The attached files were developed and intended for use as a complete enrollment package; by distributing or posting the attached materials, you agree

Transcription

1 The attached files were developed and intended for use as a complete enrollment package; by distributing or posting the attached materials, you agree that the components may not be modified, omitted or used independently of one another. Your distribution and/or posting also memorializes your agreement that Aetna Inc. is not responsible for any miscommunication resulting from the separation of these materials.

2 Open Enrollment: October 1 - October 31, 2007 Newly-hired employees will have 30 days from their date of hire to enroll. RE: Aetna Affordable Health Choices SM limited insurance plans PDS Technical Services knows how important you are to our success. We also know that finding affordable health care isn t always easy; that s why we have teamed up with Aetna* to offer health insurance. This limited accident and sickness insurance plan offers you and your dependents Medical coverage. Premium payments for your benefits will be deducted directly from your paycheck. Enclosed Materials (Your enrollment kit includes:) Temporary Member Identification (bottom of this letter): Once you enroll, you should use this until you receive your permanent IDs. This Temporary Identification is valid following your first payroll deduction. How to Enroll Guide (back of letter): Use this guide to walk you through the enrollment process. Plan Brochure (color): Contains information on available tools and discounts that you receive for participating. Benefits Summary: Describes the specific benefits associated with your plan. Election Form: Use as a worksheet to capture your benefit elections for quick reference while online or using our automated telephone system. Important Disclosure Information: Provides information on the rules associated with your plan. If you are missing any of the contents of this kit, please see your employer or call Customer Service at Remember, you only have a limited time to enroll; if you choose not to enroll, you cannot participate until the next open enrollment, unless you have a qualifying life event. Si necesita ayuda en español, por favor llame al Centro del Servicio al Cliente al de lunes a viernes de 8:00 a.m. a 8:00 p.m. horario del Este. Cut out your Temporary Member Identification along the dotted line. MEDICAL PPO DOI PDS TECHNICAL SERVICES COMPANY NO.: AETNA AFFORDABLE HEALTH CHOICES SM PPO BIN# RX EMPLOYEE NAME: AND COVERED DEPENDENTS FOR MEMBER SERVICES CALL PAYOR NUMBER Key Terms: Deductible: the amount you pay annually for covered services before your plan starts paying. Member Coinsurance: your portion of the cost of covered services after the deductible has been met. Preferred Provider Organization (PPO): a network of doctors and facilities who provide discount services to plan members. Copayment (Copay): The set amount you pay for each covered service for example: doctor s office visits and prescription drugs. Inpatient: services that require a minimum of 24 hours in the hospital; all other services are considered outpatient. * Insurance Plans are underwritten by Aetna Life Insurance Company. Plans are administered by Strategic Resource Company (SRC). Health insurance plans contain exclusions and limitations. Material is subject to change. For OK residents only, policy forms issued include GR-9 and GR-29.

3 Enrolling is easy! Enrollment in this limited accident and sickness insurance plan is quick and easy review the following steps to sign up today. Step One - Review the enclosed materials and ask questions if you need more information or don t completely understand something, give us a call. We re here to answer questions before you enroll! Step Two - Make your decisions and use your Election Form as a worksheet. Step Three - To make your benefit elections, either go online or call our automated telephone system. Online: Go online to make your benefit elections. You will need the following user name and password: Website: Username: Password: 4559 Select Log In (upper right corner); select Log In again on the next screen and follow all steps. Remember to print out a copy of your confirmation page for your records. Automated Telephone System: For each benefit, identify the number that matches the level of coverage you want. Fill in the corresponding blanks with the coverage code you choose for each benefit. This 1-digit number makes up your Benefit Code. You may enroll in one medical option only. Medical Medical Option 1 Option 2 No Coverage 0 0 Yourself Only 1 4 Yourself Plus One 2 5 Yourself & Family 3 6 Benefit Code(fill in): Next, call our automated telephone system to make your benefit elections. Automated Telephone: Access Code: 4559 Follow all steps. If selecting dependent coverage or assigning a beneficiary, you will be transferred to a Customer Service Representative to capture that information. Record your confirmation number here: Your enrollment is only complete after receiving a confirmation number. Employees electing medical will receive plastic identification (ID) cards at their home address along with important membership information. ID Cards are not needed to access any of the other benefit elections. Making changes: If you are within your open enrollment period, you may make changes to your elections by completing an Election Form following the online instructions or calling the automated telephone system and following the voice prompts. If you are outside of your open enrollment period, there are certain events that will allow you to make changes to your elections. Log in to the SRC website or see your employer. You will be provided with the information to determine if you are eligible to make such changes. Contact us: (Monday-Friday, 8 a.m. to 8 p.m. ET) or HEALTH CARE PROVIDER: The person listed on the front of this card has been enrolled under a limited major medical plan sponsored by the employer listed on the front of this card. Covered members are entitled to benefits under the applicable plan, subject to exclusions and limitations. This card does not guarantee coverage. For verification of coverage, filing a claim or for questions other than the discount programs, contact us at the number printed on the front of this card or mail us at the address below. INSURED: Network physicians, hospitals, and other health care providers are independent contractors and are neither agents nor employees of Aetna Life Insurance Company. EMERGENCY URGENT CARE: Call your local emergency hotline (ex.911) or go to the nearest emergency facility. For AETNA VISION DISCOUNTS call For LASIK call For CONTACTS DIRECT call Strategic Resource Company P.O. Box Columbia, SC Notice to Members Concerning Health Care Services: Your share of the payment for health care services may be based on the agreement between your health plan and your provider. Under certain circumstances, this agreement may allow your provider to bill you for amounts up to the provider s regular billed charges.

4 Aetna Affordable Health ChoicesSM A Limited Accident & Sickness PPO Insurance Plan Valuable benefits. Affordable program. Healthy extras. Special discounts. Inventory Code (7/06) B

5 Aetna Affordable Coverage you nee You want health insurance benefits. But you need a plan you can afford. Be well. Stay well. Enroll today. You know how important it is stay well not only for yourself, but for family members who may depend on you. Now Aetna can help, with a health insurance plan especially for you. Aetna Affordable Health Choices is a limited accident and sickness insurance plan. We call it limited because it contains caps on benefits. It delivers the most requested benefits at affordable prices. It s the health care coverage you need at a cost you can afford. What s more, as a member, you will have access to the Aetna network of health care professionals, plus valuable tools, information and discounts to help you maintain a healthy lifestyle. We look forward to welcoming you as a member! How to use your Aetna Affordable Health Choices Visit a Preferred Provider Aetna s network includes over 735,000 health care professionals nationwide. These doctors, therapists and other caregivers meet Aetna standards and give special rates to our members, which is why we call them preferred. When you visit a preferred provider for covered medical needs, you will either make a copayment or you will need to cover the annual deductible out of pocket, before your benefits begin. Your Aetna insurance will then pay the balance up to your plan's limits. You can quickly find a preferred provider by using a computer to visit our DocFind directory online or by calling customer service. Or, Go Outside the Network You don t have to stay in the network. You can visit any qualified caregiver for covered medical needs. However, your payment for the office visit may be higher. Also, you may need to pay an annual deductible. This is the amount of medical costs you pay out of pocket, before your benefits begin. Once you meet your deductible, you will receive coinsurance benefits. You pay a part of the covered medical expense, and Aetna will pay the balance up to your plan limits. Language Assistance If you need assistance in any language, please call Member Services at Si necesita asistencia en cualquier idioma, por favor llame a Servicios al Cliente al Insurance Plans are underwritten by Aetna Life Insurance Company. Plans are administered by Strategic Resource Company (SRC). Aetna Corporate Controller figures, 05/31/06

6 Health Choices.. Coverage you can afford. DocFind Our online directory helps you choose the doctors and other health care professionals that meet your needs, 24 hours a day, 7 days a week. Visit Special Discounts As an Aetna member, you are entitled to all these discounts.* It s one more way we help to protect your health. Hearing Discount Program Receive a 40% discount** on hearing exams and services with HearPO at 1,500 participating locations nationwide. Oral Health Care Discounts Receive savings on products and services to help improve dental and overall health. There are more Special Discounts on the back page... Welcome to Wellness with Aetna Affordable Health Choices.

7 More Special Discounts With your medical membership, you are also entitled to: Aetna Pharmacy Management In addition to prescription discounts, we help protect your health by providing information to help control certain medical conditions. Alternative Health Care Programs Natural Alternatives Discounts on alternative therapy services such as acupuncture therapy, chiropractic manipulation, massage therapy and nutritional counseling. (Use Aetna DocFind to locate alternative health care professionals.) Natural Products Discounts on natural health products such as aromatherapy, biomagnetics, homeopathy, natural body care, yoga tools and more. Vitamin Advantage Discounts on vitamins, nutritional and herbal supplements. Fitness Program Enjoy discounted rates on memberships at participating health clubs contracted with GlobalFit as well as savings on home exercise equipment. Vision One Discounts** on eyewear, contact lenses, LASIK eye surgery and eye care accessories. Participating optical centers include Sears Optical, Lenscrafters, Target Optical and many Pearle Vision locations. To learn more about these Programs and Discounts After you enroll, get more information by visiting or calling the Member Services number on your ID card. * These discount programs are rate-access programs and may be in addition to any plan benefits. Discount and other similar health programs offered hereunder are not insurance. Program features are not guaranteed under the plan contract and may be discontinued at any time. Program providers are solely responsible for the products and services provided hereunder. Aetna does not endorse any vendor, product or service associated with these programs. It is necessary to be a member of an Aetna plan to access the program participating providers. ** Discounts are from the provider's usual fee for the service (retail price). These discount programs are not insured benefits, but provide access to discount programs maintained by Aetna Inc. and its affiliates. Aetna Affordable Health Choices Coverage you need. Coverage you can afford. If you need assistance in any language, please call Member Services at Si necesita asistencia en cualquier idioma, por favor llame a Servicios al Cliente al This material is for informational purposes only and is neither an offer of coverage nor medical advice.it contains only a partial, general description of plan benefits or programs and does not constitute a contract. Aetna does not provide medical/ dental care or treatment. Consult the plan documents (Schedule of Benefits, Certificate of Coverage, Evidence of Coverage, Group Agreement) to determine governing contractual provisions, including procedures, exclusions and limitations relating to the plan. Health insurance plans contain exclusions and some benefits are subject to limitations or visit maximums. With the exception of Aetna Rx Home Delivery service, all participating physicians, hospitals and other health care providers are independent contractors and are neither agents nor employees of Aetna. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change. Notice of the change shall be provided in accordance with applicable state law. Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC. Vision One is a registered trademark of Cole Vision Corporation. LASIK surgery discounts are offered by the U.S. Laser network. Providers are independent surgeons and are not agents or representatives of EyeMed, Aetna Health Inc. and/or its affiliates. The oral health care discount promotions do not constitute medical/ dental advice or any endorsement by Aetna of any specific product, drug or pharmaceutical; nor is it a guarantee of any outcomes or medical/ dental results. Aetna may receive a fee related to the referenced discount. Epic, Philips and Aetna are independent contractors and are neither employees nor agents of the other. This material is subject to change (7/06) Available in Spanish. Disponible en Español Aetna Inc. B

8 PDS Technical Services OPTION 1 PLAN FEATURES Physician Office Visits Deductible (per coverage year) 1 Member Coinsurance 3 (applies to all expenses unless otherwise stated.) Inpatient Care Outpatient Care Maximum Annual Benefit Benefit Specific Limits (in or out of network - subject to deductible) PRESCRIPTION DRUG BENEFIT Generic Drugs Brand-name Drugs Maximum Monthly Benefit PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY Preferred Provider (in network) $15 copay; deductible waived $15 base deductible; 20% 3 thereafter $100 Individual $200 Individual $200 Family 2 $400 Family 2 20% 20% Outpatient expenses Other hospital services Preferred Provider (in network) Non-Preferred Provider (out of network) 40% 40% $5,000 in or out of network, per covered person $500 in or out of network $500 in or out of network Non-Preferred Provider (out of network) $10 copay; deductible waived 20% 3 ; deductible waived $20 copay; deductible waived 20% 3 ; deductible waived $35 in or out of network Members receive a discount at the point of sale and pay the applicable copay (and any balance over the monthly limit). There are no claims to file. Covers only medical prescriptions, except for dental prescriptions issued in connection with treatment resulting from a covered accident. 1 All covered expenses accumulate toward both the preferred and non-preferred Deductible. Unless otherwise indicated, the Deductible must be met prior to benefits being payable. 2 Once Family Deductible is met, all family members will be considered as having met their Deductible for the remainder of the coverage year. You will have met your Family Deductible when two covered family members have each paid their own deductibles in a coverage year. 3 Where benefit is expressed as a percentage, the lower of the recognized charge(s) or the discounted PPO charge(s) will be the basis of payment. Other hospital services are certain hospital charges other than room and board. They include but are not limited to, pharmacy, medical and surgical supplies and devices, lab and x-rays and operating and recovery room expenses. Out-of-area employees -- covered expenses reimbursed at the in network level. If you live in an area that does not have an in network health care provider, you will be considered out-of-area and receive in network benefits for eligible expenses. Please note that if you travel to an area that has an in network health care provider but use an out of network health care provider, you will not be eligible for in network benefits. 07/16/2007 Page 1

9 PDS Technical Services OPTION 2 PLAN FEATURES Physician Office Visits Deductible (per coverage year) 1 Member Coinsurance 3 (applies to all expenses unless otherwise stated.) PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY Inpatient Care Outpatient Care Maximum Annual Benefit 20% 20% 40% 40% $10,000 in or out of network, per covered person Benefit Specific Limits Outpatient expenses $1,000 in or out of network (in or out of network - subject to deductible) Other hospital services $1,000 in or out of network PRESCRIPTION DRUG BENEFIT Generic Drugs Brand-name Drugs Maximum Monthly Benefit Preferred Provider (in network) $15 copay; deductible waived $15 base deductible; 20% 3 thereafter $100 Individual $200 Individual $200 Family 2 $400 Family 2 Preferred Provider (in network) Non-Preferred Provider (out of network) Non-Preferred Provider (out of network) $10 copay; deductible waived 20% 3 ; deductible waived $20 copay; deductible waived 20% 3 ; deductible waived $35 in or out of network Members receive a discount at the point of sale and pay the applicable copay (and any balance over the monthly limit). There are no claims to file. Covers only medical prescriptions, except for dental prescriptions issued in connection with treatment resulting from a covered accident. 1 All covered expenses accumulate toward both the preferred and non-preferred Deductible. Unless otherwise indicated, the Deductible must be met prior to benefits being payable. 2 Once Family Deductible is met, all family members will be considered as having met their Deductible for the remainder of the coverage year. You will have met your Family Deductible when two covered family members have each paid their own deductibles in a coverage year. 3 Where benefit is expressed as a percentage, the lower of the recognized charge(s) or the discounted PPO charge(s) will be the basis of payment. Other hospital services are certain hospital charges other than room and board. They include but are not limited to, pharmacy, medical and surgical supplies and devices, lab and x-rays and operating and recovery room expenses. Out-of-area employees -- covered expenses reimbursed at the in network level. If you live in an area that does not have an in network health care provider, you will be considered out-of-area and receive in network benefits for eligible expenses. Please note that if you travel to an area that has an in network health care provider but use an out of network health care provider, you will not be eligible for in network benefits. 07/16/2007 Page 2

10 PDS Technical Services YOUR MEDICAL BENEFITS ALSO INCLUDE: EYEWEAR DISCOUNT PROGRAM* PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY Aetna Vision SM Discounts, a nationwide network of vision care providers, offers you and your family glasses, contact lenses, nonprescription sunglasses, contact lens solutions and other eye care accessories at a discounted price. Plus, you can receive discounts on eye exams and LASIK eye surgery. For exams and eyewear call For contacts call For LASIK customer service call You can also locate a local provider by visiting PRESCRIPTION DRUG DISCOUNT PROGRAM* The Prescription Drug discount program gives you and your family access to more than 52,000 retail pharmacies across the continental U.S., Puerto Rico, and the Virgin Islands (as of 1/1/05). You can also use our Aetna Rx Home Delivery service; a fast, easy way to fill the prescriptions you take regularly. To locate a participating pharmacy, call toll-free or visit *Discount programs provide access to discounted prices and are not insured benefits. EXCLUSIONS AND LIMITATIONS This is a summary list. Coverages, features, limitations and exclusions may vary by state. This is not a contract. Only the insurance policy can provide the actual terms, coverages, amounts, conditions, limitations and exclusions. Except to the extent coverage for such benefit is specifically provided in your Booklet-Certificate, coverage is not provided for the following charges: Medical Pre-existing Condition Limitation: Medical expenses for a pre-existing condition are not covered (full postponement rule) for the first 365 days after the enrollee s enrollment date. The lookback period for determining a pre-existing condition (conditions for which diagnosis, care and treatment was recommended or received) is 180 days prior to the enrollment date. The pre-existing limitation period may be reduced by the number of days of prior creditable coverage the member has as of the enrollment date. In order to reduce or possibly eliminate your exclusion period based on your creditable coverage, you should provide us a copy of any certificates of creditable coverage you have. Please contact Member Services at if you need assistance on obtaining a certificate of creditable coverage from your prior carrier or if you have any questions regarding the pre-existing condition exclusion. The pre-existing condition limitation does not apply to newborn or adopted children, or to any pregnancy. As used above, creditable coverage means a person s prior medical coverage as defined in the Federal Health Insurance Portability and Accountability Act (HIPAA) of /16/2007 Page 3

11 PDS Technical Services Medical Exclusions: PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY Services and supplies not necessary, as determined by Aetna, for the diagnosis, care, or treatment of the disease or injury involved; Service or supply rendered by someone who is related to a covered person by blood (e.g. sibling, parent, grandparent, child), marriage (e.g., spouse or in-law) or adoption or is normally a member of the covered persons household; Injury arising out of or in the course of employment or which is compensable under any Worker s Compensation or Occupational Disease Act or Law; Care, treatment, services or supplies that are not prescribed, recommended, or approved by the person s attending physician or dentist; Experimental or investigational services, drugs, or supplies except to the extent required by law; Cosmetic or Reconstructive Surgery: This does not apply to reconstructive surgery incidental to or following surgery resulting from trauma, infection, or other diseases of the involved part; or because of congenital disease or anomaly of a covered person; or reconstructive surgery on a non-diseased breast to restore and achieve symmetry between two breasts following a mastectomy; Dental Care and treatment, except that required by injury and rendered within 6 months of the injury; Educational testing, or training related to learning disabilities or developmental delays; Services of a resident physician or intern rendered in that capacity; Made only because there is insurance or a person is not legally obligated to pay; Custodial care; Any expense incurred before the effective date of the policy or after the date the policy terminates; Eye surgery mainly to correct refractive errors; Education, special education, or job training whether or not given in a facility that also provides medical or psychiatric treatment; Therapy, supplies, or counseling for sexual dysfunctions or inadequacies that do not have a physiological or organic basis; Any drugs or supplies used for the treatment of erectile dysfunction, impotence, or sexual dysfunction or inadequacy; Performance, or lifestyle enhancement drugs or supplies; Artificial insemination, in vitro fertilization, or embryo transfer or any related procedures except where required by law to be covered; Routine physical exams, routine vision exams, routine dental exams, routine hearing exams, immunizations, or other preventive services and supplies, except to the extent coverage for such exams, immunizations, services, or supplies is specifically provided in your Booklet-Certificate; Marriage, family, child, career, social adjustment, pastoral, or financial counseling; Acupuncture therapy, except when its performed by a physician as a form of anesthesia in connection with surgery that is covered under this Plan; Speech therapy, except to restore speech to a person who has lost existing speech function as the result of a disease or injury; Inpatient or outpatient treatment of alcoholism, drug abuse and mental disorders; Private duty nursing; An injury sustained while the covered person was legally intoxicated or under the influence of alcohol as defined by the jurisdiction in which the injury occurred; An injury sustained while the covered person was voluntarily using any drug, narcotic or controlled substance unless as prescribed by a physician; Charges made by a hospital or treatment facility owned or run by the U.S. government unless a charge is made for such services in the absence of insurance; Charges made to treat an illness or injury sustained while flying as a pilot or crew member of any aircraft or travel or flight. This includes boarding or alighting in any vehicle or device while being used for any test or experimental purposes or while being operated by; for; or under; the direction of any military authority other than the Military Airlift Command of the United States or similar air transport service of any other country; Charges made by a hospital which does not unconditionally require payment (this does not apply to charges billed by Veterans Administration Hospitals); Charges made by a physician for non-surgical medical treatment given to a covered person while confined in an inpatient facility; Charges made for outpatient services and supplies that are not deemed to be physician office visits; emergency room visits; diagnostic and surgical services; or prescription drugs and medicines; Voluntary sterilization procedure or the reversal of a sterilization procedure; Weight Control services including: surgical procedures, medical treatments, weight control/loss programs; food supplements; or exercise programs; Furnished, paid for, or for which benefits are provided or required under any law of a government; Those made for prescription drugs and medicines prescribed by a physician [on an inpatient and/or outpatient basis]; Charges in excess of the Recognized Charge, based on the 80th percentile of the Medicode Medical Data Research Tables. 07/16/2007 Page 4

12 PDS Technical Services PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY This material is for information only and is not an offer or invitation to contract. Insurance plans contain exclusions and limitations. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location. Discount programs provide access to discounted prices and are not insured benefits. Material is subject to change. Insurance plans are underwritten by Aetna Life Insurance Company. Plans are administered by Strategic Resource Company (SRC). For OK residents only, policy forms issued include GR-9 and GR /16/2007 Page 5

13 Aetna Affordable Health Choices SM Election Form PDS Technical Services Group No IF YOU ARE NOT CHANGING YOUR EXISTING COVERAGE, YOU DO NOT NEED TO COMPLETE THIS FORM. A. INFORMATION ABOUT YOU Print Your Name (First, Middle Initial, Last) Mailing Address City State Zip Code Home Phone ( ) Date of Birth (MM/DD/YYYY) Social Security Number B. YOUR ELECTION (Check the appropriate box.) I am not currently enrolled and I elect to. I am currently enrolled and I elect to. Enroll in the coverage choice selected below. Decline this opportunity to participate. Change my current coverage with the choice selected below. Change my personal and/or dependent information. Drop my current coverage choice. By selecting the coverage choice below, I authorize my employer to deduct from my paycheck, before taxes are deducted, any required contribution. Your Signature Today s Date (MM/DD/YYYY) C. YOUR COVERAGE CHOICES For each coverage you wish to adjust: MEDICAL You may elect either Option 1 or Option 2. Add Drop Change To 1) Check the appropriate box ( ) for the action you wish to make (add/drop/change to); and 2) Check the appropriate box ( ) for whom this action applies. (List Dependents on the back of this form) Weekly Cost Option 1 Yourself Only... $ Yourself Plus One... $ Yourself and Family... $ Option 2 Yourself Only... $ Yourself Plus One... $ Yourself and Family... $ QUALIFYING LIFE EVENTS A. LOSS OF OTHER COVERAGE (LOC): If you previously declined health coverage because you or your dependents were already covered under another health plan and you or your dependents have lost that other coverage, you may be allowed to enroll yourself and your dependents within 31 days of the LOC. If you are entitled to this special enrollment, complete sections A & B (above) then go to the list on the right and check the box next to your LOC, supply the date of the LOC, and finish completing the form through section D. Check the box of the description that identifies your LOC. Divorce, legal separation or death Termination of employment of a dependent Reduction of a dependent s hours Termination of your or your dependents COBRA rights Loss of employer s contribution to spouse s coverage Dependent child losing eligibility as a dependent Other loss of coverage Date of the LOC: B. FAMILY STATUS CHANGES (FSC): Whether you are currently enrolled or previously declined coverage, you may be allowed to add, increase, decrease or drop coverage when you experience certain FSC events within 31days of the FSC. If you are so entitled because of a recent FSC, complete sections A & B (above) then go to the list on the right and check the box next to your FSC, supply the date of the FSC, and finish completing this form through section D. Check the box of the description that identifies your FSC. Divorce, legal separation or death Marriage Birth or adoption of a dependent Other Date of the FSC: FOR YOUR EMPLOYER S USE ONLY Employee ID: Hire Date (MM/DD/YYYY): Pay Type: Total Deduction: $ Location or Site Code: Authorized Signature: Today s Date (MM/DD/YYYY): EF: ED002 (03/05) This Election Form is not Proof of Coverage.

14 D. DEPENDENT INFORMATION Check here if you have more dependents and provide all requested information on a separate sheet and attach it to this form. Add Drop Change To Print Dependent s Name (First, Middle Initial, Last) Sex Male Female Social Security Number Relationship Date of Birth If over 18, is your child: Full-time student? Street Address If this dependent has a different address than you, list it here: City State Zip Code Disabled? Add Drop Change To Add Drop Change To Add Drop Change To Add Drop Change To Add Drop Change To Print Dependent s Name (First, Middle Initial, Last) Sex Male Female Social Security Number Relationship Date of Birth If over 18, is your child: Full-time student? Street Address If this dependent has a different address than you, list it here: City State Zip Code Print Dependent s Name (First, Middle Initial, Last) Sex Male Female Social Security Number Relationship Date of Birth If over 18, is your child: Full-time student? Street Address If this dependent has a different address than you, list it here: City State Zip Code Print Dependent s Name (First, Middle Initial, Last) Sex Male Female Social Security Number Relationship Date of Birth If over 18, is your child: Full-time student? Street Address If this dependent has a different address than you, list it here: City State Zip Code Print Dependent s Name (First, Middle Initial, Last) Sex Male Female Social Security Number Relationship Date of Birth If over 18, is your child: Full-time student? Street Address If this dependent has a different address than you, list it here: City State Zip Code Print Dependent s Name (First, Middle Initial, Last) Sex Male Female Social Security Number Relationship Date of Birth If over 18, is your child: Full-time student? Street Address If this dependent has a different address than you, list it here: City State Zip Code Disabled? Disabled? Disabled? Disabled? Disabled? Record keeping by Strategic Resource Company (SRC). Insurance plans are underwritten by Aetna Life Insurance Company. EF: ED002 (03/05) This Election Form is not Proof of Coverage.

15 Important Disclosure Information For Aetna Affordable Health Choices SM Plans Plan of Benefits Your plan of benefits will be determined by your plan sponsor and underwritten by the Aetna Life Insurance Company, 151 Farmington Avenue, Hartford, Connecticut, The benefits and main points of the Group Policy for persons covered under your plans of benefits will be set forth in the Description of Coverage Booklet which will be provided to you at a later date. Cost Sharing You are responsible for any copayments, coinsurance and deductibles for covered services. You will need to satisfy any applicable cost sharing before the plan will begin to pay benefits. Copayment, coinsurance and deductible amounts are listed in your benefits summary and plan document. How Aetna Compensates Your Health Care Provider All the participating physicians are independent practicing physicians that are neither employed nor exclusively contracted with Aetna. Individual physicians are in the network by either directly contracting with Aetna and/or affiliating with a group or organization that contracts with us. Participating physicians, hospitals and other providers in our network are compensated in various ways for the services covered under your plan. Per individual service or case (fee for service at contracted rates). Per hospital day (per diem contracted rates). Claims Payment for Nonparticipating Providers and Use of Claims Software If your plan provides coverage for services rendered by nonparticipating providers, you should be aware that Aetna determines the usual, customary and reasonable fee for a provider by referring to commercially available data reflecting the customary amount paid to most providers for a given service in that geographic area or by accessing other contractual arrangements. If such data is not commercially available, our determination may be based upon our own data or other sources. Aetna may also use computer software and other tools to take into account factors such as the complexity, amount of time needed and manner of billing. You may be responsible for any charges Aetna determines are not covered under your plan. Medically Necessary Medically necessary means that the service or supply is provided by a physician or other health care provider exercising prudent clinical judgment for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that provision of the service or supply is: Clinically appropriate in accordance with generally accepted standards of medical practice in term of type frequency, extent, site and duration, Considered effective in accordance with generally accepted standards of medical practice for the illness, injury or disease; and Not primarily for the convenience of you, or for the physician or other health care provider; and Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the illness, injury or disease. Generally accepted standards of medical practice means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community. In the absence of such credible scientific evidence, the Plan s determinations of whether a service or supply meets generally accepted standards of medical practice shall be consistent with physician specialty society recommendations and otherwise shall be based on the views of physicians practicing in relevant clinical areas and any other relevant factors. * Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. w w w.aetna.com SRC C (1/07) 1

16 Clinical Policy Bulletins ( CPBs ) Aetna s CPBs describe Aetna s policy determinations of whether certain services or supplies are medically necessary, based upon a review of currently available clinical information. Clinical determinations in connection with individual coverage decisions are made on a case-by case basis consistent with applicable policies. Aetna s CPBs do not constitute medical advice. Treating providers are solely responsible for your medical advice and treatment. You should discuss any CPB related to their coverage or condition with their treating provider. While Aetna s CPBs are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. You and your providers will need to consult the benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. CPBs are regularly updated and are therefore subject to change. Aetna s CPBs are available online at w w w.aetna.com. Complaints, Appeals and External Review Filing a Complaint or Appeal Aetna is committed to addressing your coverage issues, complaints and problems. If you have a coverage issue or other problem, call Member Services at the toll-free number on your ID card. If Member Services is unable to resolve your issue to your satisfaction, it will be forwarded to the appropriate department for handling. If you are dissatisfied with the outcome of your initial contact, you may file an appeal. If you are not satisfied after filing a formal appeal, you may request a second level appeal of the decision. Your appeal will be decided in accordance with the procedures applicable to your plan and applicable state law. Refer to your plan documents for further details regarding your plan s appeal procedure. External Review Aetna established an external review process to give eligible members the opportunity of requesting an objective and timely independent review of certain coverage denials. Once the applicable appeal process has been exhausted, eligible members may request an external review of the decision if the coverage denial, for which the member would be financially responsible, involves more than $500*, and is based on lack of medical necessity or on the experimental or investigational nature of the proposed service or treatment. Standards may vary by state, if a state-mandated external review process exists and applies to your plan. An independent review organization (IRO) will assign the case to a physician reviewer with appropriate expertise in the area in question. After all necessary information is submitted, an external review generally will be decided within 30 calendar days of the request. Expedited reviews are available when a member s physician certifies that a delay in service would jeopardize the member s health. Once the review is complete, the plan will abide by the decision of the external reviewer. The cost for the review will be borne by Aetna (except where state law requires members to pay a filing fee as part of the state-mandated program). Certain states mandate external review of additional benefit or service issues; some may require a filing fee. In addition, certain states mandate the use of their own external review process for medical necessity and experimental/ investigational coverage decisions. These state mandates may not apply to self-funded plans. For further details regarding your plan s appeal process and the availability of an external review process, call the Member Services toll-free number on your ID card where you may obtain an external review request form. You also may call your state insurance or health department or consult their website for additional information regarding statemandated external review procedures. Confidentiality and Privacy Notices Aetna considers personal information to be confidential and has policies and procedures in place to protect it against unlawful use and disclosure. By personal information, we mean information that relates to a member s physical or mental health or condition, the provision of health care to the member, or payment for the provision of health care to the member. Personal information does not include publicly available information or information that is available or reported in a summarized or aggregate fashion but does not identify the member. When necessary or appropriate for your care or treatment, the operation of our health plans, or other related activities, we use personal information internally, share it with our affiliates, and disclose it to health care providers (doctors, dentists, pharmacies, hospitals and other caregivers), payors (health care provider organizations, employers who sponsor self-funded health plans or who share responsibility for the payment of benefits, and others who may be financially responsible for payment for the *Does not apply in some states, including North Carolina. 2

17 services or benefits you receive under your plan), other insurers, third-party administrators, vendors, consultants, government authorities, and their respective agents. These parties are required to keep personal information confidential as provided by applicable law. Participating network providers are also required to give you access to your medical records within a reasonable amount of time after you make a request. Some of the ways in which personal information is used include claims payment; utilization review and management; medical necessity reviews; coordination of care and benefits; preventive health, early detection, and disease and case management; quality assessment and improvement activities; auditing and antifraud activities; performance measurement and outcomes assessment; health claims analysis and reporting; health services research; data and information systems management; compliance with legal and regulatory requirements; formulary management; litigation proceedings; transfer of policies or contracts to and from other insurers, HMOs and third party administrators; underwriting activities; and due diligence activities in connection with the purchase or sale of some or all of our business. We consider these activities key for the operation of our health plans. To the extent permitted by law, we use and disclose personal information as provided above without member consent. However, we recognize that many members do not want to receive unsolicited marketing materials unrelated to their health benefits. We do not disclose personal information for these marketing purposes unless the member consents. We also have policies addressing circumstances in which members are unable to give consent. To obtain a hard copy of our Notice of Privacy Practices, which describes in greater detail our practices concerning use and disclosure of personal information, please write to Strategic Resource Company (SRC) Post Office Box 23759, Columbia, SC You can also visit w w w.aetna.com for a direct link to the Notice of Privacy Practices by selecting the Privacy Notices link at the bottom of the page. w w w.aetna.com 3

18 State Variations* Georgia Members can call (toll-free) to confirm that the preferred provider in question is in the network and/or accepting new patients. Members have direct access to the participating primary Ob/Gyn provider of their choice and do not need a referral from their PCP for a routine well-woman exam, including a Pap smear when appropriate and an unlimited number of visits for gynecologic problems and follow-up care. Members also have direct access to the participating dermatologist provider of their choice and do not need a referral from their primary care physicians to access dermatologic benefits covered under their health plan. A summary of any agreement or contract between Aetna and any health care provider will be made available upon request by calling the Member Services telephone number on your ID card. The summary will not include financial agreements as to actual rates, reimbursements, charges, or fees negotiated by Aetna and the provider. The summary will include a category or type of compensation paid by Aetna to each class of health care provider under contract with Aetna. Consumer Choice Option The Consumer Choice Option is available for Georgia residents enrolled in certain Aetna managed care plans. Under this benefit option, with certain restrictions required by law and an additional monthly premium cost, members of certain Aetna managed care plans may nominate an out-of-network provider to provide covered services for themselves and their covered family members. Your benefits and any applicable copayments will be the same as for in-network providers. The out-of-network provider must agree to accept the Aetna compensation, to adhere to the plan s quality assurance requirements, and to meet all other reasonable criteria required by the plan of its innetwork participating providers. It is possible the provider you nominate will not agree to participate. This option is available for an increased premium in addition to the premium you would otherwise pay. Your increased premium responsibility will vary depending on whether you have a single plan or family coverage, and on the type of insurance, riders, and coverage. Exact pricing and any additional information can be obtained by calling Please have your Aetna member ID card available when you call. Hawaii Informed Consent Members have the right to be fully informed prior to making any decision about any treatment, benefit, or nontreatment. Your provider will: discuss all treatment options, including the option of no treatment at all; ensure that persons with disabilities have an effective means of communication with the provider and other members of the managed care plan; and discuss all risks, benefits, and consequences of treatment and non-treatment. Your provider will also discuss with you and your immediate family both living wills and durable powers of attorney in relation to medical treatment. Insurance Division Telephone Number: You may contact the Hawaii Insurance Division and the Office of Consumer Complaints at Illinois While every provider listed in the provider directory contracts with Aetna to provide primary care services, not every provider listed will be accepting new patients. Although Aetna has identified those providers who were not accepting patients as known to Aetna at the time the Provider Directory was created, the status of the physician s practice may have changed. For the most current information regarding the status of any physician s practice, please contact either the selected physician or call Member Services at the toll-free number on your ID card. Illinois law requires health plans to provide the following information annually to enrollees and to prospective enrollees upon request: a complete list of participating health care providers in the health care plan s service area and a description of the following terms of coverage: 1. The service area; 2. The covered benefits and services with all exclusions, exceptions and limitations; 3. The pre-certification and other utilization review procedures and requirements; 4. A description of the process for the selection of a PCP, any limitation on access to specialists, and the plan s standing referral policy; *In some states, Aetna provides additional consumer disclosures in documents also posted on our website at w w w.aetna.com. 4

19 5. The emergency coverage and benefits, including any restrictions on emergency care services; 6. The out-of-area coverage and benefits, if any; 7. The enrollee s financial responsibility for copayments, deductibles, premiums, and any other out-of-pocket expenses; 8. The provisions for continuity of treatment in the event a health care provider s participation terminates during the course of an enrollee s treatment by the provider; 9. The appeals process, forms, and time frames for health care services appeals, complaints, and external independent reviews, administrative complaints, and utilization review complaints, including a phone number to call to receive more information from the health care plan concerning the appeals process; and 10. A statement of all basic health care services and all specific benefits and services to be provided to enrollees by a State law or administrative rule. Additionally, upon written request, the health plan will provide enrollees with a description of the financial relationship between the health plan and any health care provider, including, if requested, the percentage of copayments, deductibles, and total premiums spent on health care related expenses and the percentage of copayments, deductibles and total premiums spent on other expenses, including administrative expenses. Kansas Kansas law permits you to have the following information upon request: 1. A complete description of the health care services, items and other benefits to which the insured is entitled in the particular health plan which is covering or being offered to such person; 2. A description of any limitations, exceptions or exclusions to coverage in the health benefit plan, including prior authorization policies, restricted drug formularies or other provisions which restrict access to covered services or items by the insured; 3. A listing of the plan s participating providers, their business addresses and telephone numbers, their availability, and any limitation on an insured s choice of provider; 4. Notification in advance of any changes in the health benefit plan which either reduces the coverage or benefits or increases the cost to such person; and 5. A description of the grievance and appeal procedures available under the health benefit plan and an insured s rights regarding termination, disenrollment, nonrenewal or cancellation of coverage. Kentucky Any provider who meets our enrollment criteria and who is willing to meet the terms and conditions for participation has a right to become a participating provider in our network. Emergency Medical Condition Definition A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, that a prudent layperson would reasonably have cause to believe constitutes a condition that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part; or with respect to a pregnant woman who is having contractions, a situation in which there is inadequate time to effect a safe transfer to another hospital before delivery; or a situation in which transfer may pose a threat to the health or safety of the woman or the unborn child. Louisiana Aetna will not in any way use the results of genetic testing to discriminate against applicants or enrollees. Maryland Behavioral Health Care Expense Form To obtain a copy of the Behavioral Health Care Expense Form, please call the number located on the back of your ID card. Michigan Contact the Michigan Department of Consumer and Industry Services at to verify participating providers licenses or to access information on formal complaints and disciplinary actions filed or taken against participating providers. Upon request, pursuant to Michigan law, the following information can be supplied to you: 1. date of provider certification by applicable nationally recognized board or other organization; 2. names of licensed facilities where providers have privileges; 3. prior authorization requirements and limitations including medication formulary restrictions; 4. information about financial relationships between providers and the health plan. w w w.aetna.com 5

20 Intractable Pain Coverage Aetna provides benefits for the evaluation and treatment of intractable pain when it is determined to be medically necessary and otherwise eligible by Aetna. Intractable pain means a pain state in which the cause of the pain cannot be removed or otherwise treated and which, in the generally accepted practice of allopathic or osteopathic medicine, no relief of the cause of the pain or cure of the cause of the pain is possible or none has been found after reasonable efforts, including, but not limited to, evaluation by the attending physician and by one or more other physicians specializing in the treatment of the area, system, or organ of the body perceived as the source of the pain. To obtain this and further information on the health plan, you may call Member Services at Texas Please refer to the plan design overview and summary of riders contained in your pre-enrollment packet for a brief description of the services and benefits covered under your particular plan, as well as those services and benefits that are excluded. After enrollment, you can refer to your plan documents for a more complete description of your covered services and benefits and the exclusions under your plan. For information on whether a specific service is covered or excluded, please contact Member Services at the toll-free number on your ID card. 6