

The rates and benefits will match those offered in Virginia. If the out-of-situs employee resides in a non-network area, the employee will be enrolled in an indemnity plan. Plan sponsors will need to continue to meet small group underwriting guidelines, and the majority of eligible employees must be in Virginia.

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In all instances, extraterritorial benefits that may apply on any of the out-of-state employees will be implemented to the extent these are more comprehensive than the domiciled state benefits. These benefits will only apply to the out-of-state employees in the states where required.

For dental products, an out-of-state dental plan will be offered to employees who live and work outside the situs region defined above.

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

Aetna reserves the right to change any of the above fees and to impose additional fees upon prior written notice.

M E M B E r ’ S h S A P L A N

A wAy T O M A N A g E h E A LT h A N D h E A LT h C A r E E x P E N S E S

hEALTh SAVINgS ACCOUNT (hSA)

No set-up or administrative fees

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

h S A A C C O U N T

�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

T O D Ay Use for qualified expenses

with tax-free dollars

F U T U r EPlan for future and retiree

health-related costs

h I g h - D E D U C T I B L E h E A LT h P L A N

� 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%

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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. 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.

SECTION 125 CAFETErIA PLANS AND SECTION 132 TrANSIT rEIMBUrSEMENT ACCOUNTSEmployees 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)TRAs allow participants to use pretax dollars to pay transportation and parking expenses for the purpose of commuting to and from work.

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

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T r A D I T I O N A L — h M O N O - r E F E r r A L P L A N O P T I O N SPlan Options VA HMO NO-REFERRAL 1.4

($20/$500)+,*,(3)VA HMO NO-REFERRAL 2.4

($25/10%)+,*,(3)

Member Benefits In-NetworkNo Referral Needed

In-NetworkNo Referral Needed

Member Coinsurance N/A N/A

Plan year Deductible N/A N/A

Plan year Out-of-Pocket Maximum1

(Prescription drugs do not apply toward the Out-of-Pocket Maximum.)$1,500 per member $3,000 family

$2,500 per member $5,000 family

Lifetime Maximum Benefit Unlimited Unlimited

Preventive Care

well-Baby/Child Exams (Age and frequency schedules apply.)

$0 Copay $0 Copay

Adult Physical Exams (Limited to one exam per plan year.)

$0 Copay $0 Copay

routine gyN Exams (Limited to a routine exam, pap smear and other appropriate tests using any FDA-approved gynecologic cytology screening technologies, once every 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 Visit $20 Copay $25 Copay

Specialist Office Visit $40 Copay $50 Copay

Outpatient Services — Lab $0 Copay $0 Copay

Outpatient Services — x-ray $40 Copay $50 Copay

Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans)

$200 Copay $200 Copay

Chiropractic Services (20 visits per plan year)

$40 Copay $50 Copay

Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per plan year)

$40 Copay $50 Copay

Outpatient Speech Therapy (30 visits per plan year)

$40 Copay $50 Copay

Durable Medical Equipment ($2,500 Plan Year Maximum)

50% 50%

Inpatient hospital $500 Copay per Admission 10%

Outpatient Surgery $300 Copay 10%

Emergency room (Copay waived if admitted.) $200 Copay $200 Copay

Urgent Care $75 Copay $75 Copay

Mental health/Substance Abuse — Inpatient (Biological: Unlimited days. Non-Biological: 30 days per plan year. Combined Inpatient Mental Health and Substance Abuse Rehab.)

$500 Copay per Admission 10%

Prescription Drugs

Prescription Drug Deductible N/A N/A

Prescription Drugs — retail: 30-day supply

$10/$35/$60 $10/$35/$60

Prescription Drugs — Mail Order: 31-90-day supply

$20/$70/$120 $20/$70/$120

Contraceptives and Diabetic Supplies Included Included

90 Day Transition of Coverage (TOC) for Prior Authorization2 Included Included

Aetna Specialty CarerxSM Drugs $200 Copay $200 Copay

*Optional Features: Morbid Obesity Morbid Obesity

See pages 22-23 for important plan provisions.

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T r A D I T I O N A L — h M O N O - r E F E r r A L P L A N O P T I O N SPlan Options VA HMO NO-REFERRAL 3.4

($25/20%)+,*,(3)VA HMO NO-REFERRAL 4.4

($25/30%)+,*,(3)




Plan year Deductible N/A N/A

Plan year Out-of-Pocket Maximum 1

(Prescription drugs do not apply toward the Out-of-Pocket Maximum.)$3,000 per member $6,000 family



Preventive Care


$0 Copay $0 Copay


$0 Copay $0 Copay


$0 Copay $0 Copay

routine Mammograms $0 Copay $0 Copay


$0 Copay $0 Copay







$200 Copay $200 Copay


$50 Copay $50 Copay


$50 Copay $50 Copay


$50 Copay $50 Copay


50% 50%

Inpatient hospital 20% 30%

Outpatient Surgery 20% 30%




20% 30%

Prescription Drugs



$10/$35/$60 $10/$35/$60


$20/$70/$120 $20/$70/$120



Aetna Specialty CarerxSM Drugs $200 Copay $200 Copay



1212

T r A D I T I O N A L — P O S N O - r E F E r r A L P L A N O P T I O N SPlan Options VA POS NO-REFERRAL 1.4 ($20/$500)+,*,(4) VA POS NO-REFERRAL 2.4 ($25/10%)+,*,(4)


Out-of-Network5

No Referral NeededIn-NetworkNo Referral Needed

Out-of-Network5

No Referral Needed

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

Plan year Deductible 1 N/A $500 per member $1,000 family

N/A $1,000 per member $2,000 family


(Deductible applies to the Out-of-Pocket Maximum. Prescription drugs do not apply toward the Out-of-Pocket Maximum.)





Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited

Preventive Care

well-Baby/Child Exams (Age and frequency schedules apply. In-network and out-of-network combined.)

$0 Copay 0%; deductible waived $0 Copay 0%; deductible waived

Adult Physical Exams (Limited to one exam per plan year. In-network and out-of-network combined.)

$0 Copay 30% after deductible $0 Copay 30% after deductible

routine gyN Exams (Limited to a routine exam, pap smear and other appropriate tests using any FDA-approved gynecologic cytology screening technologies, once every 365 days. In-network and out-of-network combined.)


routine Mammograms $0 Copay 30% after deductible $0 Copay 30% after deductible

routine Eye Exam (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 Visit $20 Copay 30% after deductible $25 Copay 30% after deductible

Specialist Office Visit $40 Copay 30% after deductible $50 Copay 30% after deductible

Outpatient Services — Lab $0 Copay 30% after deductible $0 Copay 30% after deductible

Outpatient Services — x-ray $40 Copay 30% after deductible $50 Copay 30% after deductible



Chiropractic Services (20 visits per plan year. In-network and out-of-network combined.)


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


Outpatient Speech Therapy (30 visits per plan year. In-network and out-of-network combined.)


Durable Medical Equipment ($2,500 Plan Year Maximum. In-network and out-of-network combined.)

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

Inpatient hospital $500 Copay per Admission

30% after deductible 10% 30% after deductible

Outpatient Surgery $300 Copay 30% after deductible 10% 30% after deductible

Emergency room (Copay waived if admitted.) $200 Copay $200 Copay $200 Copay $200 Copay

Urgent Care $75 Copay 30% after deductible $75 Copay 30% after deductible

Mental health/Substance Abuse — Inpatient (Biological: Unlimited days. Non-Biological: 30 days per plan year. Combined Inpatient Mental Health and Substance Abuse Rehab. In-network and out-of-network combined.)

$500 Copay per Admission


Prescription Drugs

Prescription Drug Deductible N/A N/A N/A N/A


$10/$35/$60 Not Covered $10/$35/$60 Not Covered



Contraceptives and Diabetic Supplies Included Not Covered Included Not Covered

90 Day Transition of Coverage (TOC) for Prior Authorization3

Included Not Covered Included Not Covered

Aetna Specialty CarerxSM Drugs $200 Copay Not Covered $200 Copay Not Covered




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T r A D I T I O N A L — P P O P L A N O P T I O N SPlan Options VA PPO 1.4 ($20/$500)+,* VA PPO 2.4 ($25/10%)+,*


Out-of-Network4

No Referral NeededIn-NetworkNo Referral Needed

Out-of-Network4

No Referral Needed

Member Coinsurance 0% 30% after deductible 10% 30% after deductible

Plan year Deductible 1 N/A $500 per member $1,000 family

N/A $1,000 per member $2,000 family







Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited

Preventive Care


$0 Copay 0%; deductible waived $0 Copay 0%; deductible waived

Adult Physical Exams (Limited to one exam per 12 months. In-network and out-of-network combined.)


routine gyN Exams (Limited to a routine exam, pap smear and other appropriate tests using any FDA-approved gynecologic cytology screening technologies, once every plan year. In-network and out-of-network combined.)


routine Mammograms $0 Copay 30% after deductible $0 Copay 30% after deductible



Aetna VisionSM Discount Program Included Not Covered Included Not Covered

Primary Physician Office Visit $20 Copay 30% after deductible $25 Copay 30% after deductible

Specialist Office Visit $40 Copay 30% after deductible $50 Copay 30% after deductible

Outpatient Services — Lab $40 Copay 30% after deductible $50 Copay 30% after deductible

Outpatient Services — x-ray $40 Copay 30% after deductible $50 Copay 30% after deductible










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

Inpatient hospital $500 Copay per Admission


Outpatient Surgery $300 Copay 30% after deductible 10% 30% after deductible

Emergency room (Copay waived if admitted.) $200 Copay $200 Copay $200 Copay $200 Copay

Urgent Care $75 Copay 30% after deductible $75 Copay 30% after deductible

Mental health/Substance Abuse — Inpatient (Biological Mental Health and Substance Abuse: Unlimited days. Non-Biological Mental Health: 30 days per plan year. In-network and out-of-network combined.)

$500 Copay per Admission


Prescription Drugs

Prescription Drug Deductible N/A N/A N/A N/A


$10/$35/$60 $10/$35/$60 + 30% $10/$35/$60 $10/$35/$60 + 30%



Contraceptives and Diabetic Supplies Included Included Included Included

90 Day Transition of Coverage (TOC) for Prior Authorization3

Included Included Included Included

Aetna Specialty CarerxSM Drugs $200 Copay Not Covered $200 Copay Not Covered



14


T r A D I T I O N A L — P P O P L A N O P T I O N SPlan Options VA PPO 3.4 ($25/20%)+,*


Out-of-Network4

No Referral Needed

Member Coinsurance 20% 50% after deductible

Plan year Deductible 1 N/A $2,000 per member $4,000 family






Preventive Care


$0 Copay 0%; deductible waived


$0 Copay 50% after deductible



routine Mammograms $0 Copay 50% after deductible



Aetna VisionSM Discount Program Included Not Covered

Primary Physician Office Visit $25 Copay 50% after deductible

Specialist Office Visit $50 Copay 50% after deductible

Outpatient Services — Lab $50 Copay 50% after deductible

Outpatient Services — x-ray $50 Copay 50% after deductible










50% 50% after deductible

Inpatient hospital 20% 50% after deductible

Outpatient Surgery 20% 50% after deductible


Urgent Care $75 Copay 50% after deductible


20% 50% after deductible

Prescription Drugs



$10/$35/$60 $10/$35/$60 + 30%


$20/$70/$120 Not Covered



Aetna Specialty CarerxSM Drugs $200 Copay Not Covered

*Optional Features: Morbid Obesity


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C O N S U M E r D I r E C T E D — P P O C O N S U M E r D I r E C T E D P L A N O P T I O N SPlan Options VA PPO CONSUMER DIRECTED PLAN 1.4 ($1,000 Ded)+,*


Out-of-Network4

No Referral Needed

Member Coinsurance 20% after deductible 50% after deductible

Plan year Deductible 1 $1,000 per member $2,000 family







Preventive Care


$0 Copay; deductible waived 0%; deductible waived


$0 Copay; deductible waived 50% after deductible



routine Mammograms $0 Copay; deductible waived 50% after deductible




Primary Physician Office Visit $25 Copay, deductible waived 50% after deductible

Specialist Office Visit $50 Copay, deductible waived 50% after deductible

Outpatient Services — Lab $50 Copay, deductible waived 50% after deductible

Outpatient Services — x-ray $50 Copay, deductible waived 50% after deductible


$200 Copay after deductible 50% after deductible








50% after deductible 50% after deductible

Inpatient hospital 20% after deductible 50% after deductible

Outpatient Surgery 20% after deductible 50% after deductible

Emergency room (Copay waived if admitted.) $200 Copay after deductible $200 Copay after deductible

Urgent Care $75 Copay after deductible 50% after deductible



Prescription Drugs



$10/$35/$60 $10/$35/$60 + 30%


$20/$70/$120 Not Covered






16


CONSUMEr DIrECTED — hMO NO-rEFErrAL hSA COMPATIBLE PLAN OPTIONSPlan Options VA HMO NO-REFERRAL

HSA COMPATIBLE 1.4 ($1,500 Ded)+,*,(4)

VA HMO NO-REFERRAL HSA COMPATIBLE 2.4

($2,500 Ded)+,*,(4)




Plan year Deductible1

(All covered prescription drug and medical expenses, except in-network preventive care services, apply to the deductible.)

$1,500 Individual $3,000 Family



(All amounts paid as deductible, copayments, or coinsurance for covered services and supplies apply toward the Out-of-Pocket Maximum.)




Preventive Care


$0 Copay; deductible waived $0 Copay; deductible waived





routine Mammograms $0 Copay; deductible waived $0 Copay; deductible waived




Primary Physician Office Visit $20 Copay after deductible $30 Copay after deductible

Specialist Office Visit $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


$200 Copay after deductible $200 Copay after deductible









Inpatient hospital $500 Copay per Admission after deductible

$300 Copay per Day, 5 Day Copay Maximum per Admission, after deductible

Outpatient Surgery $200 copay after deductible $200 Copay after deductible


Urgent Care $75 Copay after deductible $75 Copay after deductible


$500 Copay per Admission after deductible


Prescription Drugs

Prescription Drug Deductible Integrated medical/pharmacy deductible

Integrated medical/pharmacy deductible


$10/$35/$60 after integrated deductible







Aetna Specialty CarerxSM Drugs $200 Copay after integrated deductible

$200 Copay after integrated deductible



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C O N S U M E r D I r E C T E D — P P O h S A C O M PAT I B L E P L A N O P T I O N SPlan Options VA PPO HSA COMPATIBLE 1.4 ($1,500 Ded)+,*


Out-of-Network4

No Referral Needed











Preventive Care











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

Specialist Office Visit $40 Copay after deductible 30% after deductible

Outpatient Services — Lab $40 Copay after deductible 30% after deductible

Outpatient Services — x-ray $40 Copay after deductible 30% after deductible











Inpatient hospital $500 Copay per Admission after deductible

30% after deductible

Outpatient Surgery $300 copay after deductible 30% after deductible




$500 Copay per Admission after deductible


Prescription Drugs




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



Not Covered




Not Covered



18


C O N S U M E r D I r E C T E D — P P O h S A C O M PAT I B L E P L A N O P T I O N SPlan Options VA PPO HSA COMPATIBLE 2.4 ($2,500 Ded)+,*


Out-of-Network4

No Referral Needed











Preventive Care

























Inpatient hospital $300 Copay per Day, 5 Day Copay Maximum per Admission, after deductible


Outpatient Surgery $200 Copay after deductible 30% after deductible






Prescription Drugs




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



Not Covered




Not Covered



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C O N S U M E r D I r E C T E D — h E A LT h N E T w O r k O P T I O N — h E A LT h r E I M B U r S E M E N T A r r A N g E M E N T ( h r A ) Plan Options VA HEALTH NETWORK OPTION AHF HRA 1.4 ($2,500 Ded)+,*,(4)


Out-of-Network5

No Referral Needed

healthFund Amount (Per plan year. Fund changes between tiers requires a life status change qualifying event.)

$500 Individual/$1,000 Family (In-network and out-of-network combined.)

healthFund Coinsurance (Percentage at which the Fund will reimburse.) 100%

healthFund Administration The Fund will be used to pay for the member’s responsibility, including the deductible and coinsurance. Once the deductible is met, the underlying medical plan provides coverage and if a Fund balance still exists, the Fund will pay the members’ responsibility (i.e., the member’s share of copay or coinsurance) until the Plan Year Out-of-Pocket Maximum has been reached or the Fund has been exhausted, whichever comes first. Preventive services and prescription drug benefits will be subject to the medical and pharmacy plan provisions and will not be eligible for reimbursement by the Fund.

healthFund rollover Any remaining HealthFund benefit amount at the end of the plan year is rolled over into next year’s HealthFund benefit amount.



(All covered expenses, except in-network preventive services, mandated benefits and prescription drug benefits apply to the deductible.)








Preventive Care



Adult Physical Exams (Limited to one exam per plan year. In-network and out-of-network combined.)


routine gyN Exams (Limited to a routine exam, pap smear and other appropriate tests using any FDA-approved gynecologic cytology screening technologies, once every 365 days. In-network and out-of-network combined.)










Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) $200 Copay after deductible 30% after deductible









Inpatient hospital $300 Copay per Day, 5 Day Copay Maximum per Admission, after deductible

$300 Copay per Day, 5 Day Copay Maximum per Admission, plus 30%, after deductible

Outpatient Surgery $200 Copay after deductible $200 Copay plus 30% after deductible



Mental health/Substance Abuse — Inpatient (Biological: Unlimited days. Non-Biological: 30 days per calendar year. Combined Inpatient Mental Health and Substance Abuse Rehab. In-network and out-of-network combined.)


$300 Copay per Day, 5 Day Copay Maximum per Admission, plus 30%, after deductible

Prescription Drugs


Prescription Drugs — retail: 30-day supply $10/$35/$60 Not Covered

Prescription Drugs — Mail Order: 31-90-day supply $20/$70/$120 Not Covered

Contraceptives and Diabetic Supplies Included Not Covered

90 Day Transition of Coverage (TOC) for Prior Authorization3 Included Not Covered




20


T r A D I T I O N A L — I N D E M N I T y P L A N O P T I O NPlan Options VA INDEMNITY 1.4 ($500 Ded)+,*

Member Benefits Out-of-Network4

No Referral Needed

Member Coinsurance 30% after deductible

Plan year Deductible1 $500 per member $1,000 family

Plan year Out-of-Pocket Maximum2 (Deductible applies to the Out-of-Pocket Maximum. Prescription drugs do not apply toward the Out-of-Pocket Maximum.)


Lifetime Maximum Benefit Unlimited

Preventive Care


0%; deductible waived

Adult Physical Exams (Limited to one exam per 12 months.)




routine Mammograms 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





Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per plan year.)






Inpatient hospital 30% after deductible

Outpatient Surgery 30% after deductible

Emergency room 30% after deductible

Urgent Care 30% after deductible

Mental health/Substance Abuse — Inpatient (Biological Mental Health and Substance Abuse: Unlimited days. Non-Biological Mental Health: 30 days per plan year.)


Prescription Drugs

Prescription Drug Deductible N/A


$10/$35/$60


$20/$70/$120

Contraceptives and Diabetic Supplies Included

90 Day Transition of Coverage (TOC) for Prior Authorization3 Included

Aetna Specialty CarerxSM Drugs $200 Copay



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TrADITIONAL — SMALL grOUP MANDATED PLANS — VA ESSENTIAL AND STANDArD hMO PLANSPlan Options VA ESSENTIAL HMO 1.4

PLAN (WITH DENTAL)+,*VA STANDARD HMO 1.4 PLAN (WITH DENTAL)+,*

Member Benefits In-NetworkReferral Needed

In-NetworkReferral Needed


Calendar year Deductible N/A N/A

Calendar year Out-of-Pocket Maximum1 $5,000 Individual $15,000 Family



Preventive Care


$0 Copay $0 Copay

Adult Physical Exams (Age and frequency schedules apply.)

$0 Copay $0 Copay


$0 Copay $0 Copay

routine Mammograms (Limited to one baseline mammogram for ages 35 through 39; and one mammogram per calendar year for ages 40 and over.)

$0 Copay $0 Copay

routine Eye Exam (Age and frequency schedule apply.)

$0 Copay $0 Copay







$20 Copay $20 Copay

Chiropractic Services Not Covered Not Covered

Outpatient Physical/Occupational/Speech Therapy (Limited to time period physician certifies significant improvement will result.)

Not Covered $20 Copay

Durable Medical Equipment (No Calendar Year Maximum.)

$0 Copay $0 Copay

Inpatient hospital $400 Copay per admission $400 Copay per admission

Outpatient Surgery $20 Copay $20 Copay

Emergency room (Copay waived if admitted.)

$20 Copay $20 Copay


Mental health/Substance Abuse — Inpatient (21 days per calendar year for Inpatient Mental Health and Substance Abuse combined.)

$400 Copay per admission $400 Copay per admission

Dental Coverage Plan provides coverage for preventive and acute dental care for children. Please refer to Aetna’s Producer World website at www.aetna.com for more detailed benefit description.

Plan provides coverage for preventive and acute dental care for children and adults. Please refer to Aetna’s Producer World website at www.aetna.com for more detailed benefit description.

Prescription Drugs


Prescription Drugs — retail: 34-day supply $10 $10

Prescription Drugs — Mail Order 35-90 day supply $10 $10

Contraceptives Included Included

Diabetic Supplies Excluded Excluded

90 Day Transition of Coverage (TOC) for Prior Authorization N/A — Prior authorization does not apply to this plan.

N/A — Prior authorization does not apply to this plan.

Aetna Specialty CarerxSM Drugs Covered under Medical Plan Covered under Medical Plan

*Optional Features: Essential or standard health benefit plans without dental are also available. Small employers, electing to be covered under an essential or standard health benefit plan, have the option to choose coverage that does not provide dental benefits. Small employers making such election must purchase separate dental coverage for all eligible employees and eligible dependents from a dental services plan authorized pursuant to Chapter 45 (§38.2-4500 et seq.) of Title 38.2 of the Code of Virginia.


22


IMPOrTANT PLAN PrOVIS IONS

The federal health care reform legislation known as the Patient Protection and Affordable Care Act was signed into law on March 23, 2010. A number of new reforms are effective September 23, 2010, including coverage for dependents up to age 26, elimination of lifetime benefit dollar maximums, restriction of annual dollar maximums on essential health benefits, removal of cost sharing for preventive services and elimination of pre-existing condition exclusions for dependent children under 19 years of age. Your Aetna Avenue benefit program does comply with the new reform legislation.

All Plan Options (Pages 10-21) + This is a partial description of benefits available; for more information, refer to the specific plan design summary. Some benefits are subject to limitations or visit maximums. Members or Providers may be required to pre-certify or obtain prior approval for certain services.Note: For a summary list of Limitations and Exclusions, refer to pages 46-49. Please refer to Aetna’s Producer World® web site at www.aetna.com for more detailed small business benefit descriptions. Or for more information, please contact your licensed agent or Aetna Sales Representative.

Traditional — hMO No-referral Options (Pages 10-11)1 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.2 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.

3 “No Referral” Provision: 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.

Traditional — POS No-referral Options (Page 12)1 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.2 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




5 You may choose providers in our network (physicians and facilities) or may visit an out-of-network provider. Typically, you will pay substantially more money out of your own pocket if you choose to use an out-of-network doctor. 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 Your 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.

Traditional — PPO and Consumer Directed — PPO Consumer Directed Plan Options (Pages 13-15)1 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





Aetna pays a percentage of the recognized charge, as defined in Your 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.

Consumer Directed — hMO No-referral hSA Compatible Options (Page 16)1 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.2 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.

3 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.


Consumer Directed — PPO hSA Compatible Plan Options (Pages 17-18) 1 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.2 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.



Aetna pays a percentage of the recognized charge, as defined in Your 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.

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Consumer Directed — health Network Option — health reimbursement Arrangement (hrA) Plan Option (Page 19) 1 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.2 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.




Aetna pays a percentage of the recognized charge, as defined in Your 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.

Traditional — Indemnity Plan Option (Page 20)1 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




4 Payment for care is determined based upon the lowest 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.

Traditional — Small group Mandated Plans — VA Essential and Standard Plan Options (Page 21)1 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.

IMPOrTANT PLAN PrOVIS IONS

24


Aetna Avenue

D E N TA L O V E rV I E w

The Mouth MattersSM

Research shows that more than 90 percent of all medical illnesses are detectable in the mouth and that 75 percent of people over the age of 35 have periodontal (gum) disease.1 Untreated oral diseases can have a big impact on the quality of life. This means that a dentist may be the first health care provider to diagnose a health problem!

Aetna Dental/Medical IntegrationSM (DMI) program, available at no additional charge to plan sponsors that 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.2 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.

1The professional entity, Academy of General Dentistry, 2007. 2”Dental/medical integration, Improved oral health can lead to a better overall health” Smart Business Chicago (1/07).

DMI may not be available in all states.

A E T N A D E N TA L ® P L A N S

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.

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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 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 Aetna PPO fee schedule, rather than the reasonable and customary charge. The member will share in more of the costs and may be balance-billed. This plan offers members a quality dental insurance plan with a significantly lower premium that encourages in-network usage.

Freedom-of-Choice plan design option

Get maximum flexibility with our two-in-one dental plan design. The Freedom-of-Choice plan design option provides the administrative ease of one plan, yet members get to choose between the DMO and PPO Max 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.

Consumer-directed — Aetna DentalFund® plan

The Aetna DentalFund plan is one of the first dental plans to combine a dental fund benefit with a base dental plan. The paid premium covers both the fund benefit and the traditional benefits of the dental plan. The plan combines the Fund with a PPO Max plan where preventive care is paid through the dental plan. Your employees can use their funds to pay for basic and major services received from any licensed dentist. If any dental fund dollars are not used during the year, they can be rolled over and added to the following year’s dental fund balance.

*Discounts for non-covered services may not be available.

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Dual Option plan

In the Dual Option plan design the DMO must 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 lower group rates and the convenience of payroll deductions. Employers choose how the plan is funded. It can be entirely member-paid or employers can contribute up to 50 percent.

Aetna Dental Preventive CareSM Plan

The Preventive Care plan is a lower cost dental plan that covers preventive and diagnostic procedures. Members pay nothing for these services and may get a discount† on the network dentist’s charges for non-covered services when visiting an Aetna PPO dentist. This includes orthodontic work for adults and teeth whitening.*


*Discounts for non-covered services may not be available. †Discounts are not insurance.

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S M A L L g r O U P D E N TA L P L A N SAvailable With an Aetna Medical Plan to Groups with 2-50 Eligible Employees

Available Without Medical Plan (Dental Standalone) to Groups with 3-50 Eligible Employees

Option 2DMO Access

Option 3Freedom-of-Choice —

Monthly selection between the DMO and PPO Max

Option 4PPO Max 1500

DMO Plan 42(DMO Access)

DMO Plan100/90/60

PPO Max Plan100/70/40


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

Dental Fund N/A N/A N/A N/A

Annual Deductible per Member (Does not apply to Diagnostic & Preventive services)

None None $50; 3X Family Maximum

$50; 3X Family Maximum

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

DIAgNOSTIC SERVICES

Oral Exams

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%

PREVENTIVE SERVICESAdult 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 $100 100% 100% 100%

BASIC SERVICESAmalgam filling — 2 surfaces $32 90% 70% 80%

resin filling — 2 surfaces, anterior $55 90% 70% 80%

Oral Surgery

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

Extraction of impacted tooth — soft tissue $80 90% 70% 80%

*MAjOR SERVICESComplete upper denture $500 60% 40% 50%

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

Crown — Porcelain with noble metal1 $488 60% 40% 50%

Pontic — Porcelain with noble metal1 $488 60% 40% 50%

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

Oral Surgery

removal of impacted tooth — partially bony

$175** 60% 40% 50%

Endodontic Services

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

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

Periodontic Services

Scaling & root planing — per quadrant $65 90% 40% 50%

Osseous surgery — per quadrant $445** 60% 40% 50%

*ORTHODONTIC SERVICES $2,300 copay $2,300 copay Not covered Not covered

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

* Coverage Waiting Period: 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 the Basic Dental Rider in Plan Option 1; DMO in Plan Options 2 & 3 or on the PPO in Plan Options 6 & 8.

** 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.Fixed dollar amounts on the DMO in Plan Options 2 & 3 including office visit and ortho copays are the member’s responsibility. 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 Option 2.Access to negotiated discounts: On the PPO plans in Plan Options 3-8, members may be eligible to receive non-covered services at the PPO negotiated rate when visiting a participating PPO dentist at any time, including during the Coverage Waiting Period.The DMO in Plan Option 2 cannot be sold on a standalone basis to a customer with primary business location in Maryland. Must be part of a Dual Option sale packaged with either Plan Options 4, 5, or 7. Most Oral Surgery, Endodontic and Periodontic services are covered as Basic Services on the DMO in Plan Options 2 & 3 and the PPO in Plan Option 5.Plan Options 3, 4, & 6-8; PPO Max Non-Preferred (Out-of-Network) Coverage is limited to a maximum of the Plan’s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area.The DentalFund in Plan Option 6 can be used to pay for any non-covered service. Any unused portion of the Fund will roll over to the next calendar year.Orthodontic coverage is available only to groups with 10 or more eligibles and for dependent children only.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.Aetna Dental Access Network is not insurance or a benefits plan. It only provides access to discounted fees for dental services obtained from providers who participate in the Aetna Dental Access network. Members are solely responsible for all charges incurred using this access, and are expected to make payment to the provider at the time of treatment.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 page 50.

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S M A L L g r O U P D E N TA L P L A N SAvailable With an Aetna Medical Plan to Groups with 2-50 Eligible Employees

Available Without Medical Plan (Dental Standalone) to Groups with 3-50 Eligible Employees

Option 5Active PPO Plan

Option 6Consumer Directed

Option 7PPO Max 1000

Option 8Preventive Care

Preferred Plan100/80/50

Non-Preferred Plan80/60/40

DentalFund/PPO Max100/0/0


PPO Max Plan100/0/0

Office Visit Copay N/A N/A None N/A N/A

Dental Fund N/A N/A $50 Single;$100 Family

N/A N/A




None $50; 3X Family Maximum

None

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

DIAgNOSTIC SERVICES

Oral Exams

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

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

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

x-rays

Bitewing — single film 100% 80% 100% 100% 100%

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

PREVENTIVE SERVICESAdult Cleaning 100% 80% 100% 100% 100%

Child Cleaning 100% 80% 100% 100% 100%

Sealants — per tooth 100% 80% 100% 100% 100%

Fluoride application — with cleaning 100% 80% 100% 100% 100%

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

BASIC SERVICESAmalgam filling — 2 surfaces 80% 60% Not covered 70% Not covered

resin filling — 2 surfaces, anterior 80% 60% Not covered 70% Not covered

Oral Surgery

Extraction — exposed root or erupted tooth 80% 60% Not covered 70% Not covered

Extraction of impacted tooth — soft tissue 80% 60% Not covered 70% Not covered

*MAjOR SERVICESComplete upper denture 50% 40% Not covered 40% Not covered

Partial upper denture (resin base) 50% 40% Not covered 40% Not covered

Crown — Porcelain with noble metal1 50% 40% Not covered 40% Not covered

Pontic — Porcelain with noble metal1 50% 40% Not covered 40% Not covered

Inlay — Metallic (3 or more surfaces) 50% 40% Not covered 40% Not covered

Oral Surgery


50% 40% Not covered 40% Not covered

Endodontic Services

Bicuspid root canal therapy 80% 60% Not covered 40% Not covered

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


Scaling & root planing — per quadrant 80% 60% Not covered 40% Not covered

Osseous surgery — per quadrant 50% 40% Not covered 40% Not covered

*ORTHODONTIC SERVICES 50% 40% Not covered Not covered Not covered

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

* Coverage Waiting Period: 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 the Basic Dental Rider in Plan Option 1; DMO in Plan Options 2 & 3 or on the PPO in Plan Options 6 & 8.

** 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.Fixed dollar amounts on the DMO in Plan Options 2 & 3 including office visit and ortho copays are the member’s responsibility. 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 Option 2.Access to negotiated discounts: On the PPO plans in Plan Options 3-8, members may be eligible to receive non-covered services at the PPO negotiated rate when visiting a participating PPO dentist at any time, including during the Coverage Waiting Period.The DMO in Plan Option 2 cannot be sold on a standalone basis; this must be part of a Dual Option sale packaged with either Plan Options 4, 5, or 7.Most Oral Surgery, Endodontic and Periodontic services are covered as Basic Services on the DMO in Plan Options 2 & 3 and the PPO in Plan Option 5.Plan Options 3, 4, & 6-8; PPO Max Non-Preferred (Out-of-Network) Coverage is limited to a maximum of the Plan’s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area.The DentalFund in Plan Option 6 can be used to pay for any non-covered service. Any unused portion of the Fund will roll over to the next calendar year.Orthodontic coverage is available only to groups with 10 or more eligibles and for dependent children only.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.Aetna Dental Access Network is not insurance or a benefits plan. It only provides access to discounted fees for dental services obtained from providers who participate in the Aetna Dental Access network. Members are solely responsible for all charges incurred using this access, and are expected to make payment to the provider at the time of treatment.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 page 50.


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S M A L L g r O U P V O L U N TA ry D E N TA L P L A N SAvailable With or Without an Aetna Medical Plan to Groups with 3-50 Eligible Employees

Voluntary Option 2

DMO Access

Voluntary Option 3Freedom-of-Choice —

Monthly selection between the DMO and PPO Max

Voluntary Option 4PPO Max

Voluntary Option 5

Preventive Care

DMO Plan 42(DMO Access)

DMO Plan100/90/60



PPO Max Plan100/0/0

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

Dental Fund N/A N/A N/A N/A N/A


None None $75; 3X Family Maximum


None

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

DIAgNOSTIC SERVICES

Oral Exams

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

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

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

x-rays

Bitewing — single film No Charge 100% 100% 100% 100%

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

PREVENTIVE SERVICESAdult Cleaning No Charge 100% 100% 100% 100%

Child Cleaning No Charge 100% 100% 100% 100%

Sealants — per tooth $10 100% 100% 100% 100%

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

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

BASIC SERVICESAmalgam filling — 2 surfaces $32 90% 70% 80% Not covered

resin filling — 2 surfaces, anterior $55 90% 70% 80% Not covered

Oral Surgery

Extraction — exposed root or erupted tooth $30 90% 70% 80% Not covered

Extraction of impacted tooth — soft tissue $80 90% 70% 80% Not covered

*MAjOR SERVICESComplete upper denture $500 60% 40% 50% Not covered

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

Crown — Porcelain with noble metal1 $488 60% 40% 50% Not covered

Pontic — Porcelain with noble metal1 $488 60% 40% 50% Not covered

Inlay — Metallic (3 or more surfaces) $463 60% 40% 50% Not covered

Oral Surgery


$175** 60% 40% 50% Not covered

Endodontic Services

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

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


Scaling & root planing — per quadrant $65 90% 40% 50% Not covered

Osseous surgery — per quadrant $445** 60% 40% 50% Not covered

*ORTHODONTIC SERVICES $2,400 copay $2,400 copay Not covered Not covered Not covered

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

The DMO in Voluntary Plan Option 2 cannot be sold as full-replacement coverage, it must be combined with Voluntary Plan Option 4 in a Dual Option package. * Coverage Waiting Period: 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 the DMO in

Voluntary Plan Options 2 & 3 or the PPO in Voluntary Plan Option 5. ** 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.Fixed dollar amounts on the DMO in Plan Options 2 & 3 including office visit and ortho copays are the member’s responsibility. 1 There will be an additional patient charge for the actual cost for gold/high noble metal for these procedures for the DMO in Voluntary Plan Option 2.Access to negotiated discounts: On the PPO plans in Voluntary Plan Options 3, 4 & 5, members may be eligible to receive non-covered services at the PPO negotiated rate when visiting a participating PPO dentist at any time, including during the Coverage Waiting Period.Most Oral Surgery, Endodontic and Periodontic services are covered as Basic Services on the DMO in Voluntary Plan Options 2 & 3.Voluntary Plan Options 3, 4 & 5; PPO Max Non-Preferred (Out-of-Network) Coverage is limited to a maximum of the Plan’s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area.All voluntary plans require a minimum of 3 to enroll. Orthodontic coverage is available only to groups with 10 or more eligibles and for dependent children only.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.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.Aetna Dental Access Network is not insurance or a benefits plan. It only provides access to discounted fees for dental services obtained from providers who participate in the Aetna Dental Access network. Members are solely responsible for all charges incurred using this access, and are expected to make payment to the provider at the time of treatment.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 page 50.

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S M A L L g r O U P O U T- O F - S TAT E P P O D E N TA L P L A N SAvailable with Aetna Medical Plan to Groups With 2-50 Employees and Available Without Aetna Medical Plan to Groups With 3-50 Employees

Low OptionNo Ortho

Low OptionOrtho

Medium OptionNo Ortho

Medium OptionOrtho





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






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

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 SERVICESAdult 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 SERVICESAmalgam filling — 2 surfaces 80% 80% 80% 80%

resin filling — 2 surfaces, anterior 80% 80% 80% 80%

Oral Surgery

Extraction — exposed root or erupted tooth 80% 80% 80% 80%

Extraction of impacted tooth — soft tissue 80% 80% 80% 80%

*MAjOR SERVICESComplete upper denture 50% 50% 50% 50%

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

Crown — Porcelain with noble metal 50% 50% 50% 50%

Pontic — Porcelain with noble metal 50% 50% 50% 50%

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

Oral Surgery


50% 50% 50% 50%

Endodontic Services

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

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


Scaling & root planing — per quadrant 50% 50% 50% 50%

Osseous surgery — per quadrant 50% 50% 50% 50%

*ORTHODONTIC SERVICES Not covered 50% Not covered 50%

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

*Coverage Waiting Period: Must be an enrolled member of the Plan for 12 months before becoming eligible for coverage of any Major Service including Orthodontic Services.Access to negotiated discounts: On all PPO Max plans, members may be eligible to receive non-covered services at the PPO negotiated rate when visiting a participating PPO dentist at any time, including during the Coverage Waiting Period.PPO Max Non-Preferred (Out-of-Network) Coverage is limited to a maximum of the Plan’s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area.Orthodontic coverage is available only to groups with 10 or more eligibles and for dependent children only.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 page 50.For out-of-state employees in all states except: Arkansas, Alaska, Hawaii, Idaho, Maine, Massachusetts, Montana, North Carolina, North Dakota, New Hampshire, New Mexico, South Dakota, Vermont, Wyoming.

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S M A L L g r O U P O U T- O F - S TAT E P P O V O L U N TA ry D E N TA L P L A N S

Available With or Without Aetna Medical Plan With 3-50 Employees

Option 1No Ortho

Option 1Ortho



Office Visit Copay N/A N/A




Annual Maximum Benefit $1,000 $1,000

DIAgNOSTIC SERVICES

Oral Exams

Periodic oral exam 100% 100%

Comprehensive oral exam 100% 100%

Problem-focused oral exam 100% 100%

x-rays

Bitewing — single film 100% 100%

Complete series 100% 100%

PREVENTIVE SERVICESAdult Cleaning 100% 100%

Child Cleaning 100% 100%

Sealants — per tooth 100% 100%

Fluoride application — with cleaning 100% 100%

Space maintainers 100% 100%

BASIC SERVICESAmalgam filling — 2 surfaces 80% 80%

resin filling — 2 surfaces, anterior 80% 80%

Oral Surgery

Extraction — exposed root or erupted tooth 80% 80%

Extraction of impacted tooth — soft tissue 80% 80%

*MAjOR SERVICESComplete upper denture 50% 50%

Partial upper denture (resin base) 50% 50%

Crown — Porcelain with noble metal 50% 50%

Pontic — Porcelain with noble metal 50% 50%

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

Oral Surgery


50% 50%

Endodontic Services

Bicuspid root canal therapy 50% 50%

Molar root canal therapy 50% 50%


Scaling & root planing — per quadrant 50% 50%

Osseous surgery — per quadrant 50% 50%

*ORTHODONTIC SERVICES Not covered 50%

Orthodontic Lifetime Maximum Does not apply $1,000

*Coverage Waiting Period: Must be an enrolled member of the Plan for 12 months before becoming eligible for coverage of any Major Service including Orthodontic Services.Access to negotiated discounts: On all PPO Max plans, members may be eligible to receive non-covered services at the PPO negotiated rate when visiting a participating PPO dentist at any time, including during the Coverage Waiting Period.PPO Max Non-Preferred (Out-of-Network) Coverage is limited to a maximum of the Plan’s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area.Orthodontic coverage is available only to groups with 10 or more eligibles and for dependent children only.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 page 50.For out-of-state employees in all states except: Arkansas, Alaska, Hawaii, Idaho, Maine, Massachusetts, Montana, North Carolina, North Dakota, New Hampshire, New Mexico, South Dakota, Vermont, Wyoming.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.


32

Aetna Life Insurance Company (Aetna) Small Group packaged life and disability insurance or benefits plans include a range of flat-dollar insurance options bundled together in one monthly per-employee rate. These products are easy to understand and offer affordable benefits to help your employees protect their families in the event of illness, injury or death. You’ll benefit from streamlined plan installation, administration and claims processing, and all of the benefits of our standalone life and disability products for small groups. Or, simply choose from our portfolio of group basic term life and disability insurance plans.

L I F E I N S U r A N C EWe 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 benefit 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.

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

Accelerated death benefit — Also called the “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 Essentials, 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.

Aetna Avenue

LIFE AND DISABILITy O V E rV I E w

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A D & D U LT r A ®

AD&D Ultra is standardly included with our small group life and disability package, and provides employees and their families with the same coverage as a typical accidental death and dismemberment plan — and then some. This includes extra features at no additional cost to you, 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

D I S A B I L I T y I N S U r A N C EFinding disability services 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. Aetna understands this.

Our in-depth 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 claim 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.

I N T E g r AT E D h E A LT h A N D D I S A B I L I T yWith our Integrated Health and Disability program, we can link medical and disability data to help anticipate concerns, take action and get your employees back to work sooner:

� Predictive modeling identifies medical members most likely to experience a disability, potentially preventing a disability from occurring or minimizing the impact for better outcomes.

� Health Insurance Portability and Accountability Act (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 Integrated Health and Disability 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 51.

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

34


Life insurance policies and Disability insurance plans/policies are offered and/or underwritten by Aetna Life Insurance Company (Aetna). See page 33.

T E r M L I F E P L A N O P T I O N S2-9 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

Class Schedules Not Available Up to 3 classes (with a minimum requirement of 3 employees in each class) — the benefit amount of the highest class cannot be more than 5 times the benefit amount of the lowest class even if only 2 classes are offered

Premium waiver 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

guaranteed Issue $20,000 10-25 employees $75,000 26-50 employees $100,000

Participation requirements 100% 100% on non-contributory plans; With Medical — 70% on contributory plans Standalone (26-50) — 75% on contributory plans

Contribution requirements 100% Employer Contribution Minimum 50% Employer Contribution

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

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

OPTIONAL DEPENDENT TERM LIFE

Spouse Amount Not Available $5,000

Child Amount Not Available $2,000

Available With an Aetna Medical Plan to Groups with 2-50 Eligible Employees Available With an Aetna Dental Plan to Groups with 10-50 Eligible Employees Available Standalone (Without Medical or Dental Plans) to Groups with 26-50 Eligible Employees

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

PACkAgED LIFE AND DISABILITy PLAN OPTIONSBasic Life Plan Design

Low Option Medium Option High Option

Benefit Flat $10,000 Flat $20,000 Flat $50,000

guaranteed Issue 2-9 Lives 10-50 Lives

$10,000 $10,000

$20,000 $20,000

$20,000 $50,000

reduction Schedule Employee’s Original Life Amount Reduces to 65% at age 65; 40% at age 70; 25% at age 75

Employee’s Original Life Amount Reduces to 65% at age 65; 40% at age 70; 25% at age 75

Employee’s Original Life Amount Reduces to 65% at age 65; 40% at age 70; 25% at age 75

Disability Provision Premium Waiver 60 Premium Waiver 60 Premium Waiver 60

Conversion Included Included Included

Accelerated Death Benefit

Up to 75% of benefit; 24 month acceleration



Dependent Life Spouse $5,000; Child $2,000

Spouse $5,000; Child $2,000

Spouse $5,000; Child $2,000

AD&D ULTRA

AD&D Ultra® Matches Basic Life Benefit

Matches Basic Life Benefit

Matches Basic Life Benefit

AD&D Ultra® Additional Features

Seat Belt/Airbag, Education, Child Care, Repatriation, Coma, Total Disability, 365-Day Covered Loss

DISABILITY PLAN DESIgN

Monthly Benefit Flat $500; No offsets

Flat $1,000; offsets are Workers’ Compensation, any State Disability Plan and Primary and Family Social Security benefits if applicable

Elimination Period 30 days 30 days 30 days

Definition of Disability Own Occupation: Earnings loss of 20% or more.

Own Occupation: Earnings loss of 20% or more.

First 24 months of benefits: Own Occupation Earnings Loss of 20% or more; Any reasonable occupation thereafter: 40% earnings loss.

Benefit Duration 24 months 24 months 60 months

Pre-Existing Condition Limitation

3/12 3/12 3/12

Types of Disability Occupational & Non-Occupational

Occupational & Non-Occupational

Occupational & Non-Occupational

Separate Periods of Disability

15 days during elimination period 6 months thereafter



Mental health/Substance Abuse

Duration same as all other conditions Duration same as all other conditions 24 months

waiver of Premium Included Included Included

OTHER PLAN PROVISIONS

Employer Contribution 2-9 Lives — 100% employer paid 10+ Lives — 50-100% employer paid

2-9 Lives — 100% employer paid 10+ Lives — 50-100% employer paid

2-9 Lives — 100% employer paid 10+ Lives — 50-100% employer paid

Minimum Participation 2-9 Lives — 100% 10+ Lives — 75%

2-9 Lives — 100% 10+ Lives — 75%

2-9 Lives — 100% 10+ Lives — 75%

Eligibility Active Full Time Employees Active Full Time Employees Active Full Time Employees

Class Schedules 2-9 Lives: Not Available; 10-50 Lives: Up to 3 classes (with a minimum requirement of 3 employees in each class) — the benefit amount of the highest class cannot be more than 5 times

the benefit amount of the lowest class even if only two classes are offered.

rate guarantee 1 year 1 year 1 year

rates PEPM $8.00 $15.00 $27.00


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Aetna Avenue

S M A L L g r O U PU N D E rw r I T I N g g U I D E L I N E S

F O r B U S I N E S S E S w I T h 5 0 O r F E w E r E L I g I B L E E M P L O y E E S V I r g I N I A

This material is for informational purposes only and is not intended to be all inclusive. Other policies and guidelines may apply.

Note: State and federal legislation/regulations, including Small Group Reform and HIPAA, take precedence over any and all Underwriting Rules. Exceptions to Underwriting Rules require approval of the Regional Underwriting Manager except where Head Underwriter approval is indicated. This information is the property of Aetna and its affiliates (“Aetna”), and may only be used or transmitted with respect to Aetna products and procedures, as specifically authorized by Aetna, in writing.

Case Submission Dates

��Groups with 2-50 eligible employees must have all completed paperwork into Aetna Small Group Underwriting by the 20th of the month for the 1st of the month effective dates and by the 5th of the month for 15th of the month effective date. The New Business Acknowledgement Letter must be submitted if these cut-off dates are not met.

��Any cases received after the cut-off date will be considered on an exception basis only, as approved by the Underwriting Unit Manager.

�� If not approved, the effective date will be moved to the next available effective date.

COBrA and/or State Continuees

��COBRA coverage will be extended in accordance with the federal law.

��COBRA and State Continuees are not eligible for Life or Disability coverage.

��COBRA and State Continuees are included in the Medical underwriting of the group.

��Health information must be provided on COBRA and state continuees along with the rest of the group.

��COBRA/State Continuees’ qualifying event, length, start and end date must be provided.

�� Employers with 20 or more employees (full and part time) are eligible to offer COBRA coverage.

�� Employers with less than 20 employees (full and part time) are eligible to offer State Continuation.

��Note: COBRA/State Continuees are not to be included for purpose of counting employees to determine the size of the group. Once the size of the group has been determined and it is determined that the law is applicable to the group, COBRA/State Continuees can be included for coverage subject to normal underwriting guidelines.

Dependent Eligibility

�� Eligible dependents include an employee’s spouse. If both husband and wife work for the same company, they may enroll together or separately, except in two life groups, where the spouse must enroll separately.

��Domestic partners may be covered as an eligible dependent if the employer elects this designation at contract effective or renewal date.

��Dependent children, as defined in plan documents in accordance with state and federal law, are eligible for medical and dental coverage up to age 26.

��Grandchildren are eligible if court ordered.

�� For dependent life, dependents are eligible from 14 days of age up to their 19th birthday, or up to their 23rd birthday, if in school.

�� Individuals cannot be covered as an employee and dependent under the same plan, nor may children be eligible for coverage through both parents and be covered by both under the same plan.

��Dependents are not eligible for AD&D Ultra® or Disability.

�� For Medical and Dental, dependents must enroll in the same benefits as the employee (participation is not required).

�� Employees may select coverage for eligible dependents under the Dental plan even if they select single coverage under the Medical Plan. See product-specific Life/AD&D and Disability guidelines under Product Specifications.

Effective Date �� The effective date must be the 1st or the 15th of the month.

�� The effective date requested by the employer may be up to 60 days in advance.

Electronic Funds Transfer

��Once the group is issued customers can pay their monthly premiums online or by calling an automated phone number, 1-866-350-7644, with no extra charge. This eliminates the need for checks, envelopes and postage while also supplying peace of mind that payments have been received.

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Employee Eligibility

�� Eligible employees are those employees and active owners who are permanent and work on a full-time basis, as defined by the employer, and who meet any authorized waiting period requirements. Aetna’s minimum acceptable hours per week is 30.

�� This includes a sole proprietor or partner of a partnership, if included as an employee in the health benefits plan of employer.

��Coverage must be extended to all employees meeting the above conditions, unless they belong to a union class excluded as the result of a collective bargaining arrangement.

�� Employees/Individuals not eligible for coverage include 1099 contractors, temporary, seasonal, substitute, uncompensated employee, volunteer, early retiree (<65 years of age), inactive owner, shareholder only, officer who is not active, managing member who is not active, investor only or a silent partner.

retirees

�� Early Retiree coverage is not available.

��Coverage is available for Medicare-eligible retirees and/or active Medicare-eligibles in accordance with the Small Group Medicare Underwriting Guidelines.

��Medicare eligible retirees who are enrolled in an Aetna Medicare Plan are eligible to enroll in Standard Dental Plans in accordance with these Dental Underwriting Guidelines.

�� Retirees are not eligible for Life, Disability or Voluntary Dental coverage.

Employer Definition

��An employer who employed at least 2 but not more than 50 employees on business days during the preceding calendar year and who employs at least 2 employees on the first day of the plan year. All persons treated as a single employer under specified sections of Section 414 of the Internal Revenue Service Code, shall be treated as one employer.

Employer Eligibility

��Group applicants that do not meet the above definition of a small employer are not eligible for coverage.

��Medical plans can be offered to sole proprietorships, partnerships or corporations.

��Organizations must not be formed solely for the purpose of obtaining health coverage.

�� Taft Hartley groups and closed groups are not eligible.

��Dental and Disability have ineligible industries which are listed separately under Product Specifications.

�� The Dental ineligible industry list does not apply when Dental is sold in combination with Medical.

Initial Premium Check

�� The initial premium check should be in the amount of the first month’s premium and drawn on a company check.

�� The initial premium check is not a binder check and does not bind Aetna to provide coverage.

�� If the request for coverage is withdrawn or denied due to business ineligibility, participation and/or contributions not met, the premium will be returned to the employer.

�� If the initial premium check is returned for non-sufficient funds, coverage will be terminated retroactive to the effective date.

Licensed, Appointed Producers

��Only appropriately licensed Agents/Producers appointed by Aetna may market, present, sell and be paid commission on the sale of Aetna products.

�� License and appointment requirements vary by state and are based on the contract state of the small employer group being submitted.

Multi-Option Plans

��A minimum of 1 person must enroll in each plan when a dual option is offered.

��Groups can offer 2 medical plans, provided the 2 plans offered have different medical features. The same medical plan with different prescription drug plans cannot be offered.

��Groups with 20-50 enrolling employees can offer 3 medical plans. If 3 plans are offered, they must have different medical features. The same medical plan with different prescription drug plans cannot be offered.

Municipalities and Townships

��A township is generally a small unit that has the status and powers of local government.

��A municipality is an administrative entity composed of a clearly defined territory and its population, and commonly denotes a city, town or village. A municipality is typically governed by a mayor and city council, or municipal council. In most countries, a municipality is the smallest administrative subdivision to have its own democratically elected officials.

��Underwriting Requirements

– Quarterly Wage and Tax Statement (QWTS)

– W2 — Elected or appointed officials and Trustees “may” be eligible for group coverage based on the charter or legislation. If so, they may not be on the QWTS; rather, they may be paid via W2. In that case, provide a copy of their prior year W2.

– If elected officials are to be covered, provide a copy of the charter or contract indicating which classes or employees are to be covered, the minimum hours required to work per week to be eligible for coverage, and confirmation that coverage will be offered to all employees meeting the minimum number and participation will be maintained.

Newly Formed Business (in operation less than 3 months)

The following documentation must be provided for consideration:

�� Business License (not a professional license). If not available, provide a copy of the Partnership Agreement, Articles of Organization, or Articles of Incorporation; and

�� Employer identification number/federal tax ID number; and

��Quarterly Wage and Tax Statement. If not available, when will one be filed? and

�� The most recent two consecutive pay periods, which include hours worked, taxes withheld, check number and wages earned; or

��A letter from Certified Public Accountant listing the names of all employees (full and part-time), the number of hours worked each week, dates of hire, and weekly salary. Have payroll records been established? If not, when? Will a Quarterly Wage and Tax Statement be filed? If so, when?

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PEO (Professional Employer Organization)

��As long as the PEO provides payroll specific for the small group and we can determine it is a small group, even though the small group may be reported under the PEO tax ID number, the group may be considered subject to underwriting approval.

Prior Aetna Coverage

��Groups that have been terminated for non-payment by Aetna will not be eligible to reapply until: (1) 12 months after the termination date; and (2) payment of 2 months of premium in advance of issuance of the health benefits plan. Additionally, all premiums still owed on the prior Aetna plan must be paid in full.

��Medical claims will be reviewed along with the health information provided on the employee application and included in the overall medical assessment of the group.

rates �� Rates are based on final enrollment.

�� Tabular Rates: 2-9 enrolling employees.

��Composite Rates: 10-50 enrolling employees

rating Information

�� Rates are based on final enrollment and require that:

– No portion of the member’s cost sharing, including, but not limited to, copayments, deductibles and/or coinsurance balances will be subsidized or funded by the employer, with the exception of a federally-qualified Health Reimbursement Arrangement (HRA), or Health Savings Account (HSA), whether insured or self-funded, including, but not limited to, a partially self-funded Section 105 wrap around, now or in the future; and

– Employer is not funding the deductible of the quoted health plan through an HRA or HSA arrangement in excess of 75% annually.

��All quotes are subject to change based on additional information that becomes available in the quoting process and during case submission/installation, including any change in census.

�� If both husband and wife work for the same company and apply under one contract, rates will be based on the oldest adult.

��All rates will be quoted on a 4-tier structure: single, couple, employee plus child(ren), family.

replacing Other group Coverage

��Current carrier bill with billing summary and employee roster is required.

�� The employer should be told not to cancel any existing medical coverage until it has been notified of approval from the Aetna Underwriting unit.

Signature Dates �� The Aetna Employer Application and all employee applications must be signed and dated prior to and within 60 days of the requested effective date.

��All employee applications must be completed by the employee himself/herself.

Spin-Off groups (current Aetna customers leaving an Aetna group only)

Aetna will consider the group with the following:

��A letter from the group or broker indicating the group is enrolling as a spin off. Letter needs to include the name of the group from which it is spinning off.

��Ownership documents showing that the spin-off company is a newly formed separate entity.

��A minimum of 2 weeks’ payroll. If the group that is spinning off has been in business longer than 2 weeks, payroll will be required for the amount of time in business up to a maximum of 6 consecutive weeks.

��Current Aetna customers leaving an Aetna group will have medical claims reviewed along with the health information provided on the employee application and included in the overall medical assessment of the group.

Tax Information/ Documents

��Must submit a copy of the most recent VEC/Quarterly Wage and Tax Statement (Unemployment Compensation Tax Form), which must contain the names, salaries, etc., of all employees of the employer group.

�� The QWTS must contain the names and wages of all employees of the employer group.

�� Employees who have terminated, work part time or are newly hired should be noted accordingly on the QWTS.

��Any handwritten comments added to the QWTS must be signed and dated by the employer. The underwriter may request payroll in questionable situations.

��Newly hired employees should be written in on the QWTS and signed by the employer. The underwriter may request pay roll in questionable situations.

��Churches must provide Form 941, including a copy of the payroll records with employee names, wages and hours which must match the totals on Form 941.

�� Proprietors, partners or officers of the business who do not appear on the QWTS need to complete Aetna’s Small Group Proof of Eligibility Form (https://www.aetna.com/producer/SmallGroup/forms/virginia.html) and submit one of the following. This list is not all inclusive. The employer may provide any other documentation to establish eligibility.

Sole Proprietor � Franchise

� Limited Liability Company (operating as a Sole Proprietor)

� IRS Form 1040 along with Schedule C (Form 1040) IRS Form 1040 along with Schedule SE (Form 1040)

� IRS Form 1040 along with Schedule F (Form 1040) � IRS 1040 along with Schedule K1 (Form 1065) � Any other documentation the owner would like to provide to determine eligibility

Partner � Partnership

� Limited Liability Partnership

� IRS Form 1065 Schedule K-1 � IRS Form 1120 S Schedule K-1 along with Schedule E (Form 1040) � Partnership agreement if established within 2 years — Eligible partners must be listed on agreement

� Any other documentation the owner would like to provide to determine eligibility

Corporate Officer � Limited Liability Company (operating as C Corp)

� C-Corporation

� Personal Service Corporation

� S-Corporation

� IRS Form 1120 S Schedule K1 along with Schedule E (Form 1040) � IRS Form 1120 W (C-Corp & Personal Service Corp) � 1040 ES (Estimated Tax) (S-Corp) � IRS Form 8832 (Entity classification as a corporation) � W2 � Articles of Incorporation if established within 2 years — Corporate officers must be listed

� Any other documentation the owner would like to provide to determine eligibility

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Two or More Companies — Affiliated, Associated or Multiple Companies,Common Ownership

Employers who have more than one business with different tax identification numbers (TINs) may be eligible to enroll as one group if the following are met:

��One owner has controlling interest of all business to be included; or

�� The owner files (or is eligible to file) an Affiliations Schedule, IRS Form 851, a combined tax return for all companies to be included. If they are eligible but choose not to file Form 851, please indicate as such. A copy of the latest filed tax return must be provided; and

��All businesses filed under one combined tax return must be enrolled as one group. For example, if the employer has three businesses and files all three under one combined tax return, then all three businesses must be enrolled for coverage. If the request is for only two of the three businesses to be enrolled, the group will be considered a carve out, will not be Guarantee Issue, and could be declined.

�� There are 50 or fewer employees in the combined employer groups.

�� The two or more groups may have multiple Standard Industrial Classification Codes (SIC); however, rates will be based on the SIC code for the group with the majority of employees.

�� Businesses with equal controlling interest may be considered, if the owners of the company designate an individual to act on behalf of all the groups.

��Underwriting reserves the right to final underwriting review, and may consider common ownership on a case-by-case underwriting exception. Example: One owner has controlling interest of all companies to be included:

Company 1 — Jim owns 75% and Jack owns 25%

Company 2 — Jim owns 55% and Jack owns 45%

Both companies can be written as one group since Jim has controlling interest in both.

waiting Period ��At initial submission of the group, the benefits waiting period may be waived upon the employer’s request. This should be checked on the Employer Application.

�� The benefits waiting period for future employees may be first of the month following 0, 1, 2, 3, 4, 5, or 6 months.

��A change to the benefits waiting period may only be made on the plan anniversary date.

��No retro active changes will be allowed.

�� Two benefit waiting periods may be selected and must be consistently applied within a class of employees as defined by the employer such as management versus non-management, hourly versus salaried, etc.

�� Benefits waiting periods must be consistently applied to all employees, including newly hired key employees.

�� For new hires, the eligibility date will be the first day of the policy month following the waiting period. Examples:

Group A — effective date is July 1st; employees will be issued an effective date of the 1st of the month following the chosen waiting period.

Group B — effective date is July 15th, employees will be issued an effective date of the 15th of the month following the chosen waiting period.

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P r O D U C T S P E C I F I C AT I O N SMedical Dental Basic Life/AD&D, Disability,

Packaged Life and Disability

Product Availability

��Groups of 2-50 eligible employees.

��May be written standalone or with ancillary coverage as noted in the following columns.

��Only non-occupational injuries and disease will be covered.

2 eligible employees

�� Standard Dental available with Medical.

�� Voluntary Dental not available.

3 to 50 eligible employees

�� Standard Dental available with or without Medical.

�� Voluntary Dental available with or without Medical.

�� Standalone available. Standalone Dental has ineligible Industries which are listed separately under the SIC code section of the guidelines.

Orthodontia coverage

��Available with 10 or more eligible employees with a minimum of 5 enrolled employees for dependent children only.

Life and/or Disability

�� 2-9 eligible employees available if packaged with Medical

�� 10-50 eligible employees available if packaged with Medical or Dental.

�� 26-50 eligible available on a standalone basis.


�� 2-50 eligible employees if packaged with Medical.

�� 10-50 eligible employees on a standalone basis.

��A plan sponsor cannot purchase both Life and Packaged Life and Disability plans.

�� Product packaging rule is a group level requirement. Employees will be able to individually elect Life, Disability or Packaged Life & Disability insurance even if they do not elect Medical coverage.

Disability

��Groups are ineligible for coverage if 60% or more of eligible employees or 60% or more of eligible payroll are for employees over 50 years old.

��Conversion options are not available.

��Available to employees only; dependents are not eligible.

�� Employees may elect Disability coverage even if they do not elect Medical coverage.

Excluded Class/Carve-Outs

��Union employees are the only class of employees that may be excluded. However, union employees are included in the total count of eligible employees in determining the case size.

��Management carve-outs are not permitted.

��Union employees, if packaged with Medical. ��Union employees, if packaged with Medical.

Employer Contribution

�� 50% of the employee-only cost or 50% of the total cost of the plan.

��Coverage can be denied based on inadequate contributions.

Standard Dental

�� 2-50 eligibles

�� 25% of the total cost of the plan or 50% of the cost of employee-only coverage.

Voluntary Dental

�� Employer contribution of less than 50% of the cost of the employee-only coverage.

�� Employee-Pay-All plans are permitted.

Standard and Voluntary

��Coverage can be denied based on inadequate contributions.


�� 100% of the total cost of the basic Life plan.


��At least 50% of the total cost of the plans excluding Optional Dependent Term Life

All

��Coverage can be denied based on inadequate contributions

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Late Applicants ��An employee or dependent who enrolls for coverage more than 31 days from the date first eligible or 31 days of the qualifying event is considered a late enrollee. Applicants without a qualifying life event (i.e., marriage, divorce, newborn child, adoption, loss of spousal coverage, etc.) are subject to the Late Entrant guidelines as noted below.

�� Voluntary cancellation of coverage is NOT a qualifying event. For example, if a spouse is covered through his/her employer and voluntarily cancels the coverage, it is not a qualifying event to be added to the other spouse’s plan. The spouse who cancelled the coverage must wait until the next plan anniversary date to be eligible to be added.

�� Late applicants will be deferred to the next plan anniversary date of the group and may reapply for coverage 30 days prior to the anniversary date.

��An employee or dependent may enroll at any time, however, coverage is limited to Preventive & Diagnostic services for the first 12 months. No coverage for most Basic and Major Services for first 12 months (24 months for Orthodontics).

�� Late Entrant provision does not apply to enrollees less than age 5.

�� Late applicants will be deferred to the next plan anniversary date of the group and may reapply for coverage 30 days prior to the anniversary date.

�� The applicant will be required to complete an individual health statement/questionnaire and provide Evidence of Insurability (EOI).

�� Life late enrollee example: Group has $50,000 life with $20,000 guarantee issue limit. Late enrollee enrolling for $50,000 would not automatically get the $20,000. Since the applicant is late, he/she must medically qualify for the entire $50,000.

Live/work Situs �� 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 headquarter location.

�� 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 headquarter location.

��Not applicable.

Medical Underwriting

��Groups cannot be denied based on medical conditions; however, rates may be adjusted for known medical conditions.

��Medical conditions of COBRA enrollees and/or state continuees are included in this rating calculation.

�� Employees residing outside the state cannot be denied based on medical conditions; however, may have rates adjusted to the maximum allowed in that state.

��NA ��All timely entrants will be issued the Guaranteed Issue amount unless reinstatement or restoration of coverage is requested.

�� Employees wishing to obtain insurance amounts above the Guaranteed Issue amounts listed below will be required to submit EOI, which means they must complete an individual health statement and may have to submit to medical evidence via medical records at their expense.

Out of Area within Virginia

��Out-of-Area employees must be enrolled in a PPO plan if available, otherwise an indemnity plan.

��Out-of-Area employees must be enrolled in a PPO plan if available, otherwise an indemnity plan.


Out-of-State Situs Employees

��Any active employee who lives and works in a state other than those included in the defined Situs is considered an out-of-situs employee.

�� For groups with 50% or fewer employees that work and reside outside of CT, DE, MD, NJ, NY, PA, VA and Washington, DC, these employees can enroll in a Virginia PPO plan (or indemnity plan if PPO network is not available).

�� If more than 50% of the group’s employees work and reside outside of CT, DE, MD, NJ, NY, PA, VA and Washington, DC, Aetna will decline coverage for these employees.

�� PPO is not available in the following states: AL, HI, ID, MN, MT, ND, NM, RI, UT, VT, WI, WY.

�� Indemnity is not available in HI or VT.

�� Employees who live and work outside of NJ, PA, DE, MD, VA, DC, NY or CT are considered outside the situs region. Out-of-State/Situs employees will be offered one of the specific Out-of-State/Situs Dental PPO plans. Employees who fall outside a Dental PPO network area will default to a comparable indemnity plan. Maximum out-of-state/situs employee percentage (and/or number of employees) will agree with the Medical guidelines.

��Out-of-State employees can only be offered one of the specific Out-of-State Dental plans; 3 PPO and 3 indemnity plan designs.

��Maximum Out-of-State employee percentage (and/or number of employees) will agree with the Medical guideline for each state.

��Out-of-State employees must be enrolled in a PPO Dental plan if available; otherwise, an indemnity Dental plan.

��OOS PPO Dental is not available in the following states: AR, AK, HI, ID, MA, ME, MT, NC, ND, NH, NM, SD, VT, and WY.


42




Participation Non-contributory plans

�� 100% participation is required for non-contributory plans. That means 100% of all employees must enroll.

Contributory plans

�� 2-50 eligible employees — 75% of the eligibles must participate, excluding those with qualifying existing spousal, governmental (Medicare, Medicaid, Military) or union coverage. Example: 22 lives, 2 covered under spouse: 22 — 2 = 20 x 75% = 15 (rounded down) must enroll.

��A minimum of two (2) employees must enroll.

ALL

��Any eligible employees waiving coverage must complete the waiver section of the Employee Application.

��Coverage can be denied based on inadequate participation.

Non-contributory plans

�� 100% participation is required, excluding those with other qualifying dental coverage.

Standard

�� 2-3 eligibles

�� 100% participation is required excluding those with other qualifying dental coverage.

Example: 3 eligibles, 1 spousal dental

3 minus 1 = 2 x 100% = 2 must enroll.

4-50 eligibles

�� 75% participation is required excluding those with other qualifying dental coverage. A minimum of 50% of total eligible employees must enroll in the dental plan.

��A minimum of two (2) employees must enroll.

Voluntary Dental

�� 3-50 eligible employees

�� 25% participation, excluding those with other qualifying existing dental coverage or a minimum of 3 enrollees (5 enrollees for orthodontia coverage), whichever is greater, is required.

Standalone Dental

�� 75% participation excluding those with other qualifying existing dental coverage. A minimum of 50% of total eligible employees must enroll in the Dental plan.

Voluntary and Standalone

�� Employees may select coverage for eligible dependents under the Dental plan, even if they elected single coverage on the Medical plan or vice versa.


Non-contributory plans

�� 100% participation is required.

Contributory plans

�� 2-9 eligibles — 100% participation

�� 10-50 eligibles — 75% participation

ALL

��COBRA and State Continuees are not eligible.

�� Retirees are not eligible.

�� Employees may elect Life insurance even if they do not elect Medical coverage, and the group must meet the required participation percentage. If not, then Life will be declined for the group. Example: 9 employees, 3 waiving medical, 9 must enroll for life.


Plan Change group Level

�� Plan anniversary date only. ��Dental plans must be requested 5 days prior to the desired effective date.

�� The future renewal date of the change will be the same as the Medical plan anniversary date.

�� Packaged Life/Disability must be requested 30 days prior to the desired effective date.

��Non-packaged plans are only available on the plan anniversary date.

Plan Change Employee Level

�� Employees are not eligible to change plans until the group’s open enrollment period, which is upon their annual renewal (except for qualified Special Enrollment events).

��May change from voluntary to standard and vice versa at anytime.

�� Employees are not eligible to change plans until the group’s open enrollment period, which is upon their annual renewal (except for qualified Special Enrollment events).

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Standard Industrial ClassificationCode (SIC)

��All industries are eligible.

�� The employer should provide the SIC code (four-digit number) or NAIC state code six-digit code) filed with the state on the business tax return and/or the Workers’ Compensation form.

��All industries are eligible if sold with Medical.

�� The following industries are not eligible when Dental is sold standalone or packaged only with Life.

SIC range SIC Description

793386117911

7361-73637999

8699

899979918811

7941-79488621-8651

7992-7997

86617922-7929

Bowling CentersBusiness AssociationsDance Studios, SchoolsEmployment AgenciesMisc Amusement and RecreationMisc Membership OrganizationsMisc ServicesPhysical Fitness FacilitiesPrivate HouseholdsProfessional Sports Clubs & Producers, Race TracksProfessional Membership Organizations, Labor Unions, Civic Social & Fraternal Organizations, Political OrganizationsPublic Golf Courses, Amusements, Membership Sports & Recreation ClubsReligious OrganizationsTheatrical Producers, Bands, Orchestras, Actors

�� Basic Term Life

All industries are eligible.

�� Packaged Life/Disability

The following industries are not eligible.

SIC range SIC Description

3291-32927500-75998010-80432892-2899

3480-34895921

8600-86991000-14997800-7999

99993310-3329

653162117381

8800-8899

Asbestos ProductsAutomotive Repairs/ServicesDoctors Offices ClinicsExplosives, Bombs & PyrotechnicsFire Arms & AmmunitionLiquor StoresMembership AssociationsMiningMotion Picture/Amusement & RecreationNon-classified EstablishmentsPrimary Metal IndustriesReal Estate — AgentsSecurity BrokersService — Detective ServicesService — Private Household

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D E N TA L O N LyCoverage waiting Period

�� For Major and Orthodontic Services, employees must be an enrolled member of the employer’s plan for 1 year before becoming eligible.

�� There is no waiting period for DMO.

��Discount plans do not qualify as previous coverage.

�� Virgin group (no prior coverage) — The waiting periods apply to employees at case inception as well as to any future hires.

�� Takeover/Replacement cases (prior coverage) — You must provide a copy of the last billing statement and schedule of benefits in order to provide credit. If a group’s prior coverage did not lapse more than 90 days prior, the waiting periods are waived. In order for the waiting period to be waived, the group must have had a Dental plan in place that covered Major (and Ortho, if applicable) immediately preceding our takeover of the business. Example: Prior Major coverage but no Ortho coverage. Aetna plan has coverage for both Major and Ortho. The Waiting Period is waived for Major services but not for Ortho services.

Product Packaging

Voluntary

��Dental Dual Option sales are not permitted. All Voluntary plans must be a single plan sold.

��All Voluntary plans require a minimum of 3 to enroll.

��Orthodontic coverage is available with 10 or more eligibles for dependent children only. A minimum of 5 employees must enroll.

Standard

��DMO can be either sold standalone or packaged with any PPO Option as a Dual Option with a minimum of 2 enrolled.

�� PPO can be sold standalone or packaged with the DMO as a Dual Option with a minimum of 2 enrolled.

�� Freedom-of-Choice cannot be packaged with any other option. It must be the only plan sold.

��Orthodontic coverage is available with 10 or more eligibles for dependent children only. A minimum of 5 employees must enroll.

Open Enrollment

��An employee or dependent can enroll at any time, but is subject to the Dental Late Entrant provision if enrollment occurs other than within 31 days of first becoming eligible, unless a qualifying life event has occurred or the enrollee is less than age 5.

Option Sales ��Option sales alongside another dental carrier are not allowed.

��All dental plans must be sold on a full replacement basis.

reinstatement (applies to Voluntary Plans only)

��Members once enrolled who have previously terminated their coverage by discontinuing their contributions may not re-enroll for a period of 24 months. All coverage rules will apply from the new effective date including, but not limited to, the Coverage Waiting Period.

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L I F E A N D D I S A B I L I T y O N LyJob Classification (Position) Schedules

�� Varying levels of coverage based on job classifications are available for groups with 10 or more lives.

��Up to 3 separate classes are allowed (with a minimum requirement of 3 employees in each class).

�� Items such as probationary periods must be applied consistently within a class of employee.

�� The benefit for the class with the richest benefit must not be greater than 5 times the benefit of the class with the lowest benefit, even if only 2 classes are offered. For example, a schedule may be structured as follows:

Position/Job Class Basic Term Life Amount Disability Packaged Life & Disability

Executives $50,000 Flat $500 High Option

Managers, Supervisors $20,000 Flat $300 Medium Option

All other Employees $10,000 Flat $200 Low Option

guaranteed Issue Coverage

��Aetna provides certain amounts of Life insurance to all timely entrants without requiring an employee to answer any Medical questions. These insurance amounts are called “Guaranteed Issue.”

�� Employees wishing to obtain increased insurance amounts will be required to submit Evidence of Insurability, which means they must complete a Medical questionnaire and may be required to provide Medical records.

��On-time enrollees who do not meet the requirements of Evidence of Insurability will receive the Guaranteed Issue Life amount.

�� Late enrollees must qualify for the entire amount and are not guaranteed any coverage.

Actively-at-work

�� Employees who are both disabled and away from work on the date their insurance would otherwise become effective will become insured on the date they return to active full-time work one full day.

Continuity of Coverage (no loss/no gain)

�� The employee will not lose coverage due to a change in carriers. This protects employees who are not actively at work during a change in insurance carriers.

�� If an employee is not actively at work, Aetna will waive the actively-at-work requirement and provide coverage, except no benefits are payable if the prior plan is liable.

Evidence of Insurability (EOI)

EOI is required when one or more of the following conditions exist:1. Life insurance coverage amounts requested are above the Guaranteed Standard Issue Limit.2. Coverage is not requested within 31 days of eligibility for contributory coverage.3. New coverage is requested during the anniversary period.4. Coverage is requested outside of the employer’s anniversary period due to qualifying life event (i.e., marriage, divorce, newborn child, adoption, loss of

spousal coverage, etc.).5. Reinstatement or restoration of coverage is requested.6. Requesting Life or Disability at the individual level and they are a late enrollee even if enrolling on the case anniversary date. Late enrollees are not

eligible for the Guaranteed Issue Limit. Example: Group has $50,000 life with $20,000 Guaranteed Issue Limit. Late enrollee enrolling for $50,000 would not automatically get the $20,000. Since the applicant is late, they must medically qualify for the entire $50,000.


46

A E T N A h M O / P O S /h E A LT h N E T w O r k O P T I O N P L A N SThese plans do not cover all health care expenses and include exclusions and limitations. Members should refer to their plan documents to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, the plan documents may contain exceptions to this list based on state mandates or the plan design or rider(s) purchased.

� All medical and hospital services not specifically covered in, or which are limited or excluded by your plan documents, including costs of services before coverage begins and after coverage terminates

�Cosmetic surgery

�Custodial care

�Dental care and dental X-rays

�Donor egg retrieval

� Experimental and investigational procedures (except for coverage for medically necessary routine patient care costs for Members participating in a cancer clinical trial)

�Hearing aids

� Immunizations for travel or work

� Implantable drugs and certain injectable drugs including injectable infertility drugs

� Infertility services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services unless specifically listed as covered in your plan documents

� Non-medically necessary services or supplies

�Orthotics

� Over-the-counter medications and supplies

�Radial keratotomy or related procedures

�Reversal of sterilization

� Services for the treatment of sexual dysfunction or inadequacies including therapy, supplies or counseling

�Special duty nursing

� Therapy or rehabilitation other than those listed as covered in the plan documents

L I M I TAT I O N S A N D E x C L U S I O N S

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A E T N A P P O P L A N SThese plans do not cover all health care expenses and include exclusions and limitations. Members should refer to their plan documents to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, plan documents may contain exceptions to this list based on state mandates.

� All medical or hospital services not specifically covered in, or which are limited or excluded in the plan documents

� Charges related to any eye surgery mainly to correct refractive errors

� Cosmetic surgery, including breast reduction

�Custodial care

�Dental care and X-rays

�Donor egg retrieval

� Experimental and investigational procedures

�Hearing aids

� Immunizations for travel or work

� Infertility services, including, but not limited to, artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services unless specifically listed as covered in plan documents

� Non-medically necessary services or supplies

�Orthotics

� Over-the-counter medications and supplies

�Reversal of sterilization

� Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies or counseling

�Special duty nursing

Aetna PPO plans: Pre-existing conditions exclusion provisionThese plans impose a pre-existing conditions exclusion, which may be waived in some circumstances (that is, creditable coverage) and may not be applicable. A pre-existing conditions exclusion means that if the member has a medical condition before coming to the plan, the member might have to wait a certain period of time before the plan will provide coverage for that condition. This exclusion applies only to conditions for which medical advice, diagnosis or treatment was recommended or received or for which the individual took prescribed drugs within 180 days.

Generally, this period ends the day before coverage becomes effective. However, if the member was in a waiting period for coverage, the 180-day period ends on the day before the waiting period begins. The exclusion period, if applicable, may last up to 365 days from the first day of coverage, or if the member was in a waiting period, from the first day of the waiting period.

If the member had prior creditable coverage within 90 days immediately before the date enrolled under the plan, then the pre-existing conditions exclusion in the plan, if any, will be waived.

If the member had no prior creditable coverage within the 90 days prior to the enrollment date (either because the member had no prior coverage or because there was more than a 90-day gap from the date the prior coverage terminated to the enrollment date), we will apply the plan’s pre-existing conditions exclusion.

In order to reduce or possibly eliminate the exclusion period based on creditable coverage, the member should provide us a copy of any Certificates of Creditable Coverage. Please contact Aetna Member Services at 1-888-80-AETNA for assistance in obtaining a Certificate of Creditable Coverage from the prior carrier or with any questions on the information noted above.

The pre-existing condition exclusion does not apply to pregnancy nor to a child under the age of 19.

Note: For late enrollees, coverage will be delayed until the plan’s next open enrollment; the pre-existing exclusion will be applied from the individual’s effective date of coverage.


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E S S E N T I A L A N D S TA N D A r D S M A L L g r O U P M A N D AT E D P L A N S ( h M O ) These plans do not cover all health care expenses and include exclusions and limitations. Members should refer to their plan documents to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, the plan documents may contain exceptions to this list based on state mandates or the plan design or rider(s) purchased.

� Pre-existing conditions or disease as provided in subsection E of 14VAC5- 234-40, except for congenital anomalies of a covered dependent child

� Services or care not medically necessary

� Illness, treatment or medical condition arising out of war or act of war, whether declared or undeclared; participation in a felony, riot or insurrection, service in the armed forces or units auxiliary thereto

� Cosmetic surgery, except that “cosmetic surgery” shall not include reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or other diseases of the involved part, and reconstructive surgery because of congenital disease or anomaly of a covered dependent child which has resulted in a functional defect

� Foot care in connection with corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain, or symptomatic complaints of the feet

� Care in connection with the detection and correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for purposes of removing nerve interference and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of, or in the vertebral column

� Treatment provided in a government hospital except for veterans in Veterans Administration or armed forces facilities for services received for which the recipient is liable; benefits provided by governmental programs (except Medicaid and Medicare) any state or federal workers’ compensation, employer’s liability or occupational disease law, or any motor vehicle no-fault law; services rendered by employees of hospitals, laboratories or other institutions; services performed by a member of the covered person’s immediate family and services for which no charge is normally made in the absence of insurance

� Rest cures, custodial care and transportation

�Radial keratotomy

� Experimental or investigative medical and surgical procedures

� Autologous bone marrow transplants

� In vitro fertilization, ovum transplants and gamete intrafallopian tube transfer, zygote intrafallopian transfer, or cryogenic or other preservation techniques used in these or similar procedures

� Telephone consultations, charges for not keeping appointments or charges for completing claim forms

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� Hearing aids or examinations for these devices in the Essential plan

� Services for surgical sexual transformation or sexual dysfunction

�Services for acupuncture

� Services for marital and family counseling, educational, behavioral, vocational, recreational and coma- stimulation therapy

�Sleep therapy

� Treatment for obesity, except for surgical treatment of morbid obesity

� Separate charges for local infiltration anesthesia or any anesthesia services conducted by the same doctor performing surgical or obstetrical services

� Smoking cessation aids or services of smoking cessation clinics

� Services by a home health agency, nursing facility or long-term care facility in the Essential plan

� Except for emergency services, services while the covered person is outside the United States

� Personal and convenience items including, but not limited to, air conditioners, humidifiers, or physical fitness equipment

Essential and Standard Small Group Mandated Plans: Pre-existing conditions exclusion provision

These plans impose a pre-existing conditions exclusion, which may be waived in some circumstances (that is, creditable coverage) and may not be applicable. A pre-existing condition exclusion means that if the member has a medical condition before coming to the plan, the member might have to wait a certain period of time before the plan will provide coverage for that condition. This exclusion applies only to conditions for which medical advice, diagnosis or treatment was recommended or received or for which the individual took prescribed drugs within 180 days.

Generally, this period ends the day before coverage becomes effective. However, if the member was in a waiting period for coverage, the 180-day period ends on the day before the waiting period begins. The exclusion period, if applicable, may last up to 365 days from the first day of coverage, or if the member was in a waiting period, from the first day of the waiting period.

If the member had prior creditable coverage within 90 days immediately before the date enrolled under the plan, then the pre-existing conditions exclusion in the plan, if any, will be waived.

If the member had no prior creditable coverage within the 90 days prior to the enrollment date (either because the member had no prior coverage or because there was more than a 90-day gap from the date the prior coverage terminated to the enrollment date), we will apply the plan’s pre-existing conditions exclusion.

In order to reduce or possibly eliminate the exclusion period based on creditable coverage, the member should provide us a copy of any Certificates of Creditable Coverage. Please contact Aetna Member Services at 1-888-70-AETNA for assistance in obtaining a Certificate of Creditable Coverage from the prior carrier or with any questions on the information noted above.

The pre-existing condition exclusion does not apply to pregnancy nor to a child under the age of 19.

Note: For late enrollees, coverage will be delayed until the plan’s next open enrollment; the pre-existing exclusion will be applied from the individual’s effective date of coverage.


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D E N TA LListed below are some of the charges and services for which these dental plans do not provide coverage. For a complete list of exclusions and limitations, refer to the plan documents.

� Dental services or supplies that are primarily used to alter, improve or enhance appearance

� Experimental services, supplies or procedures

� Treatment of any jaw joint disorder, such as temporomandibular joint disorder

� Replacement of lost, missing or stolen appliances and certain damaged appliances

� Those services that Aetna defines as not necessary for the diagnosis, care or treatment of a condition involved

Specific service limitations:

�DMO plans: Oral exams (4 per year)

� PPO plans: Oral exams (2 routine and 2 problem-focused per year)

�All plans:

−Bitewing X-rays (1 set per year)

− Complete series X-rays (1 set every 3 years)

−Cleanings (2 per year)

−Fluoride (1 per year; children under 16)

− Sealants (1 treatment per tooth, every 3 years on permanent molars; children under 16)

− Scaling & root planing (4 quadrants every 2 years)

− Osseous surgery (1 per quadrant every 3 years)

� All other limitations and exclusions in the plan documents

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A D & D U LT r AThis coverage is only for losses caused by accidents. No benefits are payable for a loss caused or contributed to by:

�A bodily or mental infirmity

� A disease, ptomaine or bacterial infection*

� Medical or surgical treatment*

� Suicide or attempted suicide (while sane or insane)

�An intentionally self-inflicted injury

� A war or any act of war (declared or not declared)

�Voluntary inhalation of poisonous gases

� Commission of or attempt to commit a criminal act

� Use of alcohol, intoxicants or drugs, except as prescribed by a physician, an accident in which the blood level as operator of a motor vehicle meets or exceeds the level at which intoxication would be presumed under the law of the state where the accident occurred shall be deemed to be caused by the use of alcohol

� Intended or accidental contact with nuclear or atomic energy by explosion and/or release

� Air or space travel, this does not apply if a person is a passenger, with no duties at all, on an aircraft being used only to carry passengers (with or without cargo)

D I S A B I L I T y No benefits are payable if the disability:

� Is due to intentionally self-inflicted injury (while sane or insane)

� Results from you committing, or attempting to commit a felony

� Is due to war or any act of war (declared or not declared)

� Is due to insurrection, rebellion or taking part in a riot or civil commotion

� Occurs during the first 12 months of your coverage and is due to a pre-existing condition for which you were diagnosed, treated or received services, treatment, drugs or medicines three months prior to your coverage effective date

� Results from an automobile accident caused by you while you are intoxicated, (“Intoxicated” means: the blood alcohol level of the driver of the automobile meets or exceeds the level at which intoxication would be presumed under the law of the state where the accident occurred)

On any day during a period of disability that a person is confined in a penal or correctional institution for conviction of a criminal or other public offense, the person will not be deemed to be disabled and no benefits will be payable.

* These do not apply if the loss is caused by an infection that results directly from the injury or surgery needed because of the injury. The injury must not be one that is excluded by the terms of the contract.

This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Rates and benefits may vary by location. Health/Dental benefits, health/dental insurance, life and disability insurance plans/policies contain exclusions and limitations. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Plan features and availability may vary by location and group size. Aetna HealthFund HRAs are subject to employer-defined use and forfeiture rules, and are unfunded liabilities of your employer. Fund balances are not vested benefits. Investment services are independently offered through HealthEquity, Inc. Aetna HealthFund HRAs are subject to employer-defined use and forfeiture rules, and are unfunded liabilities of your employer. Fund balances are not vested benefits. Discount programs provide access to discounted prices and are NOT insured benefits. The member is responsible for the full cost of the discounted prices. Plan for Your Health is a public education program from Aetna and The Financial Planning Association. Providers are independent contractors and not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Not all health, dental and disability services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna’s Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to www.aetna.com.

©2010 Aetna Inc.

14.02.970.1-VA A (6/10)

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