LEVEL 1: BANNER NETWORK DESIGNATED PROVIDERS. $4,000 Individual

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1 Aetn Whole Helth* Arizon Group Business Employees Pln Effective Dte: 08/01/2012 Bnner Helth Network HSA HDHP $4,000 80/50 (08/12) PLAN FEATURES Plese check DocFind for full list of providers prticipting in the Bnner Helth Network. Go to Aetn DocFind: Deductible (per clendr yer) $4,000 Individul $5,000 Individul $8,000 Fmily $10,000 Fmily Unless otherwise indicted, the Deductible must be met prior to benefits being pyble. All covered expenses ccumulte seprtely towrd the Level 1 nd Level 2 Deductibles. Once the Fmily Deductible is met, ll fmily members will be considered s hving met their Deductible for the reminder of the clendr yer. Member Coinsurnce (pplies to ll expenses unless otherwise stted) 20% 50% Pyment Limit (per clendr yer, excludes deductible) $1,500 Individul $3,000 Fmily All covered expenses ccumulte seprtely towrd the Level 1 nd Level 2 Pyment Limit. $2,500 Individul $5,000 Fmily Once the Fmily Pyment Limit is met, ll fmily members will be considered s hving met their Pyment Limit for the reminder of the clendr yer. All copys nd coinsurnce (including prescription drugs nd self-injectbles) except Amounts Over Allowble nd Filure to Pre-Certify penlty Amounts my be used to stisfy the Preferred Pyment Limit. Only those out-of-pocket expenses resulting from the ppliction of coinsurnce percentge (except ny Deductibles, Copys, Prescription Drugs (including self-injectbles), pyments for Mentl Disorders, Substnce Abuse, ER/Urgent Cre, DME, Amounts Over Allowble nd Filure to Pre-Certify Penlty Amounts) my be used to stisfy the Non-Preferred Pyment Limit. Lifetime Mximum Pyment for Out-of-Network Cre** Primry Cre Physicin Selection Not Applicble Not Applicble Unlimited Professionl: 105% of Medicre Fcility: 140% of Medicre Not Applicble Certifiction Requirements Certifiction for certin types of Out-of-Network cre must be obtined to void reduction in benefits pid for tht cre. Certifiction for Hospitl Admissions, Tretment Fcility Admissions, Convlescent Fcility Admissions, Home Helth Cre, nd Hospice Cre is required. Benefits will be reduced by $400 per occurrence if Certifiction is not obtined. Referrl Requirement PHYSICIAN SERVICES Office Visits to Non-Specilist None None 20% fter deductible 50% fter deductible Includes services of n internist, generl physicin, fmily prctitioner or peditricin for routine cre s well s dignosis nd tretment of n illness or injury nd in-office surgery. AZ_Bnner_HSA_4000 (v ) Aetn Life Insurnce Compny Pge 1

2 Specilist Office Visits Aetn Whole Helth* Arizon Group Business Employees Pln Effective Dte: 08/01/2012 Bnner Helth Network HSA HDHP $4,000 80/50 (08/12) 20% fter deductible 50% fter deductible Primry Cre & Specilist Physicin E-Visits 20% fter deductible 50% fter deductible An E-visit is n online internet consulttion between physicin nd n estblished ptient bout non-emergency helthcre mtter. This visit must be conducted through n Aetn uthorized internet E-visit service vendor. Register t Pre-Ntl Mternity Mternity - Delivery nd Post-Prtum Cre Wlk-in Clinics $0 copy; deductible wived 20% fter deductible 20% fter deductible 50% fter deductible 50% fter deductible 50% fter deductible Wlk-in Clinics re network, free-stnding helth cre fcilities. They re n lterntive to physicin's office visit for tretment of unscheduled, non-emergency illnesses nd injuries nd the dministrtion of certin immuniztions. It is not n lterntive for emergency room services or the ongoing cre provided by physicin. Neither n emergency room, nor n outptient deprtment of hospitl, shll be considered Wlk-in Clinic. Allergy Testing & Tretment (given by physicin) Allergy Injections (not given by physicin) 20% fter deductible 50% fter deductible 20% fter deductible 50% fter deductible PREVENTIVE CARE Routine Adult Physicl Exms nd Immuniztions Limited to 1 exm every 12 months for members ge 18 nd older. Well Child Exms nd Immuniztions Provides coverge for 7 exms in the first 12 months of life; 3 exms in the second 12 months of life;3 exms in the third 12 months of life; 1 exm per 12 months from ge 4 through ge 17. Routine Gynecologicl Exms Includes Pp smer, HPV screening nd relted lb fees. Frequency schedule pplies. Routine Mmmogrms For covered femles ge 40 nd over. Frequency schedule pplies. Women's Helth Includes: Screening for gesttionl dibetes; HPV (Humn Ppillomvirus) DNA testing, counseling for sexully trnsmitted infections; counseling nd screening for humn immunodeficiency virus; screening nd counseling for interpersonl nd domestic violence; brestfeeding support, supplies nd counseling; nd contrceptive methods nd counseling. Limittions my pply. $0 copy; deductible wived 50% fter deductible $0 copy; deductible wived 50% fter deductible $0 copy; deductible wived 50% fter deductible $0 copy; deductible wived 50% fter deductible $0 copy; deductible wived Member cost shring is bsed on the type of service performed nd the plce of service where it is rendered AZ_Bnner_HSA_4000 (v ) Aetn Life Insurnce Compny Pge 2

3 Aetn Whole Helth* Arizon Group Business Employees Pln Effective Dte: 08/01/2012 Bnner Helth Network HSA HDHP $4,000 80/50 (08/12) Routine Digitl Rectl Exm / $0 copy; deductible wived 50% fter deductible Prostte-Specific Antigen Test For covered mles ge 40 nd over. Frequency schedule pplies. Colorectl Cncer Screening Sigmoidoscopy nd Double Contrst Brium Enem - 1 every 5 yers for ll members ge 50 nd over. Preventive Colonoscopy - 1 every 10 yers for ll members ge 50 nd over. Fecl Occult Blood Testing - 1 every yer for ll members ge 50 nd over. $0 copy; deductible wived 50% fter deductible Colonoscopy (non-preventive) DIAGNOSTIC PROCEDURES Outptient Dignostic Lbortory nd X-ry (except for Complex Imging Services) See Outptient Surgery Benefit 20% fter deductible See Outptient Surgery Benefit 50% fter deductible Outptient Dignostic X-ry for Complex Imging Services Including, but not limited to, MRI, MRA, PET nd CT Scns nd ny other outptient dignostic imging service costing over $500. Precertifiction required. EMERGENCY MEDICAL CARE Urgent Cre Provider Non-Urgent Use of Urgent Cre Provider Emergency Room Copy wived if dmitted. Copy pplies to fcility chrges only. Non-Emergency cre in n Emergency Room Emergency Ambulnce 20% fter deductible 50% fter deductible 20% fter deductible Pid s Level 1 20% fter deductible Pid s Level 1 20% fter deductible 20% fter deductible HOSPITAL CARE Inptient Coverge Including mternity (prentl, delivery nd postprtum) & trnsplnts 20% fter deductible 50% fter deductible Including mternity prentl, delivery, postprtum & trnsplnts. If trnsplnt is performed through n Institute of Excellence or Ntionl Medicl Excellence fcility, benefits would be pid t Level 1. If procedure is not performed through Institutes of Excellence or Ntionl Medicl Excellence fcility, benefits would be pid t Level 2. AZ_Bnner_HSA_4000 (v ) Aetn Life Insurnce Compny Pge 3

4 Aetn Whole Helth* Arizon Group Business Employees Pln Effective Dte: 08/01/2012 Bnner Helth Network HSA HDHP $4,000 80/50 (08/12) Outptient Surgery 20% fter deductible 50% fter deductible Provided in n outptient hospitl deprtment Outptient Surgery Provided in freestnding surgicl fcility 20% fter deductible 50% fter deductible MENTAL HEALTH SERVICES (2-50 employees) Inptient Limited to 15 dys per member per clendr yer. Levels 1 nd 2 combined. Outptient Limited to 20 visits per member per clendr yer. Levels 1 nd 2 combined. [MENTAL HEALTH SERVICES ( employees)] Inptient Outptient ALCOHOL / DRUG ABUSE SERVICES (2-50 employees) Inptient Detoxifiction Limited to 3 dys per dmission, 2 dmissions per clendr yer. Levels 1 nd 2 combined. 20% fter deductible 20% fter deductible 50% fter deductible 20% fter deductible 50% fter deductible 20% fter deductible 50% fter deductible 50% fter deductible 20% fter deductible 50% fter deductible Outptient Detoxifiction Inptient nd Outptient Rehbilittion ALCOHOL / DRUG ABUSE SERVICES ( employees) Inptient Detoxifiction Outptient Detoxifiction 20% fter deductible 20% fter deductible 50% fter deductible 50% fter deductible Inptient Rehbilittion 20% fter deductible 50% fter deductible Outptient Rehbilittion OTHER SERVICES AND PLAN DETAILS 20% fter deductible 50% fter deductible AZ_Bnner_HSA_4000 (v ) Aetn Life Insurnce Compny Pge 4

5 Aetn Whole Helth* Arizon Group Business Employees Pln Effective Dte: 08/01/2012 Bnner Helth Network HSA HDHP $4,000 80/50 (08/12) Autism Spectrum Disorder 20% fter deductible 50% fter deductible ( employees) Coverge for behviorl therpy is limited to children up to ge 16. Skilled Nursing Fcility Limited to 30 dys per member per clendr yer. Levels 1 nd 2 combined. Home Helth Cre Infusion Therpy Provided in the home or physicin's office Infusion Therpy Provided in n outptient hospitl deprtment or freestnding fcility Inptient Hospice Cre Outptient Hospice Cre Outptient Speech Therpy Limited to 20 visits per member per clendr yer. Levels 1 nd 2 combined. Outptient Physicl nd Occuptionl Therpy Limited to 20 visits per member per clendr yer. Levels 1 nd 2 combined. Chiroprctic 20% fter deductible 50% fter deductible 20% fter deductible 50% fter deductible 20% fter deductible 50% fter deductible 20% fter deductible 20% fter deductible 50% fter deductible 20% fter deductible 50% fter deductible 20% fter deductible 20% fter deductible 50% fter deductible 50% fter deductible 20% fter deductible 50% fter deductible 50% fter deductible Durble Medicl Equipment Mximum benefit of $2,500 per member per clendr yer. Limit does not pply to prosthetics or orthotics. Levels 1 nd 2 combined. 20% fter deductible 50% fter deductible FAMILY PLANNING Infertility Tretment 20% fter deductible Covered only for the dignosis nd tretment of the underlying medicl condition Voluntry Steriliztion - Vsectomy Member cost shring is bsed on the type of service performed nd the plce rendered Voluntry Steriliztion - Tubl Ligtion $0 copy; deductible wived 50% fter deductible Member cost shring is bsed on the type of service performed nd the plce rendered 50% fter deductible AZ_Bnner_HSA_4000 (v ) Aetn Life Insurnce Compny Pge 5

6 Aetn Whole Helth* Arizon Group Business Employees Pln Effective Dte: 08/01/2012 Bnner Helth Network HSA HDHP $4,000 80/50 (08/12) PHARMACY - PRESCRIPTION DRUG PARTICIPATING PHARMACIES NON-PARTICIPATING BENEFITS PHARMACIES Prescription drug clendr yer deductible Integrted Medicl/Rx Deductible Integrted Medicl/Rx Deductible All covered phrmcy expenses ccumulte seprtely towrd the preferred nd non-preferred phrmcy deductible. Unless otherwise indicted, the phrmcy deductible must be met prior to phrmcy benefits being pyble. Retil Up to 30-dy supply, includes insulin $20 copy for generic drugs, $40 copy for brnd nme formulry drugs, nd $60 copy for brnd nme nonformulry drugs 20% of submitted cost fter $20 copy for generic drugs, $40 copy for brnd nme formulry drugs, nd $60 copy for brnd nme nonformulry drugs Mil Order Delivery Up to 90-dy supply Specilty CreRx SM Includes self-injectble, infused nd orl specilty drugs (retil nd mil order up to 30-dy supply. Excludes insulin. Does not ccumulte towrd Pyment Limit. $40 copy for generic drugs, $80 copy for brnd nme formulry drugs, nd $120 copy for brnd nme nonformulry drugs 20% per prescription for formulry nd non-formulry drugs 50% per prescription for formulry nd non-formulry drugs Specilty CreRx SM - First Prescription for specilty drug my be filled t prticipting retil phrmcy or Aetn Specilty Phrmcy. Subsequent fills must be through Aetn Specilty Phrmcy. Mndtory Generic with DAW override (MG w/daw Override) - The member pys the pplicble copy only, if the physicin requires brnd. If the member requests brnd when generic is vilble, the member pys the pplicble copy plus the difference between the generic price nd the brnd price. Pln includes: Contrceptive drugs nd devices obtinble from phrmcy nd dibetic supplies obtinble from phrmcy. Lifestyle/performnce drugs limited to 6 pills per month. Precertifiction included nd 90-dy Trnsition of Cre (TOC) for Precertifiction included. Formulry generic FDA-pproved Women s Contrceptives covered 100% in network. Ech Aetn Whole Helth Pln hs two level of benefits: Level 1: When members use Bnner Helth Network to coordinte ll of their cre, they relize mximum svings. Level 2; Use of ny other provider will result in lower level of benefits. While Aetn Whole Helth members hve the freedom to receive cre from ny hospitl or provider, they relize the highest benefit level nd the lowest out-of-pocket costs when they ccess cre through the Bnner Helth Network. *Aetn Whole Helth is vilble in Mricop, nd prts of Pinl counties. Mnged Choice POS Open Access network using the Bnner Helth Network. To locte providers go to Aetn DocFind t **We cover the cost of services bsed on whether doctors re "in-network" or "out-of-network". We wnt to help you understnd how much Aetn pys for your out-of-network cre. At the sme time, we wnt to mke it cler how much more you will need to py for this "out-of-network" cre. You my choose provider (doctor or hospitl) in our network. You my choose to visit n out-of-network provider. If you choose doctor who is out-of-network, your Aetn helth pln my py some of tht doctor's bill. Most of the time, you will py lot more money out of your own pocket if you choose to use n out-of-network doctor or hospitl. AZ_Bnner_HSA_4000 (v ) Aetn Life Insurnce Compny Pge 6

7 Aetn Whole Helth* Arizon Group Business Employees Pln Effective Dte: 08/01/2012 Bnner Helth Network HSA HDHP $4,000 80/50 (08/12) When you choose out-of network cre, Aetn limits the mount it will py. This limit is clled the "recognized" or "llowed" mount. When you choose out-of-network cre, Aetn "recognizes" n mount bsed on wht Medicre pys for these services. The government sets the Medicre rte. Your doctor sets his or her own rte to chrge you. It my be higher --sometime much higher -- thn wht your Aetn pln "recognizes". Your doctor my bill you for the dollr mount tht Aetn doesn't "recognize". You must lso py ny coinsurnce nd deductibles under you pln. No dollr mount bove the "recognized chrge" counts towrd your deductible or out-of-pocket mximums. To lern more bout how we py out-of-network benefits visit Aetn.com. Type "how Aetn pys" in the serch box. You cn void these extr costs by getting your cre from Aetn's brod network of helth cre providers. Go to nd click on "Find Doctor" on the left side of the pge. If you re lredy member, sign on to your Aetn Nvigtor member site. This pplies when you choose to get cre out-of-network. When you hve no choice (for exmple: emergency room visit fter cr ccident, or for other emergency services), we will py the bills s if you got cre in-network. You py cost shring nd deductibles for your in-network level of benefits nd you should contct Aetn if your provider sks you to py more. You re not responsible for ny outstnding blnce billed by your providers for emergency services beyond your cost shring nd deductibles. Wht's This pln does not cover ll helth cre expenses nd includes exclusions nd limittions. Members should refer to their pln documents to determine which helth cre services re covered nd to wht extent. The following is prtil list of services nd supplies tht re generlly not covered. However, your pln documents my contin exceptions to this list bsed on stte mndtes or the pln design purchsed. Ÿ All medicl or hospitl services not specificlly covered in, or which re limited or excluded in the pln documents; Ÿ Chrges relted to ny eye surgery minly to correct refrctive errors; Ÿ Cosmetic surgery, including brest reduction; Ÿ Custodil cre; Ÿ Dentl cre nd x-rys; Ÿ Donor egg retrievl; Ÿ Experimentl nd investigtionl procedures; Ÿ Hering ids; Ÿ Immuniztions for trvel or work; Ÿ Infertility services, including, but not limited to, rtificil insemintion nd dvnced reproductive technologies such s IVF, ZIFT, GIFT, ICSI nd other relted services, unless specificlly listed s covered in your pln documents; Ÿ Long Term rehbilittion; Ÿ Non-mediclly necessry services or supplies; Ÿ Orthotics except dibetic orthotics; Ÿ Over-the-counter medictions nd supplies; Ÿ Reversl of steriliztion; Ÿ Services for the tretment of sexul dysfunction or indequcies, including therpy, supplies, counseling nd prescription drugs; Ÿ Specil duty nursing; Ÿ Therpy or rehbilittion other thn those listed s covered in the pln documents; AZ_Bnner_HSA_4000 (v ) Aetn Life Insurnce Compny Pge 7

8 Aetn Whole Helth* Arizon Group Business Employees Pln Effective Dte: 08/01/2012 Bnner Helth Network HSA HDHP $4,000 80/50 (08/12) Ÿ Tretment of behviorl disorders; Ÿ Weight control services including surgicl procedures, medicl tretments, weight control/loss progrms, dietry regimens nd supplements, ppetite suppressnts nd other medictions; food or food supplements, exercise progrms, exercise or other equipment; nd other services nd supplies services nd supplies tht re primrily intended to control weight or tret obesity, including Morbid Obesity, or for the purpose of weight reduction, regrdless of the existence of comorbid conditions. Pre-existing Conditions Exclusion Provision This pln imposes pre-existing conditions exclusion, which my be wived in some circumstnces (tht is, creditble coverge) nd my not be pplicble to you. A pre-existing conditions exclusion mens tht if you hve medicl condition before coming to our pln, you might hve to wit certin period of time before the pln will provide coverge for tht condition. This exclusion pplies only to conditions for which medicl dvice, dignosis or tretment ws recommended or received or for which the individul took prescribed drugs within six months. Generlly, this period ends the dy before your coverge becomes effective. However, if you were in witing period for coverge, the six month period ends on the dy before the witing period begins. The exclusion period, if pplicble, my lst up to 12 months from your first dy of coverge, or, if you were in witing period, from the first dy of your witing period. If you hd prior creditble coverge within 90-dys immeditely before the dte you enrolled under this pln, then the preexisting conditions exclusion in your pln, if ny, will be wived. If you hd less thn six months of creditble coverge immeditely before the dte you enrolled, your pln's pre-existing conditions exclusion period will be reduced by the mount (tht is, number of dys) of tht prior coverge. In order to reduce or possibly eliminte your exclusion period bsed on your creditble coverge, you should provide us copy of ny Certifictes of Creditble Coverge you hve. Plese contct your Aetn Member Services representtive t for PPO nd for HMO/CPOS if you need ssistnce in obtining Certificte of Creditble Coverge from your prior crrier or if you hve ny questions on the informtion noted bove. The pre-existing condition exclusion does not pply to pregnncy or to child under the ge of 19. Note: For lte enrollees, coverge will be delyed until the pln's next open enrollment; the pre-existing exclusion will be pplied from the individul's effective dte of coverge. This mteril is for informtionl purposes only nd is neither n offer of coverge nor medicl dvice. It contins only prtil, generl description of pln benefits or progrms nd does not constitute contrct. Aetn does not provide helth cre services nd, therefore, cnnot gurntee results or outcomes. Consult the pln documents (i.e. Group Insurnce Certificte nd/or Group Policy) to determine governing contrctul provisions, including procedures, exclusions nd limittion relting to the pln. With the exception of Aetn Rx Home Delivery, ll preferred providers nd vendors re independent contrctors in privte prctice nd re neither employees nor gents of Aetn or its ffilites. Aetn Rx Home Delivery, LLC, is subsidiry of Aetn Inc. The vilbility of ny prticulr provider cnnot be gurnteed, nd provider network composition is subject to chnge without notice. AZ_Bnner_HSA_4000 (v ) Aetn Life Insurnce Compny Pge 8

9 Aetn Whole Helth* Arizon Group Business Employees Pln Effective Dte: 08/01/2012 Bnner Helth Network HSA HDHP $4,000 80/50 (08/12) Some benefits re subject to limittions nd/or visit mximums. Certin services require precertifiction, or prior pprovl of coverge. Filure to precertify for these services my led to substntilly reduced benefits or denil of coverge. Some of the benefits requiring precertifiction my include, but re not limited to, inptient hospitl, inptient mentl helth, inptient skilled nursing, outptient surgery, substnce buse (detoxifiction, inptient nd outptient rehbilittion). When the Member s preferred provider is coordinting cre, the preferred provider will obtin the precertifiction. Precertifiction requirements my vry. If your pln covers outptient prescription drugs, your pln my include drug formulry (preferred drug list). A formulry is list of prescription drugs generlly covered under your prescription drug benefits pln on preferred bsis subject to pplicble limittions nd conditions. Your phrmcy benefit is generlly not limited to the drugs listed on the formulry. The medictions listed on the formulry re subject to chnge in ccordnce with pplicble stte lw. For informtion regrding how medictions re reviewed nd selected for the formulry, formulry informtion, nd informtion bout other phrmcy progrms such s precertifiction nd step-therpy, plese refer to Aetn's website t Aetn.com, or the Aetn Mediction Formulry Guide. Aetn receives rebtes from drug mnufcturers tht my be tken into ccount in determining Aetn's Preferred Drug List. Rebtes do not reduce the mount member pys the phrmcy for covered prescriptions. In ddition, in circumstnces where your prescription pln utilizes copyments or coinsurnce clculted on percentge bsis or deductible, use of formulry drugs my not necessrily result in lower costs for the member. Members should consult with their treting physicins regrding questions bout specific medictions. Refer to your pln documents or contct Member Services for informtion regrding the terms nd limittions of coverge. Aetn Rx Home Delivery refers to Aetn Rx Home Delivery, LLC, subsidiry of Aetn, Inc., tht is licensed phrmcy providing mil-order phrmcy services. Aetn's negotited chrge with Aetn Rx Home Delivery my be higher thn Aetn Rx Home Delivery's cost of purchsing drugs nd providing mil-order phrmcy services. While this informtion is believed to be ccurte s of the print dte, it is subject to chnge. In cse of emergency, cll 911 or your locl emergency hotline, or go directly to n emergency cre fcility. Plns re provided by Aetn Life Insurnce Compny. For more informtion bout Aetn plns, refer to Aetn Inc. AZ_Bnner_HSA_4000 (v ) Aetn Life Insurnce Compny Pge 9