AETNA HEALTH OF UTAH INC. (WYOMING) CERTIFICATE OF COVERAGE In-network and out-of-network coverage under the Aetna

Transcription

1 AETNA HEALTH OF UTAH INC. (WYOMING) WY Silver HNOption /50 WYO CERTIFICATE OF COVERAGE In-network and out-of-network coverage under the Aetna This Certificate of Coverage ("Certificate") is part of the Group Agreement ("Group Agreement") between Aetna Health of Utah Inc., hereinafter referred to as Aetna, and the Contract Holder. The Group Agreement determines the terms and conditions of coverage. The Certificate describes covered health care benefits. Provisions of this Certificate include the Schedule of Benefits, and any amendments, endorsements, inserts, or attachments. Amendments, endorsements, inserts, or attachments may be delivered with the Certificate or added thereafter. Coverage is not provided for any services received before coverage starts or after coverage ends, except as shown in the Continuation and Conversion section of this Certificate. Certain words have specific meanings when used in this Certificate. The defined terms appear in bold type with initial capital letters. The definitions of those terms are found in the Definitions section of this Certificate. This Certificate is not in lieu of insurance for Workers Compensation. This Certificate is governed by applicable federal law and the laws of Wyoming. Coverage under this plan is non-occupational. Only non-occupational injuries and non-occupational illnesses are covered under this plan. If you are an owner of the company that applied for coverage under this plan and no other sources of coverage or reimbursement are available to you for the services or supplies, then you will also be covered for occupational injuries and occupational illnesses. Other sources of coverage or reimbursement may include workers compensation, or an occupational illness or similar program under local, state or federal law. A source of coverage or reimbursement will be considered available to you even if you waived your right to payment from that source. If you are also covered under a workers compensation law or similar law, and submit proof that you are not covered for a particular illness or injury under such law, that illness or injury will be considered non-occupational regardless of cause. READ THIS ENTIRE CERTIFICATE CAREFULLY. IT DESCRIBES THE RIGHTS AND OBLIGATIONS OF MEMBERS AND AETNA. IT IS THE CONTRACT HOLDER S AND THE MEMBER'S RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CERTIFICATE. IN SOME CIRCUMSTANCES, CERTAIN MEDICAL SERVICES ARE NOT COVERED OR MAY REQUIRE PRECERTIFICATION BY AETNA. POS WY SG 2016 COC V001 1 Wyoming Small Group Off Exchange

2 NO SERVICES ARE COVERED UNDER THIS CERTIFICATE IN THE ABSENCE OF PAYMENT OF CURRENT PREMIUMS SUBJECT TO THE GRACE PERIOD AND THE PREMIUMS SECTION OF THE GROUP AGREEMENT. THIS CERTIFICATE APPLIES TO COVERAGE ONLY AND DOES NOT RESTRICT A MEMBER S ABILITY TO RECEIVE HEALTH CARE SERVICES THAT ARE NOT, OR MIGHT NOT BE, COVERED BENEFITS UNDER THIS CERTIFICATE. PARTICIPATING PROVIDERS, NON-PARTICIPATING PROVIDERS, INSTITUTIONS, FACILITIES OR AGENCIES ARE NEITHER AGENTS NOR EMPLOYEES OF AETNA. Important Unless otherwise specifically provided, no Member has the right to receive the benefits of this plan for health care services or supplies furnished following termination of coverage. Benefits of this plan are available only for services or supplies furnished during the term the coverage is in effect and while the individual claiming the benefits is actually covered by the Group Agreement. Benefits may be modified during the term of this plan as specifically provided under the terms of the Group Agreement or upon renewal. If benefits are modified, the revised benefits (including any reduction in benefits or elimination of benefits) apply for services or supplies furnished on or after the effective date of the modification. There is no vested right to receive the benefits of the Group Agreement. POS WY SG 2016 COC V001 2 Wyoming Small Group Off Exchange

3 TABLE OF CONTENTS Section Page Aetna Procedure 1 Eligibility and Enrollment 7 Covered Benefits 13 Exclusions and Limitations 53 Termination of Coverage 73 Continuation and Conversion 76 Claim Procedures/Complaints and Appeals 79 /Dispute Resolution Coordination of Benefits 87 Subrogation and Right of Recovery 93 Responsibility of Members 96 General Provisions 97 Definitions 102 POS WY SG 2016 COC V001 3 Wyoming Small Group Off Exchange

4 AETNA PROCEDURE This Plan provides coverage for medical expenses for the treatment of illness or injury. It does not provide benefits for all medical care. The plan also provides coverage for certain preventive and wellness benefits. With your plan, you can directly access any participating or non-participating physician, hospital provider for covered services and supplies under the plan. This Plan includes participating providers that are identified generically throughout the Contact as participating providers and nonparticipating providers. The plan pays benefits differently when services and supplies are obtained through non-participating providers under this Plan. Important Note: Network providers have contracted with Aetna, an affiliate or third party vendor to provide health care services and supplies to Aetna plan members. Network providers are generally identified in the printed directory and the on-line version of the provider Directory you can find this information on DocFind on or by calling the number on your identification card. Out-of-network providers are not listed in the Aetna directory. Selecting a Participating Primary Care Physician At the time of enrollment, each Member may choose to select a Primary Care Physician (PCP) that is a Participating Provider from Aetna s Directory of Participating Providers to access Covered Benefits as described in this Contract. The choice of a PCP is made solely by the Member. If the Member is a minor or otherwise incapable of selecting a PCP, the Subscriber should select a PCP on the Member s behalf. The Primary Care Physician The PCP coordinates a Member's medical care, as appropriate, either by providing treatment or may direct the Member to other Participating Providers. The PCP can also order lab tests and x-rays, prescribe medicines or therapies, and arrange hospitalization. The PCP provides services for the treatment of routine illnesses, injuries, well baby and preventive care services which do not require the services of a Specialist, and for non-office hour Urgent Care services under this plan. The Member s selected PCP or that PCP s covering Physician is required to be available 7 days a week, 24 hours a day for Urgent Care services. A Member will be subject to the PCP Copayment listed on the Schedule of Benefits when a Member obtains Covered Benefits from any Participating PCP. Certain PCP offices are affiliated with integrated delivery systems or other provider groups (i.e., Independent Practice Associations and Physician-Hospital Organizations), and Members who select these PCPs will generally be referred to Specialists and Hospitals within that system or group. However, if the group does not include a Provider qualified to meet the Member s medical needs, the Member may request to have services provided by nonaffiliated Providers. If the Member s PCP performs, suggests, or recommends a Member for a course of treatment that includes services that are not Covered Benefits, the entire cost of any such non-covered services will be the Member s responsibility. POS WY SG 2016 COC V001 4 Wyoming Small Group Off Exchange

5 Availability of Providers Aetna cannot guarantee the availability or continued participation of a particular Provider. Either Aetna or any Participating Provider may terminate the Provider contract or limit the number of Members that will be accepted as patients. If the PCP initially selected cannot accept additional patients, the Member will be notified and given an opportunity to make another PCP selection. The Member must then cooperate with Aetna to select another PCP. Until a PCP is selected, benefits are limited to coverage for Medical Emergency care. Changing a PCP You may change your PCP at any time by calling Member Services at the toll-free telephone number listed on the Member s identification card or by written or electronic submission of the Aetna s change form. A Member may contact Aetna to request a change form or for assistance in completing that form. The change will become effective upon Aetna s receipt and approval of the request. Ongoing Reviews Aetna conducts ongoing reviews of those services and supplies which are recommended or provided by Health Professionals to determine whether such services and supplies are Covered Benefits under this Certificate. If Aetna determines that the recommended services and supplies are not Covered Benefits, the Member will be notified. If a Member wishes to appeal such determination, the Member may then contact Aetna to seek a review of the determination. Please refer to the Claim Procedures/Complaints and Appeals/Dispute Resolution section of this Certificate. POS WY SG 2016 COC V001 5 Wyoming Small Group Off Exchange

6 Services and Supplies Which Require Precertification Precertification is required for the following types of medical expenses: Inpatient and Outpatient Care ART Services Bariatric Surgery (obesity) Complex Imaging Comprehensive Infertility Services Cosmetic and reconstructive surgery Emergency transportation by airplane Injectables (immunoglobins, growth hormones, Multiple Sclerosis medications, Osteoporosis medications, Botox, Hepatitis C medications) Kidney Dialysis Knee surgery Outpatient back surgery not performed in a physician s office Private duty nursing Sleep studies Stays in a hospital Stays in a skilled nursing facility Stays in a rehabilitation facility Stays in a residential treatment facility for treatment of Mental Disorders and Substance Abuse Stays in a hospice facility Wrist Surgery The Out-of Network Precertification Process Precertification should be secured within the timeframes specified below. To obtain precertification, call Aetna at the telephone number listed on the back of your ID card. This call must be made: For non-emergency admissions: For an emergency admission: For an urgent admission: For outpatient non-emergency medical services requiring Precertification: You or a member of your family, your Physician or the facility will need to call and request Precertification at least 14 days before the date you are scheduled to be admitted. You or a member of your family, your Physician or the facility should call within 48 hours or as soon as reasonably possible after you have been admitted. You or a member of your family, your Physician or the facility will need to call before you are scheduled to be admitted. You or a member of your family, your Physician or the facility must call at least 14 days before the outpatient care is provided, or the treatment or procedure is scheduled. Aetna will provide a written notification to you and your Physician of the Precertification decision where required under applicable State law. If your Precertified expenses are approved the approval is good for 30days as long as you remain enrolled in the plan. POS WY SG 2016 COC V001 6 Wyoming Small Group Off Exchange

7 Precertification, Precertify, Precertified A process where Aetna is contacted before certain services are provided, such as hospitalization or outpatient services, or prescription drugs are prescribed to determine whether the services being recommended or the drugs prescribed are considered covered expenses under the plan. It is not a guarantee that benefits will be payable if, for example, it is determined at the time the claim is submitted that you were not eligible for benefits at that time. Precertification Penalty Aetna will reduce the benefits payable under this Certificate by the percentage or dollar amount set forth on the Schedule of Benefits if the procedures for Precertification set forth in this Certificate are not followed. The Member will be responsible to pay the unpaid balance of the benefits. FAILURE TO PRECERTIFY WILL RESULT IN A REDUCTION OF BENEFITS UNDER THIS CERTIFICATE. PLEASE REFER TO THE SCHEDULE OF BENEFITS FOR THE PRECERTIFICATION PENALTY. The additional percentage or dollar amount of the Recognized Charge which a Member may pay as a penalty for failure to obtain Precertification under this section is not a Covered Expense, and will not be applied to the Deductible amount or the Maximum Out-of-Pocket Limit, if any. Eligibility Subscriber ELIGIBILITY AND ENROLLMENT To be eligible to enroll as a Subscriber, an individual must: Meet all applicable eligibility requirements agreed upon by the Contract Holder employer and Aetna; and Live or work in the Service Area Determining if You Are in an Eligible Class You are in an eligible class if you are a regular full-time employee, as defined by your employer. Determining When You Become Eligible You become eligible for the plan on your eligibility date, which is determined as follows: On the Effective Date of the Plan If you are in an Eligible Class on the effective date of your plan, your Eligibility Date is the effective date of this Plan or, if later, the date you complete the period of continuous service required by your employer. Your employer determines the criteria that is used to define the Eligible Class for coverage under this Certificate. Such criteria are based solely upon conditions related to your employment. See your employer for details. POS WY SG 2016 COC V001 7 Wyoming Small Group Off Exchange

8 After the Effective Date of the Plan If you are in an Eligible Class on the date of hire, your Eligibility Date is the effective date of this Plan or, if later, the date you complete the period of continuous service required by your employer. Your employer determines the criteria that is used to define the Eligible Class for coverage under this Certificate. Such criteria are based solely upon conditions related to your employment. See your employer for details. Waiting Period Once you enter an eligible class, you will need to complete the waiting period before your coverage under this plan begins. Obtaining Coverage for Dependents To be eligible to enroll as a Covered Dependent, the Contract Holder must provide dependent coverage for Subscribers who are eligible and must be: Your legal spouse; Your dependent children; Coverage for Dependent Children To be eligible for coverage, a dependent child must be: Under 26 years of age. Covered Benefits for a Covered Dependent who is not capable of self-support due to mental or physical incapacity will be continued past the maximum age for a child. An eligible dependent child includes: Your biological children. Your stepchildren. Your legally adopted children. Your foster children, including any children placed with you for adoption. Any children for whom you are responsible under court order. Your grandchildren in your court-ordered custody. Any child whose parent is your child and your child is covered as a dependent under this Plan. Any other child with whom you have a parent-child relationship. No individual may be covered both as an employee and dependent and no individual may be covered as a dependent of more than one employee. A Member who resides outside the Service Area is required to choose a PCP and return to the Service Area for Covered Benefits. The only services covered outside the Service Area are Emergency Services and Urgent Care. POS WY SG 2016 COC V001 8 Wyoming Small Group Off Exchange

9 How And When To Enroll Enrollment Unless otherwise noted, an eligible individual and any eligible dependents may enroll in Aetna regardless of health status, age, or requirements for health services within 31 days from the eligibility date. Newly Eligible Individuals and Eligible Dependents An eligible individual and any eligible dependents may enroll within 31 days of the eligibility date. Open Enrollment Period Eligible individuals or dependents who are eligible for enrollment but do not enroll as stated above, may be enrolled during any subsequent Open Enrollment Period upon submission of complete enrollment information and Premium payment to Aetna. Enrollment of Newly Eligible Dependents Newborn Children A newborn child is covered for 31 days from the date of birth. To continue coverage beyond this initial period, the child must be enrolled in Aetna within the initial 31 day period. If coverage does not require the payment of an additional Premium for a Covered Dependent, the Subscriber must still enroll the child within 31 days after the date of birth. The coverage for newly born, adopted children, and children placed for adoption consists of coverage of injury and sickness, including the necessary care and treatment of congenital defects and birth abnormalities, and within the limits of this Certificate. Coverage includes necessary transportation costs from place of birth to the nearest specialized Participating treatment center. Adopted Children A legally adopted child or a child for whom a Subscriber is a court appointed legal guardian, and who meets the definition of a Covered Dependent, will be treated as a dependent from the date of adoption or upon the date the child was placed for adoption with the Subscriber. Placed for adoption means the assumption and retention of a legal obligation for total or partial support of a child in anticipation of adoption of the child. The Subscriber must make a written request for coverage within 31 days of the date the child is adopted or placed with the Subscriber for adoption. Special Rules Which Apply to Children Qualified Medical Child Support Order Coverage is available for a dependent child not residing with a Subscriber and who resides outside the Service Area, if there is a qualified medical child support order requiring the Subscriber to provide dependent health coverage for a non-resident child. The child must meet the definition of a Covered POS WY SG 2016 COC V001 9 Wyoming Small Group Off Exchange

10 Dependent, and the Subscriber must make a written request for coverage within 31 days of the court order. Handicapped Children Coverage is available for a child who has reached the maximum dependent age for a child under this Certificate and is chiefly dependent upon the Subscriber for support and maintenance and is incapable of self-support due to mental or physical incapacity. The incapacity must have commenced prior to the age the dependent would have lost eligibility. In order to continue coverage for a handicapped child, the Subscriber must provide evidence of the child's incapacity and dependency to Aetna within 31 days of the date the child's coverage would otherwise terminate. Proof of continued incapacity, including a medical examination, must be submitted to Aetna as requested, but not more frequently than annually beginning after the 2 year period following the child's attainment of the age specified on the Schedule of Benefits. This eligibility provision will no longer apply on the date the dependent s incapacity ends. Notification of Change in Status It shall be a Member s responsibility to notify Aetna of any changes which affect the Member s coverage under this Certificate, unless a different notification process is agreed to between Aetna and Contract Holder. Such status changes include, but are not limited to, change of address, change of Covered Dependent status, and enrollment in Medicare or any other group health plan of any Member. Additionally, if requested, a Subscriber must provide to Aetna, within 31 days of the date of the request, evidence satisfactory to Aetna that a dependent meets the eligibility requirements described in this Certificate. Special Enrollment Period An eligible individual and eligible dependents may be enrolled during a Special Enrollment Periods. A Special Enrollment Period may apply when an eligible individual or eligible dependent loses other health coverage or when an eligible individual acquires a new eligible dependent through marriage, birth, adoption or placement for adoption. Special Enrollment Period for Certain Individuals Who Lose Other Health Coverage: An eligible individual or an eligible dependent may be enrolled during a Special Enrollment Period, if the following requirements, as applicable, are met: The eligible individual or the eligible dependent was covered under another group health plan or other health insurance coverage when initially eligible for coverage under Aetna; The eligible individual or eligible dependent previously declined coverage in writing under Aetna The eligible individual or eligible dependent becomes eligible for State premium assistance in connection with coverage under Aetna The eligible individual or eligible dependent loses coverage under the other group health plan or other health insurance coverage for one of the following reasons: - The other group health coverage is COBRA continuation coverage under another plan, and the COBRA continuation coverage under that other plan has since been exhausted; POS WY SG 2016 COC V Wyoming Small Group Off Exchange

11 - The other coverage is a group health plan or other health insurance coverage, and the other coverage has been terminated as a result of loss of eligibility for the coverage or employer contributions towards the other coverage have been terminated; or - The other health insurance coverage is Medicaid or an S-Chip plan and the eligible individual or eligible dependent no longer qualifies for such coverage. Loss of eligibility includes the following: - A loss of coverage as a result of legal separation, divorce or death; - Termination of employment; - Reduction in the number of hours of employment; - Any loss of eligibility after a period that is measured by reference to any of the foregoing; - Termination of Aetna coverage due to Member action- movement outside of the Aetna s service area; and also the termination of health coverage including Non-Aetna, due to plan termination. - Plan ceases to offer coverage to a group of similarly situated individuals; - Cessation of a dependent s status as an eligible dependent - Termination of benefit package Loss of eligibility does not include a loss due to failure of the individual or the participant to pay Premiums on a timely basis or due to termination of coverage for cause as referenced in the Termination of Coverage section of this Certificate. To be enrolled in Aetna during a Special Enrollment Period, the eligible individual or eligible dependent must enroll within: 31 days, beginning on the date of the eligible individual's or eligible dependent's loss of other group health plan or other health insurance coverage; or 60 days, beginning on the date the eligible individual or eligible dependent - Becomes eligible for premium assistance in connection with coverage under Aetna, or - Is no longer qualified for coverage under Medicaid or S-Chip. The Effective Date of Coverage will be the first day of the first calendar month following the date the completed request for enrollment is received. Special Enrollment Period When a New Eligible Dependent is Acquired: When a new eligible dependent is acquired through marriage, birth, adoption or placement for adoption, the new eligible dependent (and, if not otherwise enrolled, the eligible individual and other eligible dependents) may be enrolled during a special enrollment period. The special enrollment period is a period of 30 days, beginning on the date of the marriage, birth, adoption or placement for adoption (as the case may be). If a completed request for enrollment is made during that period, the Effective Date of Coverage will be: In the case of marriage, the first day of the first calendar month following the date the completed request for enrollment is received. In the case of a dependent s birth, adoption or placement for adoption, the date of such birth, adoption or placement for adoption. POS WY SG 2016 COC V Wyoming Small Group Off Exchange

12 The eligible individual or the eligible dependent enrolling during a special enrollment period will not be subject to late enrollment provisions, if any, described in this Certificate. Effective Date of Coverage Coverage shall take effect at 12:01 a.m. on the Member s effective date. Coverage shall continue in effect from month to month subject to payment of Premiums made by the Contract Holder employer and subject to the Termination section of the Group Agreement, and the Termination of Coverage section of this Certificate. Hospital Confinement on Effective Date of Coverage If a Member is an inpatient in a Hospital on the Effective Date of Coverage, the Member will be covered as of that date. Such services are not covered if the Member is covered by another health plan on that date and the other health plan is responsible for the cost of the services. Aetna will not cover any service that is not a Covered Benefit under this Certificate. To be covered, the Member must utilize Participating Providers and is subject to all the terms and conditions of this Certificate. POS WY SG 2016 COC V Wyoming Small Group Off Exchange

13 COVERED BENEFITS A Member shall be entitled to the Covered Benefits as specified below, in accordance with the terms and conditions of this Certificate. Unless specifically stated otherwise, in order for benefits to be covered, they must be Medically Necessary. For the purpose of coverage, Aetna may determine whether any benefit provided under the Certificate is Medically Necessary, and Aetna has the option to only authorize coverage for a Covered Benefit performed by a particular Provider. Preventive care, as described below, will be considered Medically Necessary. Important Note: You should review your Schedule of Benefits for the cost sharing that applies to the Covered Benefits in this section. This will help you become familiar with your payment responsibilities. Some Covered Benefits may have visit limits and maximums that apply to the service or supply. You should always review your Certificate and Schedule of Benefits together. ALL SERVICES ARE SUBJECT TO THE EXCLUSIONS AND LIMITATIONS DESCRIBED IN THIS CERTIFICATE. To be Medically Necessary, the service or supply must: Be care or treatment as likely to produce a significant positive outcome as, and no more likely to produce a negative outcome than, any alternative service or supply, both as to the disease or injury involved and the Member's overall health condition; Be care or services related to diagnosis or treatment of an existing illness or injury, except for Preventive Care Benefits, as determined by Aetna; Be a diagnostic procedure, indicated by the health status of the Member and be as likely to result in information that could affect the course of treatment as, and no more likely to produce a negative outcome than, any alternative service or supply, both as to the disease or injury involved and the Member's overall health condition; Include only those services and supplies that cannot be safely and satisfactorily provided at home, in a Physician s or Dental Provider s office, on an outpatient basis, or in any facility other than a Hospital, when used in relation to inpatient Hospital services; and As to diagnosis, care and treatment be no more costly (taking into account all health expenses incurred in connection with the service or supply) than any equally effective service or supply in meeting the above tests. In determining if a service or supply is Medically Necessary, Aetna s Patient Management Medical Director or its Physician or Dentist designee will consider: Information provided on the Member's health status; Reports in peer reviewed medical literature; Reports and guidelines published by nationally recognized health care organizations that include supporting scientific data; POS WY SG 2016 COC V Wyoming Small Group Off Exchange

14 Professional standards of safety and effectiveness which are generally recognized in the United States for diagnosis, care or treatment; The opinion of Health Professionals in the generally recognized health specialty involved; The opinion of the attending Physicians or Dental Providers, which have credence but do not overrule contrary opinions; and Any other relevant information brought to Aetna's attention. All Covered Benefits will be covered in accordance with the guidelines determined by Aetna. If a Member has questions regarding coverage under this Certificate, the Member may call the Member Services toll-free telephone number listed on the Member s identification card. THE MEMBER IS RESPONSIBLE FOR PAYMENT OF THE APPLICABLE COPAYMENTS AND DEDUCTIBLES LISTED ON THE SCHEDULE OF BENEFITS. IMPORTANT: REFER TO THE AETNA PROCEDURE SECTION OF THIS CERTIFICATE FOR THE LIST OF SERVICES AND SUPPLIES WHICH REQUIRE PRECERTIFICATION. 1. Preventive Care Benefits This section on Preventive Care describes the covered expenses for services and supplies provided when you are well. Important Notes: 1. The recommendations and guidelines of the: Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; United States Preventive Services Task Force; Health Resources and Services Administration; and American Academy of Pediatrics/Bright Futures Guidelines for Children and Adolescents. as referenced throughout this Preventive Care section may be updated periodically. This Plan is subject to updated recommendations or guidelines that are issued by these organizations beginning on the first day of the plan year, one year after the recommendation or guideline is issued. 2. If any diagnostic x-rays, lab, or other tests or procedures are ordered, or given, in connection with any of the Preventive Care benefits described below, those tests or procedures will not be covered as Preventive Care benefits. Those tests and procedures that are covered expenses will be subject to the cost-sharing that applies to those specific services under this Plan. 3. Refer to the Schedule of Benefits for information about cost-sharing and maximums that apply to Preventive Care benefits. POS WY SG 2016 COC V Wyoming Small Group Off Exchange

15 Routine Physical Exams Covered expenses include charges made by your physician, primary care physician (PCP) for routine physical exams. This includes routine vision and hearing screenings given as part of the routine physical exam. A routine exam is a medical exam given by a physician for a reason other than to diagnose or treat a suspected or identified illness or injury, and also includes: Evidence-based items that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force. Services as recommended in the American Academy of Pediatrics/Bright Futures Guidelines for Children and Adolescents. Screenings and counseling services as provided for in the comprehensive guidelines recommended by the Health Resources and Services Administration. These services may include but are not limited to: - Screening and counseling services, such as: Interpersonal and domestic violence; Sexually transmitted diseases; and Human Immune Deficiency Virus (HIV) infections. - Screening for gestational diabetes for women. - High risk Human Papillomavirus (HPV) DNA testing for women age and older and limited to once every six months-three years. X-rays, lab and other tests given in connection with the exam. For covered newborns, an initial hospital check up. Limitations: Unless specified above, not covered under this Preventive Care benefit are charges for: Services which are covered to any extent under any other part of this Plan; Services which are for diagnosis or treatment of a suspected or identified illness or injury; Exams given during your stay for medical care; Services not given by a physician or under his or her direction; Psychiatric, psychological, personality or emotional testing or exams; Preventive Care Immunizations Covered expenses include charges made by your physician, primary care physician (PCP) or a facility for: Immunizations for infectious diseases; and The materials for administration of immunizations; that have been recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. Limitations Not covered under this Preventive Care benefit are charges incurred for: Services which are covered to any extent under any other part of this Plan; Immunizations that are not considered Preventive Care such as those required due to your employment or travel POS WY SG 2016 COC V Wyoming Small Group Off Exchange

16 Preventive Care Drugs and Supplements Covered expenses include preventive care drugs and supplements (including over-the-counter drugs and supplements) obtained at a pharmacy. They are covered when they are: prescribed by a physician; obtained at a pharmacy; and submitted to a pharmacist for processing. The preventive care drugs and supplements covered under this Plan include, but may not be limited to: Aspirin: Benefits are available to adults. Oral Fluoride Supplements: Benefits are available to children whose primary water source is deficient in fluoride. Folic Acid Supplements: Benefits are available to adult females planning to become pregnant or capable of pregnancy. Iron Supplements: Benefits are available to children without symptoms of iron deficiency. Coverage is limited to children who are at increased risk for iron deficiency anemia. Vitamin D Supplements: Benefits are available to adults to promote calcium absorption and bone growth in their bodies. Coverage of preventive care drugs and supplements will be subject to any sex, age, medical condition, family history, and frequency guidelines in the recommendations of the United States Preventive Services Task Force. Important Note: For details on the guidelines and the current list of covered preventive care drugs and supplements, contact your physician or Member Services by logging onto the Aetna website and Aetna Navigator, or calling the number on the back of your ID card. Refer to the Schedule of Benefits for the cost-sharing and supply limits that apply to these benefits. Reimbursement of Preventive Care Drugs and Supplements at a Pharmacy You will be reimbursed by Aetna for the cost of the preventive care drugs and supplements when you submit proof of loss to Aetna that you purchased a preventive care drug or supplement at a pharmacy. Proof of loss means a copy of the receipt that contains the prescription information provided by the pharmacist (it is attached to the bag that contains the preventive care OTC drug or supplement). Refer to the provisions Reporting of Claims and Payment of Benefits later in this Booklet-Certificate for information. You can also contact Member Services by logging onto the Aetna website at www. aetna.com or calling the toll-free number on the back of the ID card. Well Woman Preventive Visits Covered expenses include charges made by your physician, primary care physician (PCP) obstetrician, or gynecologist for: a routine well woman preventive exam office visit, including Pap smears. A routine well woman preventive exam is a medical exam given by a physician for a reason other than to diagnose or treat a suspected or identified illness or injury; and POS WY SG 2016 COC V Wyoming Small Group Off Exchange

17 routine preventive care breast cancer genetic counseling and breast cancer (BRCA) gene blood testing. Covered expenses include charges made by a physician and lab for the BRCA gene blood test and charges made by a genetic counselor to interpret the test results and evaluate treatment. These benefits will be subject to any age; family history; and frequency guidelines that are: Evidence-based items or services that have in effect a rating of A or B in the recommendations of the United States Preventive Services Task Force; and Evidence-informed items or services provided in the comprehensive guidelines supported by the Health Resources and Services Administration. Limitations: Unless specified above, not covered under this Preventive Care benefit are charges for: Services which are covered to any extent under any other part of this Plan; Services which are for diagnosis or treatment of a suspected or identified illness or injury; Exams given during your stay for medical care; Services not given by a physician or under his or her direction; Psychiatric, psychological, personality or emotional testing or exams Screening and Counseling Services Covered expenses include charges made by your physician, primary care physician (PCP) in an individual or group setting for the following: Obesity and/or Healthy Diet Screening and counseling services to aid in weight reduction due to obesity. Coverage includes: Preventive counseling visits and/or risk factor reduction intervention; Nutritional counseling; and Healthy diet counseling visits provided in connection with Hyperlipidemia (high cholesterol) and other known risk factors for cardiovascular and diet-related chronic disease. Misuse of Alcohol and/or Drugs Screening and counseling services to aid in the prevention or reduction of the use of an alcohol agent or controlled substance. Coverage includes preventive counseling visits, risk factor reduction intervention and a structured assessment. Use of Tobacco Products Screening and counseling services to aid you to stop the use of tobacco products. Coverage includes: Preventive counseling visits; Treatment visits; and Class visits; to aid you to stop the use of tobacco products. Tobacco product means a substance containing tobacco or nicotine including: Cigarettes; Cigars; Smoking tobacco; Snuff; POS WY SG 2016 COC V Wyoming Small Group Off Exchange

18 Smokeless tobacco; and Candy-like products that contain tobacco. Sexually Transmitted Infections Covered expenses include the counseling services to help you prevent or reduce sexually transmitted infections. Genetic Risks for Breast and Ovarian Cancer Covered expenses include the counseling and evaluation services to help you assess your risk of breast and ovarian cancer susceptibility. Benefits for the screening and counseling services above are subject to any visit maximums shown in your Schedule of Benefits. Limitations: Unless specified above, not covered under this Preventive Care benefit are charges incurred for: Services which are covered to any extent under any other part of this Plan; and Services and supplies furnished by a non-designated network provider or an out-of-network provider. Tobacco cessation prescription and over-the-counter drugs Covered expenses include FDA- approved prescription drugs and over-the-counter (OTC) drugs to help stop the use of tobacco products, when prescribed by a prescriber and the prescription is submitted to the pharmacist for processing. Routine Cancer Screenings Covered expenses include, but are not limited to, charges incurred for routine cancer screening as follows: Mammograms; Fecal occult blood tests; Digital rectal exams; Prostate specific antigen (PSA) tests; Sigmoidoscopies; Double contrast barium enemas (DCBE); and Colonoscopies (removal of polyps performed during a screening procedure is a covered expense). Lung cancer screening These benefits will be subject to any age; family history; and frequency guidelines that are: Evidence-based items or services that have in effect a rating of A or B in the recommendations of the United States Preventive Services Task Force; and Evidence-informed items or services provided in the comprehensive guidelines supported by the Health Resources and Services Administration. POS WY SG 2016 COC V Wyoming Small Group Off Exchange

19 Limitations: Unless specified above, not covered under this Preventive Care benefit are charges incurred for: Services which are covered to any extent under any other part of this Plan Important Notes: 1. Refer to the Schedule of Benefits for details about cost sharing and benefit maximums that apply to Preventive Care. 2. For details on the frequency and age limits that apply to Routine Physical Exams and Routine Cancer Screenings, contact your physician or Member Services by logging onto the Aetna website or calling the number on the back of your ID card. Prenatal Care Prenatal care will be covered as Preventive Care for services received by a pregnant female in a physician's, primary care physician's (PCP), obstetrician's, or gynecologist's office but only to the extent described below. Coverage for prenatal care under this Preventive Care benefit is limited to pregnancy-related physician office visits including the initial and subsequent history and physical exams of the pregnant woman (maternal weight, blood pressure, fetal heart rate check, and fundal height). Limitations: Unless specified above, not covered under this Preventive Care benefit are charges incurred for: Services which are covered to any extent under any other part of this Plan; Pregnancy expenses (other than prenatal care as described above); and Important Notes: Refer to the Maternity Care and Related New Born Care Benefits sections of this Booklet-Certificate for more information on coverage for pregnancy expenses under this Plan, including other prenatal care, delivery and postnatal care office visits. Comprehensive Lactation Support and Counseling Services Covered expenses include comprehensive lactation support (assistance and training in breast feeding) and counseling services provided to females during pregnancy, or at any time following delivery, for breast-feeding by a certified lactation support provider. Covered expenses also include the rental or purchase of breast feeding equipment as described below. Lactation support and lactation counseling services are covered expenses when provided in either a group or individual setting. Benefits for lactation counseling services are subject to the visit maximum shown in your Schedule of Benefits. Breast Feeding Durable Medical Equipment Coverage includes the rental or purchase of breast feeding durable medical equipment for the purpose of lactation support (pumping and storage of breast milk) as follows. POS WY SG 2016 COC V Wyoming Small Group Off Exchange

20 Breast Pump Covered expenses include the following: The rental of a hospital-grade electric pump for a newborn child when the newborn child is confined in a hospital. The purchase of: - An electric breast pump (non-hospital grade). A purchase will be covered once- every year; or - A manual breast pump. A purchase will be covered once per pregnancy. If an electric breast pump was purchased within the previous one year period, the purchase of another breast pump will not be covered until a one year period has elapsed from the last purchase. Breast Pump Supplies Coverage is limited to only one purchase per pregnancy in any year where a covered female would not qualify for the purchase of a new pump. Coverage for the purchase of breast pump equipment is limited to one item of equipment, for the same or similar purpose, and the accessories and supplies needed to operate the item. You are responsible for the entire cost of any additional pieces of the same or similar equipment you purchase or rent for personal convenience or mobility. Aetna reserves the right to limit the payment of charges up to the most cost efficient and least restrictive level of service or item which can be safely and effectively provided. The decision to rent or purchase is at the discretion of Aetna. Limitations: Unless specified above, not covered under this Preventive Care benefit are charges incurred for: Services which are covered to any extent under any other part of this Plan Family Planning Services - Female Contraceptives For females with reproductive capacity, covered expenses include those charges incurred for services and supplies that are provided to prevent pregnancy. All contraceptive methods, services and supplies covered under this Preventive Care benefit must be approved by the U.S. Food and Drug Administration (FDA). Coverage includes counseling services on contraceptive methods provided by a physician, primary care physician's (PCP), obstetrician or gynecologist. Such counseling services are covered expenses when provided in either a group or individual setting. They are subject to the contraceptive counseling services visit maximum shown in your Schedule of Benefits. The following contraceptive methods are covered expenses under this Preventive Care benefit: Voluntary Sterilization Covered expenses include charges billed separately by the provider for female voluntary sterilization procedures and related services and supplies including, but not limited to, tubal ligation and sterilization implants. Covered expenses under this Preventive Care benefit would not include charges for a voluntary sterilization procedure to the extent that the procedure was not billed separately by the provider or because it was not the primary purpose of a confinement. POS WY SG 2016 COC V Wyoming Small Group Off Exchange

21 Contraceptives Contraceptives can be paid either under your medical plan or pharmacy plan depending on the type of expense and how and where the expense is incurred. Benefits are paid under your medical plan for female contraceptive prescription drugs and devices (including any related services and supplies) when they are provided, administered, or removed, by a physician during an office visit. For a list of the types of female contraceptives covered under this Plan, refer to the What the Pharmacy Plan Covers section and the Contraceptives benefit later in this Booklet-Certificate. Important Note: For a list of the types of female contraceptives covered under this Plan, refer to the section What the Pharmacy Plan Covers and the Contraceptives benefit later in this Booklet-Certificate. Refer to the provisions Reporting of Claims and Payment of Benefits later in this Booklet-Certificate for information on submitting claims. You can also contact Member Services by logging onto the Aetna website at www. aetna.com or calling the toll-free number on the back of the ID card. Important Note: This Plan does not cover all contraceptives. For a current listing, contact your physician or Member Services by logging onto the Aetna website at www. aetna.com or calling the toll-free number on the back of the ID card. Limitations: Unless specified above, not covered under this Preventive Care benefit are charges for: Services which are covered to any extent under any other part of this Plan; Services and supplies incurred for an abortion; Services provided as a result of complications resulting from a voluntary sterilization procedure and related follow-up care; Services which are for the treatment of an identified illness or injury; Services that are not given by a physician or under his or her direction; Psychiatric, psychological, personality or emotional testing or exams; Any contraceptive methods that are only "reviewed" by the FDA and not "approved" by the FDA; Male contraceptive methods, sterilization procedures or devices; The reversal of voluntary sterilization procedures, including any related follow-up care POS WY SG 2016 COC V Wyoming Small Group Off Exchange

22 Important Notes: 1. Coverage under this Preventive Care benefit does not include contraceptive methods that are: Brand-name prescription drugs; Brand-name contraceptive devices; Biosimilar prescription drugs; FDA-approved female: - Brand-name and biosimilar emergency contraceptives; - Brand-name over-the-counter (OTC) emergency contraceptives; and FDA-approved female and male brand-name over-the-counter (OTC) contraceptives; unless: Such contraceptive methods are not available within the same therapeutic drug class; or A generic equivalent, biosimilar or generic alternative, within the same therapeutic drug class is not available; and You are granted a medical exception. You may seek a medical exception by submitting a request to Aetna's Precertification Department. Any waiver granted as a result of a medical exception shall be based upon an individual, case by case medically necessary determination and coverage will not apply or extend to other covered persons. 2. A generic equivalent contains the identical amounts of the same active ingredients as the brand name prescription drug or device. A biosimilar is a biological drug that is therapeutically similar to a brand name prescription drug. A generic alternative is used for the same purpose, but can have different ingredients or different amounts of ingredients. 3. Refer to the Outpatient Prescription Drug Expenses section of this Booklet-Certificate for more information on prescription drug coverage under this Plan. 2. Physician and Other Health Professional Care Primary Care Physician Benefit Office visits during office hours. Home visits. After-hours PCP services. PCPs are required to provide or arrange for on-call coverage 24 hours a day, 7 days a week. If a Member becomes sick or is injured after the PCP's regular office hours, the Member should: - call the PCP's office; - identify himself or herself as a Member; and - follow the PCP's or covering Physician s instructions. If the Member's injury or illness is a Medical Emergency, the Member should follow the procedures outlined under the Emergency Care/Urgent Care Benefits section of this Certificate. Hospital visits. Immunizations for infectious disease, but not if solely for your employment or travel. POS WY SG 2016 COC V Wyoming Small Group Off Exchange

23 Allergy testing and allergy injections. Charges made by the Physician for supplies, radiological services, x-rays, and tests provided by the Physician. Alternatives to Physicians Office Visits Walk-in Clinic Benefits charges made by walk-in clinics for: Unscheduled, non-emergency illnesses and injuries; The administration of certain immunizations administered within the scope of the clinic s license; and Individual screening and counseling services to aid you: - In weight reduction due to obesity; - To stop the use of tobacco products; - In stress management. The stress management counseling sessions will: Help you to identify the life events which cause you stress (the physical and mental strain on your body.); and Teach you techniques and changes in behavior to reduce the stress. Benefit Limitations: Unless specified above, not covered under this benefit are charges incurred for services and supplies furnished in a group setting for screening and counseling services Important Note: Not all services are available at all Walk-In Clinics. The types of services offered will vary by the provider and location of the clinic. For a complete description of the screening and counseling services provided on the use of tobacco products and to aid in weight reduction due to obesity, refer to the Preventive Care Benefits section in this Certificate and the Screening and Counseling Services benefit for a description of these services. These services may also be obtained from your PCP. Specialist Physician Benefits Covered Benefits include outpatient and inpatient services. Member may request a second opinion regarding a proposed surgery or course of treatment recommended by Member's PCP or a Specialist. Second opinions must be obtained by a Participating Provider and are subject to precertification. Important Reminder: For a description of the preventive care benefits covered under this Certificate, refer to the Preventive Care Benefits section in this Certificate. POS WY SG 2016 COC V Wyoming Small Group Off Exchange