Aetna Life Insurance Company Hartford, Connecticut 06156

Transcription

1 Aetna Life Insurance Company Hartford, Connecticut Extraterritorial Certificate Rider (GR-9N-CR1) Policyholder: The TLC Companies Group Policy No.: GP Rider: Georgia ET Medical Issue Date: February 27, 2009 Effective Date: January 1, 2009 This certificate rider forms a part of the booklet certificate issued to you by Aetna describing the benefits provided under the policy specified above. This extraterritorial certificate-rider takes the place of any other medical extraterritorial certificate-rider issued to you on a prior date. Note: The provisions identified herein are specifically applicable ONLY for: Benefit plans which have been made available to you and/or your dependents by your Employer; Benefit plans for which you and/or your dependents are eligible; Benefit plans which you have elected for you and /or your dependents; The benefits in this rider are specific to residents of Georgia. These benefits supersede any provision in your booklet certificate to the contrary unless the provisions in your certificate result in greater benefits. You are only entitled to these benefits, if you are a resident of Georgia, and if the benefit value exceeds those benefits covered under the group policy and booklet certificate. In regards to your Open Choice, Open Choice High Deductible Health Plan, Open Access Managed Choice High Deductible Health Plan, and Open Access Managed Choice Plans: A payment percentage differential greater than 30% cannot exist between preferred and nonpreferred expenses. This rule does not apply to non-preferred physician's office visits. In regards to All Medical Plans: Within your Booklet-Certificate under the General Information About Your Coverage section, the Subrogation language appearing in the subsection Subrogation and Right of Reimbursement does not apply to employees located in Georgia. The Right of Reimbursement language does still apply. In regards to All Medical Plans: Benefit Amount The benefit amount for each covered prescription drug or refill dispensed by a preferred pharmacy will be an amount equal to the of the total charges. The total charge is determined by: the preferred pharmacy; and Aetna. Any amount so determined will be paid to the preferred pharmacy on your behalf. The Benefit Amount for each covered prescription drug or refill dispensed by a non-preferred pharmacy will be an amount equal to the of the charge that Aetna determines would have been made for the drug, if the drug had been dispensed by a preferred pharmacy.

2 In regards to your Open Access Managed Choice- Copay 500 and Open Choice - Copay 500 Plans: Generic Drugs $ 10 $ 20 On Medication Formulary $ 25 $ 50 Not on Medication Formulary $ 40 $ 80 Non- Generic Drugs $ 10 On Medication Formulary $ 25 Not on Medication Formulary $ 40

3 In regards to your Open Access Managed Choice - Copay 1000 and Open Choice - Copay 1000 Plans: Generic Drugs $ 10 $20 On Medication Formulary $ 30 $ 60 Not on Medication Formulary $ 50 $ 100 Non- Generic Drugs $ 10 On Medication Formulary $ 30 Not on Medication Formulary $ 50 In regards to your Open Access Managed Choice - Copay 1500 and Open Choice- Copay 1500 Plans: Generic Drugs $ 20 $40 On Medication Formulary $ 40 $ 80 Not on Medication Formulary $ 70 $ 140 1

4 Non- Generic Drugs $ 20 On Medication Formulary $ 40 Not on Medication Formulary $ 70 In regards to your Open Access Managed Choice- Copay 2000 and Open Choices- Copay 2000 Plans: Prescription Drug Benefits Calendar Year Deductible $ 200 This Calendar Year Deductible applies to all prescription drug expenses. Family Deductible Limit $ 600 Generic Drugs $ 20 $40 On Medication Formulary $ 40 $ 80 Not on Medication Formulary $ 70 $ 140 Non- Generic Drugs $ 20 On Medication Formulary $ 40 Not on Medication Formulary $ 70 2

5 In regards to your Open Access Managed Choice High Deductible Health Plan and Open Choice High Deductible Health Plans: Generic Drugs $ 15 $30 On Medication Formulary $ 25 $ 50 Not on Medication Formulary $ 40 $ 80 Non- Generic Drugs $ 15 On Medication Formulary $ 25 Not on Medication Formulary $ 40 In regards to your Traditional Choice Medical Plan: Generic Drugs $ 20 $40 On Medication Formulary $ 35 $ 70 Not on Medication Formulary $ 50 $ 100 3

6 Non- Generic Drugs $ 20 On Medication Formulary $ 35 Not on Medication Formulary $ 50 In regards to All Medical Plans: Additional Provisions The following additional provisions apply to your coverage: You cannot receive multiple coverage under this Plan because you are connected with more than one Employer. In the event of a misstatement of any fact affecting your coverage under this Plan, the true facts will be used to determine the coverage in force. This document describes the main features of this Plan. Additional provisions are described elsewhere in the group contract. If you have any questions about the terms of this Plan or about the proper payment of benefits, you may obtain more information from your Employer who may direct you to a local Aetna office. Otherwise, you may write to the following address: Aetna Life Insurance Company 151 Farmington Avenue Hartford, Connecticut Attention: Law Department, State Government Affairs, RW4A Your Employer hopes to continue this Plan indefinitely but, as with all group plans, this Plan may be changed or discontinued with respect to all or any class of employees. Ronald A. Williams Chairman, Chief Executive Officer, and President Aetna Life Insurance Company (A Stock Company) 4